Dementia – Video decision support tool for advance care planning in dementia: RCT

Video decision support tool for advance care planning in dementia: randomised controlled trial, BMJ, British Medical Journal, 2009;338:b2159

Angelo E Volandes, instructor1, Michael K Paasche-Orlow, associate professor2, Michael J Barry, professor1, Muriel R Gillick, professor3, Kenneth L Minaker, professor1, Yuchiao Chang, senior statistician1, E Francis Cook, professor4, Elmer D Abbo, assistant professor5, Areej El-Jawahri, research fellow1, Susan L Mitchell, associate professor 6

1 General Medicine Unit, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA, 2 Department of Medicine, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118, USA, 3 Department of Ambulatory Care and Prevention, Harvard Medical School/Harvard Pilgrim, 133 Brookline Ave, Boston, MA 02215, USA, 4 Department of Medicine, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02115, USA, 5 Department of Medicine, University of Chicago, 5801 South Ellis, Chicago, IL 60637, USA, 6 Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA


Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008.

Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

Participants Convenience sample of 200 older people (65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94).

Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (=0.79) (P<0.001 for difference).

Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

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Evidence of the efficacy of cognitive-behavioral therapy (CBT) for schizophrenia is increasing

Effectiveness of brief cognitive-behavioral therapy for schizophrenia delivered by mental health nurses: relapse and recovery at 24 months, Journal of Clinical Psychiatry, 2009 Feb;70(2):201-7

Malik N Kingdon D ,  Pelton J , Mehta R , Turkington D.

School of Neurology, Neurosciences and Psychiatry, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK.


Evidence of the efficacy of cognitive-behavioral therapy (CBT) for schizophrenia is increasing. There are very few studies of effectiveness, especially in the medium term. OBJECTIVE: To evaluate the durability of the effect of brief CBT provided by mental health nurses in community-based patients with schizophrenia (diagnosed according to ICD-10 research criteria), using time to relapse as primary outcome and days hospitalized and occupational recovery as secondary outcomes at 24-month follow-up. METHOD: A 2:1 randomized trial, conducted from 1999 to 2003, was performed to evaluate the effects of brief CBT delivered by mental health nurses trained over 10 days with ongoing supervision compared to treatment as usual (TAU), with measurement performed by raters blind to treatment allocation. RESULTS: 205 (79.8%) of 257 CBT patients and 125 (75.8%) of 165 TAU patients could be followed up at 24 months. Of 205 patients in the CBT group, 64 (31.2%) relapsed, versus 57 (45.6%) of 125 patients in the TAU group (p = .02). Patients rehospitalized from the CBT group spent a total of 6710 days in hospital (mean = 32.7 days), while those from the TAU group were inpatients for 6114 days (mean = 48.9 days) (p < .05). Twenty-one (10.2%) of 205 patients made an occupational recovery in the CBT group, and 17 (13.6%) of 125, in the TAU group (chi(2) test not significant). Mean time to relapse was 356.8 days (SD = 241.9 days) for the CBT group and 296.1 days (SD = 215.7 days) for the TAU group (OR = 1.592, 95% CI = 1.038 to 2.441, p = .033). CONCLUSION: Beneficial effects on relapse and rehospitalization following brief CBT delivered by mental health nurses in community-based patients with schizophrenia are maintained at 24-month follow-up. Occupational recovery is not improved by brief CBT.

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Relating therapy for people who hear voices: A case series

Relating therapy for people who hear voices: A case series,  Clinical Psychology & Psychotherapy, Volume 16 Issue 3,   Pages 216 – 227

Mark Hayward 1 2 *, Jo Overton 3 4, Theresa Dorey 2, Joanna Denney 3 5
1University of Surrey, UK
2Sussex Partnership NHS Foundation Trust
3University of Southampton, UK
4Hampshire Partnership Trust
52gether Foundation Trust for Gloucestershire


This paper presents a series of cases to explore the development and value of a form of relating therapy for people who hear voices. The therapy is theoretically underpinned by Birtchnell’s Relating Theory and offers a therapeutic space where hearers can explore and seek to change the relationship with their predominant voice. Five cases are presented to illustrate the processes of: (1) exploring similarities between relating to the voice and relating socially; (2) enhancing awareness of reciprocity with the voice-hearer relationship; and (3) using assertiveness training and empty chair work to facilitate change. Results were encouraging as change in control and/or distress was apparent for four of the cases. Changes in patterns of relating to voices were also apparent.

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Kate Splevins & Dr Alistair Smith – Lancashire Care NHS Foundation Trust – Do improvements in emotional distress correlate with becoming more mindful?

Do improvements in emotional distress correlate with becoming more mindful? A study of older adults, Aging & Mental Health, Volume 13, Issue 3 May 2009 , pages 328 – 335

Authors:           Kate Splevins aAlistair Smith b; Jane Simpson a
Affiliations:   a Lancaster University, Institute of Health Research, Lancaster LA1 4YT, UK
  b Psychology Department, Lancashire Care NHS Foundation Trust, Chorley, Preston PR7 1PS, UK
Objectives: The study aimed (1) to investigate changes in older adults’ emotional wellbeing (specifically depression, anxiety and stress levels) and mindful ability following a mindfulness-based cognitive therapy (MBCT) course; (2) to explore correlations between mindfulness (measured as an overall ability and as individual components; observe, describe, act with awareness and accept without judgement) and changes in depression, anxiety and stress levels.

Method: Twenty-two participants took an eight-week MBCT course. Levels of depression, anxiety and stress were recorded pre- and post-intervention, as was mindfulness ability (measured both as an overall ability and as individual components).

Results: Significant improvements in emotional wellbeing and mindfulness were reported post-MBCT, with large to moderate effect sizes. Increased mindfulness was moderately and significantly associated with improved emotional wellbeing. Increases on all four components of mindfulness were positively associated with greater emotional wellbeing, however only act with awareness and accept without judgement were significantly correlated (with reduced depression). Older adults in our sample reported higher scores on observe and act with awareness than other populations.

Conclusion: This study adds to a growing evidence-base indicating the efficacy of MBCT for depression, anxiety and stress, and extends these finding to older adults. This study found older adults to have elevated levels of certain facets of mindfulness and recommendations are made for researching the possibility that mindfulness may be an extension of the developmental process.

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Self-Injury – The findings of this study could assist health care professionals in approaching and helping both self-mutilating adolescents and their parents

Helping adolescents who self-mutilate: parental descriptions, Journal of Clinical Nursing, 2009, Volume 18 Issue 12, Pages 1711 – 1721

Marja-Liisa Rissanen, Jari Kylmä and Eila Laukkanen

Authors: Marja-Liisa Rissanen, MNSc, PhD(c), RN, Nurse Researcher, Department of Psychiatry, University Hospital of Kuopio, Kuopio, Finland; Jari Kylmä, PhD, RN, Adjunct Professor, Senior Lecturer, Department of Nursing Science, University of Kuopio, Kuopio, Finland; Eila Laukkanen, PhD, MD, Professor, Senior Physician, Department of Adolescent Psychiatry, University Hospital of Kuopio, Kuopio, Finland

Correspondence to Marja-Liisa Rissanen, Nurse Researcher, Department of Psychiatry, University Hospital of Kuopio, P.O. Box 1777, FIN-70211 Kuopio. Telephone: +358504923994.


Aim. The purpose of this qualitative descriptive study was to explore parental views on how to help adolescents who self-mutilate.

Background. Self-harm, including self-mutilation, is common among adolescents. However, parental conceptions of helping adolescents who self-mutilate have rarely been investigated in nursing science.

Design. Qualitative descriptive design.

Method. Four parents of self-mutilating adolescents were interviewed in depth. Qualitative content analysis was applied.

Results. Three main categories emerged: a description of an adolescent who self-mutilates and descriptions of ways to help self-mutilating adolescents and ways to help their parents and family. An adolescent who self-mutilates appears externally to feel very well, but inside feels lonely and inferior to others. Help may include an adolescent helping herself by performing some activities alone or in relation to other people and an adolescent receiving help from a safe and trusting human relationship. Such a relationship can be with anyone who knows about the self-mutilation and is of utmost importance, but a caring attitude is particularly expected from adults. Factors that facilitate helping were identified as well as those considered help-hindering or helpful. Help that had been provided to parents and the family included factors considered helpful and unhelpful.

Conclusion. Adolescents who self-mutilate try to help themselves, but are in need of external, probably professional help. Parents are in need of information about self-mutilation as a phenomenon to be able to help their children. Help for self-mutilating adolescents as perceived by their parents also includes help for the whole family.

Relevance to clinical practice. The findings of this study could assist health care professionals in approaching and helping both self-mutilating adolescents and their parents.

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Psychotherapy approaches for adolescents with eating disorders

Psychotherapy approaches for adolescents with eating disorders, Current Opinion in Pediatrics, Online early view 2009

Varchol L, Cooper H

aMental Health Service, MIT Medical, Massachusetts Institute of Technology, Cambridge, USA bDivision of Adolescent/Young Adult Medicine, Children’s Hospital Boston, Boston, Massachusetts, USA.


PURPOSE OF REVIEW: Adolescence is the most common period for the onset of eating disorders, and early intervention is critical. Primary care providers should feel equipped to discuss psychotherapy approaches for eating disorders with adolescents and their families and to provide appropriate referrals. The present review focuses on six prominent treatment modalities and the evidence supporting each approach. RECENT FINDINGS: Although the majority of studies about psychotherapy approaches for eating disorders focus on adult women, there is a growing body of research on effective treatments for an adolescent population. Family-based treatment (the ‘Maudsley method’) and supportive psychotherapy appear to be promising approaches for anorexia in teens. Treatments for bulimia yield extremely high relapse rates, but cognitive-behavioral therapy and family-based treatment are favored modalities. Dialectical behavior therapy and interpersonal psychotherapy may also be applicable to adolescent bulimia and binge eating. Most psychotherapists draw upon a variety of these treatment approaches, depending upon the patient’s unique presentation. Regardless of the modality used, some degree of family involvement is important in limiting dropout and improving outcomes. SUMMARY: Adolescent health providers need to be aware of the psychotherapy approaches recommended for teens with eating disorders in order to effectively refer patients to and collaborate with mental health providers.

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Older people’s views of dignity and how it can be promoted in a hospital environment

Older people’s views of dignity and how it can be promoted in a hospital environment, Journal of Clinical Nursing, Volume 18 Issue 12, Pages 1784 – 1792


Authors: Carole Webster, BSc, MSc, Postgraduate Diploma (PGD) Gerontology, RN, Lead Nurse Practice Development, Ashford and St Peter’s Hospitals NHS Trust, Chertsey, Surrey, UK; Karen Bryan, BSc(Hons), PhD, Cert MRCSLT, Professor of Clinical Practice, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK



Aim. The study investigated the lived experiences of older patients who had been in hospital, to explore their views on dignity and the factors which promote dignity.

Background. The UK government’s new ambition for old age (New Ambition for Old Age: Next Steps in implementing the National Service Framework for Older People: A Report from Professor Ian Philip, DH) states that older people should be treated with dignity. The dignity in Care Campaign (‘Dignity in Care’Public Survey, October 2006: Report of the Survey, DH) highlighted the need to raise staff’s awareness and understanding of dignity.

Design. A purposive sample of older people took part in semi- structured interviews which focussed on their recent experiences of hospital admission. Qualitative data analysis was used.

Method. Ten participants aged 73–83 were interviewed by a nurse researcher at home. All of the participants had an unplanned admission and were discharged home.

Results. The participants although generally satisfied with their care had strong views on dignity. The following factors had the potential to promote dignity; privacy for the body, cleanliness, independence and being able to exert control, sufficient time from staff, attitudes to older people and communication.

Conclusions. This study suggests that independence and effective communication are of central importance in maintaining dignity through achieving control of their situation. The participants observed that factors such as speaking inappropriately and waiting for personal care undermined older people’s perceptions of dignity. Several participants feared for their own dignity should they have cognitive problems later in their lives.

Relevance to clinical practice. Staff need to be aware that communicating in a way that conveys empathy and responds to the individual as a valued person is an important factor in maintaining dignity. Nurses on hospital wards particularly need to take measures to safeguard the dignity of older people with cognitive problems who have difficulty in making their needs known.

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Brain Health – Exercise and cognition in older adults

Exercise and cognition in older adults: is there a role for resistance training programmes? British Journal of Sports Medicine, 2009 Jan;43(1):25-7

Liu-Ambrose T, Donaldson MG.

Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada


In recent years, there has been a strong interest in physical activity as a primary behavioural prevention strategy against cognitive decline. A number of large prospective cohort studies have highlighted the protective role of regular physical activity in lowering the risk of cognitive impairment and dementia. Most prospective intervention studies of exercise and cognition to date have focused on aerobic-based exercise training. These studies highlight that aerobic-based exercise training enhances both brain structure and function. However, it has been suggested that other types of exercise training, such as resistance training, may also benefit cognition. The purpose of this brief review is to examine the evidence regarding resistance training and cognitive benefits. Three recent randomised exercise trials involving resistance training among seniors provide evidence that resistance training may have cognitive benefits. Resistance training may prevent cognitive decline among seniors via mechanisms involving insulin-like growth factor I and homocysteine. A side benefit of resistance training, albeit a very important one, is its established role in reducing morbidity among seniors. Resistance training specifically moderates the development of sarcopenia. The multifactorial deleterious sequelae of sarcopenia include increased falls and fracture risk as well as physical disability. Thus, clinicians should consider encouraging their clients to undertake both aerobic-based exercise training and resistance training not only for “physical health” but also because of the almost certain benefits for “brain health”.

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Implications of evidence-based practice for mental health nursing

Implications of evidence-based practice for mental health nursing, International Journal of Mental Health Nursing, Volume 18 Issue 3, Pages 179 – 185

Jacklin E. Fisher 1 and Brenda Happell 2

  1 School of Nursing, Australian Catholic University, North Sydney, New South Wales and   2 Department of Health Innovation, and Institute for Health and Social Science Research, CQUniversity, Rockhampton, Queensland, Australia

Correspondence to  Brenda Happell, Department of Health Innovation, Faculty of Science, Engineering and Health, and Institute for Health and Social Science Research, CQUniversity Australia, Bruce Hwy, Rockhampton, Qld 4702, Australia. Email:

 Jacklin E. Fisher, RN, RPN, MA.

 Brenda Happell, RN, RPN, BA(Hons), BEd, Dip Ed, MEd, PhD.


The introduction of evidence-based practice (EBP) and the hierarchical approach to evidence it engenders within research and evaluation has aroused controversy in the mental health professions. The aim of this paper is to present a critique of EBP with a specific relationship to mental health nursing. It will be argued that in its current form, EBP presents a potential impediment to the facilitation of consumer participation in mental health services and to the recovery model. The need for the consumer voice and the importance of the lived experience of mental illness are not readily reconciled with a strong scientific paradigm that promotes detachment and objectivity. The importance of evidence in contemporary mental health care will also be acknowledged and discussed in light of the current climate of increased consumer knowledge, fiscal constraint, and extensive social criticism of mental health-care services. The current approach to EBP requires reconstruction to support the consumer-focused nature of mental health nursing, and to facilitate the implementation of a recovery model for mental health care.

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Music-assisted relaxation to improve sleep quality: meta-analysis

Music-assisted relaxation to improve sleep quality: meta-analysis, Journal of Advanced Nursing, Online early view, 2009

Gerrit de Niet 1 , Bea Tiemens 2 , Bert Lendemeijer 3 & Giel Hutschemaekers 4

  1 Gerrit de Niet MSc RN Psychiatric Nurse and Researcher Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands
  2 Bea Tiemens PhD Epidemiologist and Senior Researcher Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands
  3 Bert Lendemeijer PhD Senior Researcher Faculty of Health, Medicine and Life Sciences, University of Maastricht, The Netherlands
  4 Giel Hutschemaekers PhD Professor Department of Social Sciences, University of Nijmegen, and Director, Gelderse Roos Mental Health Care, Institute for Professionalization, Wolfheze, The Netherlands

Correspondence to G. de Niet:


Aim. This paper is a report of a meta-analysis conducted to evaluate the efficacy of music-assisted relaxation for sleep quality in adults and elders with sleep complaints with or without a co-morbid medical condition.

Background. Clinical studies have shown that music can influence treatment outcome in a positive and beneficial way. Music holds the promise of counteracting psychological presleep arousal and thus improving the preconditions for sleep.

Data sources. We conducted a search in the Embase (1997 – July 2008), Medline (1950 – July 2008), Cochrane (2000 – July 2008), Psychinfo (1987 – July 2008) and Cinahl (1982 – July 2008) databases for randomized controlled trials reported in English, German, French and Dutch. The outcome measure of interest was sleep quality.

Methods. Data were extracted from the included studies using predefined data fields. The researchers independently assessed the quality of the trials using the Delphi list. Only studies with a score of 5 points or higher were included. A pooled analysis was performed based on a fixed effect model.

Results. Five randomized controlled trials with six treatment conditions and a total of 170 participants in intervention groups and 138 controls met our inclusion criteria. Music-assisted relaxation had a moderate effect on the sleep quality of patients with sleep complaints (standardized mean difference, −0·74; 95% CI: −0·96, −0·46). Subgroup analysis revealed no statistically significant contribution of accompanying measures.

Conclusion. Music-assisted relaxation can be used without intensive investment in training and materials and is therefore cheap, easily available and can be used by nurses to promote music-assisted relaxation to improve sleep quality.

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Art psychotherapy & borderline personality disorder – A case study

Art psychotherapy in a consumer diagnosed with borderline personality disorder: A case study, International Journal of Mental Health Nursing, Volume 18 Issue 3, Pages 164 – 172

Scott Lamont, 1 Scott Brunero 2 and Dianne Sutton 3

  1 Mental Health Service and   2 Department of Liaison Mental Health Nursing, Prince of Wales Hospital, and   3 University of Western Sydney, Sydney, New South Wales, Australia

Correspondence to  Scott Lamont, Prince of Wales Hospital, Edmund Blackett Building, Nurse Education and Research Unit, Room 7, High Street, Randwick, NSW 2031, Australia. Email:

 Scott Lamont, RN, RMN.

 Scott Brunero, RN, Dip AppSc BHSc, MNsg (Nurs Prac).

 Dianne Sutton, BA (History), Dip Prim Ed, Dip Visual Arts (Ceramics).


This case study reviews 11 sessions of art psychotherapy with a consumer diagnosed with having borderline personality disorder. A consumer who reported difficulty in communicating her lived trauma verbally and engaged in self-harming behaviour was offered individual art therapy sessions following a consultation between an art therapy student and clinical nurse consultant in an attempt to understand her experiences and to collaboratively engage her. Notes were taken after each session by the art therapy student, reflecting conversations with this consumer while they were engaged in art making, which were subsequently explored within formal clinical supervision sessions with a mental health nurse consultant. An art portfolio is reproduced. It illustrates the expressive power of image creation. The key features of the images were that of lived trauma, the externalization of thoughts and feelings, and intense emotional expression. The results of this chronological art portfolio case study indicated therapeutic benefits from the intervention for this consumer. Further investigations of this type of intervention are warranted within the mental health setting.

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Antipsychotics • Meta-analysis • Schizophrenia

Augmentation of clozapine with a second antipsychotic – a meta-analysis of randomized, placebo-controlled studies,  Acta Psychiatrica Scandinavica, Volume 119 Issue 6, Pages 419 – 425

D. M. Taylor 1,2 , L. Smith 3

  1 Pharmacy Department, South London and Maudsley NHS Foundation Trust ,   2 Pharmaceutical Sciences Division, King’s College, London and   3 Medical Research Matters, Eynsham, Oxford, UK

Correspondence to David M Taylor, Pharmacy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, UK.


Inadequate response to clozapine treatment is frequently encountered in practice and augmentation strategies have been developed in an attempt to improve response. Aims of the study were to evaluate the therapeutic effect of adding an antipsychotic drug to clozapine treatment.

Method: Meta-analysis of randomized, placebo-controlled studies of antipsychotic augmentation of clozapine treatment.

Results: Ten studies (including 522 subjects) met inclusion criteria. Antipsychotic augmentation showed significant benefit over the addition of placebo on only one outcome measure examined [mean effect size for rating scale score (BPRS/PANSS) −0.180, 95% CI −0.356 to −0.004]. Antipsychotic augmentation showed no advantage on withdrawals from trials (risk ratio 1.261, 95% CI 0.679–2.345) or on CGI scores (effect size −0.661, 95% CI −1.475 to 0.151). Duration of study was not associated with outcome (P = 0.95). There was no evidence of publication bias.

Conclusion: In studies lasting up to 16 weeks, the addition of an antipsychotic to clozapine treatment has marginal therapeutic benefit. Longer and larger trials are necessary to demonstrate the precise therapeutic utility of antipsychotic co-therapy with clozapine.

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DBT for Women with BPD – Study

A 5-Day Dialectical Behavior Therapy Partial Hospital Program for Women With Borderline Personality Disorder: Predictors of Outcome from a 3-Month Follow-up Study.Journal of Psychiatric Practice. 15(3):173-182, May 2009.

Yen, Shirley PhD *; Johnson, Jennifer PhD *; Costello, Ellen PhD +; Simpson, Elizabeth B. MD


Objective: This study describes naturalistic 3-month follow-up after discharge from a 5-day partial hospitalization dialectical behavior therapy (DBT) program for women diagnosed with borderline personality disorder (BPD). We also examined individual BPD criteria as predictors of treatment response.

Methods: Fifty women diagnosed with BPD were consecutively recruited from a partial hospital DBT program, 47 of whom (94%) completed all assessments including baseline (prior to discharge) and 3-months post-discharge assessments. Most continued with some combination of individual psychotherapy and pharmacotherapy, and all had the option of continuing with weekly DBT skills classes. Baseline scores were compared to 3-month scores using paired two-tailed non-parametric (sign) tests. Regression analyses were conducted to identify predictors of outcome.

Results: Depression, hopelessness, anger expression, dissociation, and general psychopathology scores significantly decreased over the 3-month follow-up interval, although scores on several measures remained in the clinical range. Those who endorsed emptiness, impulsivity, and relationship disturbance demonstrated improvement on a number of outcomes, while those who endorsed identity disturbance and fear of abandonment had less improvement on some outcomes.

Conclusion: These findings illustrate (1) that improvement occurred over a 3-month interval on a number of measures in patients receiving treatment as usual following discharge from a partial hospitalization program, and (2) that BPD is a complex, heterogeneous disorder for which there is no single pathognomonic criterion, so that each criterion should be considered individually in determining its potential effect on treatment outcomes.

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Mindfulness and emotion regulation difficulties in GAD

Mindfulness and emotion regulation difficulties in generalized anxiety disorder: preliminary evidence for independent and overlapping contributions, Behaviour Therapy, 2009 Jun;40(2):142-54

Roemer L, Lee JK, Salters-Pedneault K, Erisman SM, Orsillo SM, Mennin DS


Diminished levels of mindfulness (awareness and acceptance/nonjudgment) and difficulties in emotion regulation have both been proposed to play a role in symptoms of generalized anxiety disorder (GAD); the current studies investigated these relationships in nonclinical and clinical samples. In the first study, among a sample of 395 individuals at an urban commuter campus, self-reports of both emotion regulation difficulties and aspects of mindfulness accounted for unique variance in GAD symptom severity, above and beyond variance shared with depressive and anxious symptoms, as well as variance shared with one another. In the second study, individuals with GAD (n=16) reported significantly lower levels of mindfulness and significantly higher levels of difficulties in emotion regulation than individuals in a nonanxious control group (n=16). Results are discussed in terms of directions for future research and potential implications for treatment development.

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Anorexia Nervosa and Pregnancy – Case Report and proposed treatment

Anorexia nervosa and pregnancy: Having a baby when you are dying to be thin – Case report and proposed treatment guidelines , International Journal of Eating Disorders, Volume 42 Issue 4, Pages 382 – 384

Carrie Mazer-Poline, DO, Victor Fornari, MD


Pregnant women with anorexia nervosa (AN) are at risk for multiple complications to both the woman and fetus. This report examines when to obtain a psychiatric evaluation or admission to an inpatient psychiatric unit to ensure the safety of both the woman and fetus.
A case report of a pregnant woman with AN describes the risks of extreme weight loss during pregnancy and the deleterious effects on the fetus’s viability and mother’s health.
Psychiatric intervention was not requested until late in gestation, when the patient’s mental status and low weight had already deteriorated to a point of high risk to both the mother and fetus.
We propose the development of treatment guidelines for the pregnant patient with AN to ensure the delivery of optimal care for both the mother and the fetus

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Training graduate PC mental health workers to work with people diagnosis of personality disorder

Training graduate primary care mental health workers to work with people with a diagnosis of personality disorder,   The Journal of Mental Health Training, Education and Practice,  Volume 4, Number 1 / March 2009

Catherine Woodward1, Alan Jones2, Tasim Martin3

1Camden and Islington NHS Foundation Trust, University of East London
2Camden and Islington NHS Foundation Trust, Oscar Hill Service
3 Glasgow Caledonian University


It is recognised that training is required for staff working with people with a diagnosis of personality disorder, as it poses challenges requiring particular skills and abilities (National Institute for Mental Health in England, 2003a). The proposal to train graduate primary care mental health workers (GPCMHWs) to work with the client group met with some scepticism by senior clinicians. However, the experience of providing training and supervision to the graduate primary care mental health workers to work with clients with personality disorder in Camden and Islington has proved positive. Several characteristics of the GPCMHWs identified in the training literature might contribute to this positive experience. Those factors include cognitive ability, motivation to learn, age, and attitudes. Initial findings from the evaluation of the training shows that graduate workers respond positively to the training, showing improvements in self-rated knowledge and skills relating to working with the client group, and an eagerness to learn more. The relevance of this to the personality disorder capabilities framework are described.

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Schema-focused approach to group psychotherapy – BPD – RCT

A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial, Journal of Behavior Therapy and Experimental Psychiatry, Vol. 40, ( 2), June 2009, Pages 317-32

Joan M. Farrell, Ida A. Shaw and Michael A. Webber


This study tests the effectiveness of adding an eight-month, thirty-session schema-focused therapy (SFT) group to treatment-as-usual (TAU) individual previous termpsychotherapynext term for borderline personality disorder (BPD). Patients (N = 32) were randomly assigned to SFT-TAU and TAU alone. Dropout was 0% SFT, 25% TAU. Significant reductions in BPD symptoms and global severity of psychiatric symptoms, and improved global functioning with large treatment effect sizes were found in the SFT-TAU group. At the end of treatment, 94% of SFT-TAU compared to 16% of TAU no longer met BPD diagnosis criteria (p < .001). This study supports group SFT as an effective treatment for BPD that leads to recovery and improved overall functioning.

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Randomized Controlled Pilot Study – CBT – SUD – PTSD – Women

Randomized Controlled Pilot Study of Cognitive-Behavioral Therapy in a Sample of Incarcerated Women With Substance Use Disorder and PTSD, Behavior Therapy, Online early view, 2009

Caron Zlotnick, Jennifer Johnson and Lisa M. Najavits


This randomized controlled pilot study compared a cognitive-behavioral therapy (Seeking Safety; SS) plus treatment-as-usual (TAU) to TAU-alone in 49 incarcerated women with substance use disorder (SUD) and posttraumatic stress disorder (PTSD; full or subthreshold). Seeking Safety consisted of a voluntary group treatment during incarceration and individual treatment after prison release. TAU was required in the prison and comprised 180 to 240 hours of individual and group treatment over 6 to 8 weeks. Assessments occurred at intake, 12 weeks after intake, and 3 and 6 months after release from prison. There were no significant differences between conditions on all key domains (PTSD, SUD, psychopathology, and legal problems); but both conditions showed significant improvements from intake to later time points on all of these outcomes across time. Secondary analyses at follow-up found trends for SS participants improving on clinician-rated PTSD symptoms and TAU participants worsening on self-reported PTSD symptoms. Also, SS demonstrated continued improvement on psychopathology at 3 and 6 months, whereas TAU did not. However, alcohol use improved more for TAU during follow-up. Satisfaction with SS was high, and a greater number of SS sessions was associated with greater improvement on PTSD and drug use. Six months after release from prison, 53% of the women in both conditions reported a remission in PTSD. Study limitations include lack of assessment of SS outcomes at end of group treatment; lack of blind assessment; omission of the SS case management component; and possible contamination between the two conditions. The complex needs of this population are discussed.

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Beck Depression Inventory for depression screening in substance-abusing adolescents

Beck Depression Inventory for depression screening in substance-abusing adolescents, Journal of Substance Abuse Treatment, Online early view, 2009

 Geetha Subramaniam M.D.   Harrell M.A , Edward Huntley M.A. and Melinda Tracy M.S.W.

Department of Psychiatry, Johns Hopkins University, Baltimore, MD 21287, USA

Department of Psychology, American University, Washington, DC 20016, USA



Co-occurring major depressive disorder (MDD) in adolescents with substance use disorders (SUD) has been linked to poor treatment outcomes. Use of validated depression screens in adolescent SUD populations may improve the detection of depression. In this study, we evaluated the diagnostic efficiency of the Beck Depression Inventory (BDI) in detecting MDD, as assessed by psychiatrists administering the Diagnostic Interview for Children and Adolescents, and its factor structure, internal consistency, and discriminant validity in a clinical sample of adolescents with SUD (n = 145). Results indicate that BDI scores of 12 and higher had the most optimal sensitivity (73%), whereas BDI scores of 17 and higher, the most optimal specificity (75%). Five factors accounted for approximately 56% of the variance. Overall, internal consistency was high, and the BDI adequately discriminated MDD from non-MDD cases. Results support the use of BDI as a screen for MDD with moderate to high psychometric properties in an adolescent SUD sample.

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How to handle anxiety – CBT & ACT – Emotion regulation

How to handle anxiety: The effects of reappraisal, acceptance, and suppression strategies on anxious arousal, Behaviour Research and Therapy, Volume 47, Issue 5, May 2009, Pages 389-394


It has been suggested that reappraisal strategies are more effective than suppression strategies for regulating emotions. Recently, proponents of the acceptance-based behavior therapy movement have further emphasized the importance of acceptance-based emotion regulation techniques. In order to directly compare these different emotion regulation strategies, 202 volunteers were asked to give an impromptu speech in front of a video camera. Participants were randomly assigned to one of three groups. The Reappraisal group was instructed to regulate their anxious arousal by reappraising the situation; the Suppression group was asked to suppress their anxious behaviors; and the Acceptance group was instructed to accept their anxiety. As expected, the Suppression group showed a greater increase in heart rate from baseline than the Reappraisal and Acceptance groups. Moreover, the Suppression group reported more anxiety than the Reappraisal group. However, the Acceptance and Suppression groups did not differ in their subjective anxiety response. These results suggest that both reappraising and accepting anxiety is more effective for moderating the physiological arousal than suppressing anxiety. However, reappraising is more effective for moderating the subjective feeling of anxiety than attempts to suppress or accept it.

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National Social Inclusion Programme Website

National Social Inclusion Programme Website

Click on the title above to access this website

This site is hosted by the Inclusion Institute at the International School for Communities, Rights and Inclusion at the University of Central Lancashire. It is currently being developed to allow for continuing access to the resources and materials produced by NSIP as updated by the work of the Inclusion Institute and its partners.

Community Development & Social Inclusion

In the driving seat: community development and social inclusion, A life in the day, Volume 13, Number 1 / February 2009

Patience Seebohm1, Alison Gilchrist2, David Morris3

1 Mental Health, Community Development
2 Community Development Foundation
3National Social Inclusion Programme (NSIP), National Institute for Mental Health, England


It is obvious to many, but unproven to others, that community development has a positive impact on the mental health and well-being of those who are touched by it. In our recent study, Connect and Include (Seebohm & Gilchrist, 2008), we found strong evidence that individuals, groups and communities can benefit from the community development process. Positive outcomes included greater democracy and social justice, but in this article we focus on the contribution of community development to social inclusion and the benefits to mental health.

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Doing What Works – Social Inclusion and Employment

Doing What Works: Individual Placement and Support into Employment,   Sainsbury’s Centre for Mental Health, February 2009

Click on the report title to gain direct full-text access


People who experience severe and enduring mental health problems have one of the lowest employment rates in the UK. Yet the vast majority want to work, and with the right support many people can.

Large numbers of people have and can be supported to get and keep paid competitive employment through Individual Placement and Support (IPS).

Individual Placement and Support has seven key principles, each of which is needed for the service to work well. They include focusing on paid employment of an individual’s choice, and support that continues once the person gets a job.

This briefing outlines the evidence base for IPS and provides information on how to ‘do what works’.

A decade of stigma and discrimination in mental health – Lancashire

A decade of stigma and discrimination in mental health: plus ça change, plus c’est la même chose (the more things change, the more they stay the same, Journal of Psychiatric and Mental Health Nursing,  Online early view, 2009

C. LYONS 1 phd msc pg cert rnt dpsn rmn teacher’s cert, P. HOPLEY 2 msc bsc rmn & J. HORROCKS 3 rmn rgn bsc (hons) in nursing studies pg cert

 1 Senior Research Fellow, School of Nursing and Caring Sciences, Faculty of Health, University of Central Lancashire, Preston,  2 Mental Health Programme Manager for Lancashire, and  3 Director of Mental Health Strategic Development for Lancashire, Lancashire Mental Health and Social Care Partnership Team, NHS East Lancashire, Nelson, Lancashire, UK
Correspondence to C. Lyons
School of Nursing and Caring Sciences
Faculty of Health
University of Central Lancashire
Victoria Street
Preston PR1 2HE


In recent years, efforts to combat stigma and discrimination experienced by mental health service users have ranged from small local initiatives to national and international campaigns. Success has been mixed, with significant, lasting benefits appearing to be elusive. This paper explores the current nature and extent of stigma and discrimination in an area of the north of England and compares findings with those from a study undertaken a decade previously in 1997. Qualitative responses to a postal questionnaire received in 2007 were thematically analysed and compared and contrasted with findings from the 1997 study. Four broad categories of discrimination – (1) employment; (2) professional; (3) communities; and (4) family and friends – arose from the 2007 data, the most common being discrimination in employment. There were close similarities in both sets of data. Stigma and discrimination remain largely as strong, damaging and enduring as they were a decade ago. A range of pre-emptive interventions that support people prior to the escalation of mental health crises could limit the impact of stigma.

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VIRTEx Project – Community-based care to increase social activity, inclusion and support

VIRTEx project aims to promote long term health and improve social care , British Journal of Community Nursing, Vol. 14, Iss. 3, 06 Mar 2009, pp 114 – 115

Steve Sadler


Funded by the Technology Strategy Board’s Assisted Living Innovation Platform, the VIRTEx project aims to develop the potential of telehealthcare to provide community-based care and increased social activity, inclusion and support for the growing number of people with long-term needs.

A partnership between Tunstall, Fold Housing Association, Housing 21, DigiTV and the University of Sheffield will deliver an innovative research project to develop a Virtual Extra Care Service (VIRTEx) within local communities.

The aim of the VIRTEx project is to build a virtual community of connected patients and carers, to deliver flexible community-based care, preserve social inclusion and maintain a healthier lifestyle and independent living by encouraging change in behaviour.

  • ‘Using virtual extra care will allow people who live alone who might otherwise have felt isolated or lonely, the chance to experience what residents in extra care schemes enjoy—the increased levels of social activity and support’

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Housing services for people with mental disorders in England: patient characteristics, care provision and costs

Housing services for people with mental disorders in England: patient characteristics, care provision and costs, Social Psychiatry and Psychiatric Epidemiology, Online early view, 2009

Priebe S, Saidi M, Want A, Mangalore R,  Knapp M.

Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK


BACKGROUND AND AIMS: Since de-institutionalisation, housing services have taken a central role in the care of patients with severe mental illness. Yet, little is known about the characteristics of patients in different housing services, what care they receive, and what costs are generated. This study aimed to assess patient characteristics, care provision and costs in different types of housing services in England. METHODS: In 12 representative local areas in England, 250 housing services were randomly selected. Information on services, characteristics of randomly selected patients and care received were obtained from managers. RESULTS: Data from 153 services (61% response rate) and 414 patients were analysed. Most patients receive support with activities of daily living and are involved in some sort of occupational activities. 52% have a care co-ordinator in a community mental health team. Care provision and costs differed significantly between care homes, supported housing services and floating support services. CONCLUSIONS: Quality standards may have to be defined and applied to ensure that all patients in housing services receive appropriate care. More input of mental health services may be required for the rehabilitation and recovery of patients.

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Service users’ perceptions of the effective ingredients in supported employment

Service users’ perceptions of the effective ingredients in supported employment, Journal of Mental Health, Volume 18, Issue 2 April 2009 , pages 121 – 128


Authors: Robyn Lauren Johnson – Work was based at: City University, 24 Chiswell Street, London EC1Y 4TY.a;  Mike Floyd a;  Doria Pilling a;  Melanie Jane Boyce b;  Bob Grove c;  Jenny Secker d;  Justine Schneider e; Jan Slade f


Affiliations:   a City University, London
  b Institute of Health & Social Care, Anglia Ruskin University,
  c Sainsbury Centre for Mental Health,
  d South Essex Partnership NHS Trust and Anglia Ruskin University,
  e University of Nottingham and Nottinghamshire Healthcare Trust,
  f Durham University, Durham, UK



Background: The UK government is advocating the use of supported employment to help people on incapacity benefits back to work, with an emphasis on Individual Placement and Support (IPS) models. However there is little UK-based evidence on the key ingredients of effective support.

Aim: To ascertain service users’ views of what they found helpful about supported employment.

Method: Interviews were carried out with 182 people with severe and enduring mental health problems who were actively engaged with one of the six supported employment agencies included in the study.

Results: Three themes emerged: emotional support, practical assistance and a client-centred approach.

Conclusion: The findings highlight the importance of the quality of support, particularly through interpersonal dynamics, which go beyond the organizational features emphasized in the IPS model.

Declaration of interest: The study was financed from Higher Education European Social Fund Objective 3 resources and the six partner agencies made contributions in kind.


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Evaluating socially inclusive practice: Part two – findings from a mental health team

Evaluating socially inclusive practice: part two – findings from a mental health team, The Journal of Mental Health Training, Education and Practice, Volume 3, Number 4 / December 2008

Clio Berry1, Mark Hayward2, Andy Porter3

1 Sussex Partnership NHS Foundation Trust
2Sussex Partnership NHS Foundation Trust, Department of Psychology, Surrey University
3 Social Inclusion, Sussex Partnership NHS Foundation Trust


A tool was created to evaluate the socially inclusive practice of mental health teams. The tool was based on the 2007 Department of Health best practice guide for the workforce, Capabilities for Inclusive Practice (CfIP), itself based on The 10 Essential Shared Capabilities (Hope, 2004). The tool comprised three parts, a team questionnaire, a service user questionnaire, and a Care Programme Approach (CPA) care plan documentation analysis (see previous paper on pp31-41). This paper focuses on piloting the tool with mental health teams within Sussex Partnership NHS Foundation Trust as a means of showcasing the evaluation tool. Detailed findings are reported from one assertive outreach team (AOT). The findings suggest that although the team professed limited knowledge of CfIP, they endorsed all capabilities in their practice, although a low response rate limits the extent to which the current findings are generalisable. The triangulation of data provided by the tool facilitates an exploration of the variance of capabilities across team, service user, and care planning perspectives, meaning that specific areas for the improvement of the delivery of inclusive practice can be easily identified.

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Evaluating socially inclusive practice: Part one – a tool for mental health services

Evaluating socially inclusive practice: part one – a tool for mental health services, The Journal of Mental Health Training, Education and Practice, Volume 3, Number 4 / December 2008

Clio Berry1, Mark Hayward2, Andy Porter3

1 Sussex Partnership NHS Foundation Trust
2Sussex Partnership NHS Foundation Trust, Department of Psychology, Surrey University
3 Social Inclusion, Sussex Partnership NHS Foundation Trust


This paper gives an overview of the development and pilot implementation of a tool to evaluate socially inclusive practice. There are strong links between social inclusion and better mental health outcomes for people who access services, yet a very limited amount of research exists concerning ways to evaluate socially inclusive practice within mental health services. The paper describes the creation of a tripartite tool to access the views of mental health teams who work with service users, and the service users themselves. As part of the movement towards recovery and social inclusion, the Department of Health requires that social and occupational needs become embedded in care plans alongside health needs (DoH, 1999), and so an analysis of care plan documentation completed the evaluation tool. A pilot evaluation was conducted with three mental health teams in Sussex and found issues with engagement and response rate. Lessons learned and future implications are discussed.

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