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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