Frederick Sundram

Intensity, Duration, and Location of High-Definition Transcranial Direct Current Stimulation for Tinnitus Relief.

Background and Objective. Tinnitus is the perception of a phantom sound. The aim of this study was to compare current intensity (center anode 1 mA and 2 mA), duration (10 minutes and 20 minutes), and location (left temporoparietal area [LTA] and dorsolateral prefrontal cortex [DLPFC]) using 4 × 1 high-definition transcranial direct current stimulation (HD-tDCS) for tinnitus reduction. Methods. Twenty-seven participants with chronic tinnitus (>2 years) and mean age of 53.5 years underwent 2 sessions of HD-tDCS of the LTA and DLPFC in a randomized order with a 1 week gap between site of stimulation. During each session, a combination of 4 different settings were used in increasing dose (1 mA, 10 minutes; 1 mA, 20 minutes; 2 mA, 10 minutes; and 2 mA, 20 minutes). The impact of different settings on tinnitus loudness and annoyance was documented. Results. Twenty-one participants (77.78%) reported a minimum of 1 point reduction on tinnitus loudness or annoyance scales. There were significant changes in loudness and annoyance for duration of stimulation, F(1, 26) = 10.08, P < .005, and current intensity, F(1, 26) = 14.24, P = .001. There was no interaction between the location, intensity, and duration of stimulation. Higher intensity (2 mA) and longer duration (20 minutes) of stimulation were more effective. Conclusions. A current intensity of 2 mA for 20-minute duration was the most effective setting used for tinnitus relief. The stimulation of the LTA and DLPFC were equally effective for suppressing tinnitus loudness and annoyance.

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy

OBJECTIVES Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs. METHODS A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs. RESULTS Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p<0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression. CONCLUSIONS Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.

Medical examiner and coroner reports: uses and limitations in the epidemiology and prevention of late-life suicide

Late‐life suicide is a growing public health concern in many parts of the world. Understanding the contributory factors to completed suicide is essential to inform the development of effective suicide risk assessment and management. The aim of this study is to synthesise the findings in studies that used coroner or medical examiner records to determine these contributory factors.

Tips and Traps: Lessons From Codesigning a Clinician E-Monitoring Tool for Computerized Cognitive Behavioral Therapy

Background Computerized cognitive behavioral therapy (cCBT) is an acceptable and promising treatment modality for adolescents with mild-to-moderate depression. Many cCBT programs are standalone packages with no way for clinicians to monitor progress or outcomes. We sought to develop an electronic monitoring (e-monitoring) tool in consultation with clinicians and adolescents to allow clinicians to monitor mood, risk, and treatment adherence of adolescents completing a cCBT program called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts). Objective The objectives of our study were as follows: (1) assess clinicians’ and adolescents’ views on using an e-monitoring tool and to use this information to help shape the development of the tool and (2) assess clinician experiences with a fully developed version of the tool that was implemented in their clinical service. Methods A descriptive qualitative study using semistructured focus groups was conducted in New Zealand. In total, 7 focus groups included clinicians (n=50) who worked in primary care, and 3 separate groups included adolescents (n=29). Clinicians were general practitioners (GPs), school guidance counselors, clinical psychologists, youth workers, and nurses. Adolescents were recruited from health services and a high school. Focus groups were run to enable feedback at 3 phases that corresponded to the consultation, development, and postimplementation stages. Thematic analysis was applied to transcribed responses. Results Focus groups during the consultation and development phases revealed the need for a simple e-monitoring registration process with guides for end users. Common concerns were raised in relation to clinical burden, monitoring risk (and effects on the therapeutic relationship), alongside confidentiality or privacy and technical considerations. Adolescents did not want to use their social media login credentials for e-monitoring, as they valued their privacy. However, adolescents did want information on seeking help and personalized monitoring and communication arrangements. Postimplementation, clinicians who had used the tool in practice revealed no adverse impact on the therapeutic relationship, and adolescents were not concerned about being e-monitored. Clinicians did need additional time to monitor adolescents, and the e-monitoring tool was used in a different way than was originally anticipated. Also, it was suggested that the registration process could be further streamlined and integrated with existing clinical data management systems, and the use of clinician alerts could be expanded beyond the scope of simply flagging adolescents of concern. Conclusions An e-monitoring tool was developed in consultation with clinicians and adolescents. However, the study revealed the complexity of implementing the tool in clinical practice. Of salience were privacy, parallel monitoring systems, integration with existing electronic medical record systems, customization of the e-monitor, and preagreed monitoring arrangements between clinicians and adolescents.

Death wishes among older people assessed for home support and long-term aged residential care

Death wishes in older people are common and may progress to suicidal ideation and attempts. This study used routinely collected data from the interRAI Home Care assessment to examine the prevalence and clinical predictors of death wishes in older New Zealanders assessed for home support and long‐term aged residential care.

Social anxiety apps: a systematic review and assessment of app descriptors across mobile store platforms

Question The aim of this systematic review is twofold: (1) to characterise the purpose and description of available social anxiety apps and (2) to review the evidence on the effectiveness of social anxiety apps. Study selection and analysis A search was conducted on three major mobile platforms: Apple iTunes, Google Play and Windows Store. Apps were included if they addressed social anxiety and used an English language interface. A systematic review of the literature from MEDLINE, EMBASE, PsycINFO, Cochrane, Scopus and Web of Science to identify evidence-based evaluations of social anxiety apps was also undertaken. Findings Of the 1154 apps identified, 38 apps met the inclusion criteria: iTunes (n=18), Google Play (n=16) and Windows Store (n=4). Over 60% of apps were exclusively focused on social anxiety, while the remainder targeted social anxiety and related conditions. Most developers did not provide information on their organisational affiliations or their content source. Most apps used multimedia while 17 apps used text only. Finally, although the systematic review of the literature identified 94 articles, none of which met inclusion criteria. Conclusions Social anxiety apps have the potential to overcome barriers to accessing treatment; however, none of the apps identified have had studies on their effectiveness published. As the evidence base is lacking, it is therefore not currently possible to recommend their use.

Understanding the Progression from Physical Illness to Suicidal Behavior: A Case Study Based on a Newly Developed Conceptual Model

ABSTRACT Suicide in older people is a significant public health issue given the aging population and increasing suicide rates with age in many parts of the world. Depression and physical illness are two factors consistently associated with suicidal behavior in older people; however, their inter-relationships are not well understood. We present here a case study based on a newly developed conceptual model illustrating the various medical, psychological, social and resilience factors involved in the progression of physical illness to suicidal behavior. This model provides a framework for clinicians to understand protective factors and address late-life suicide risk.

Visualizing psychiatric formulation

Objective: Despite the importance of psychiatric formulation, it remains one of the most challenging tasks for medical students and trainees. To facilitate teaching and learning this essential skill, we propose a visual metaphor in order to conceptualise psychiatric formulation. Conclusions: It is expected that this paper will assist educators and learners to better conceptualise psychiatric formulation through activating prior knowledge through this visual metaphor. Future educational research will determine the effectiveness of this proposed learning tool.

The resource utilisation of medically unexplained physical symptoms

Objectives: As patients with medically unexplained physical symptoms may present frequently to hospital settings and receive potentially unnecessary investigations and treatments, we aimed to assess the frequency and type of medically unexplained physical symptoms presentations to clinical services and estimate the associated direct healthcare costs. Methods: This study was undertaken at the largest district health board in New Zealand. All patients with a diagnosed presentation of medically unexplained physical symptoms in 2013 were identified using the district health board’s clinical coding system. The clinical records (medical and psychiatric) of 49 patients were examined in detail to extricate all medically unexplained physical symptoms–related secondary care activity within 6 months before or after their medically unexplained physical symptoms presentation. Standardised national costing methodology was used to calculate the associated healthcare costs. Results: In all, 49% of patients attended hospital settings at least twice during 2013. The majority of presentations were for neurological or respiratory concerns. The total cost for the sample was GBP89,636 (median: GBP1,221). Costs were most significant in the areas of inpatient admissions and emergency care. Conclusion: Medically unexplained physical symptoms result in frequent presentations to hospital settings. The costs incurred are substantial and comparable to the costs of chronic medical conditions with identifiable pathology. Improving recognition and management of medically unexplained physical symptoms has potential to offer more appropriate and cost-effective healthcare outcomes.

A brief treatment for fear of heights: A randomized controlled trial of a novel imaginal intervention

Objective To assess the effectiveness of a novel imaginal intervention for people with acrophobia. Methods The design was a randomized controlled trial with concealed randomization and blinded to other participants’ intervention. The intervention was a single novel imaginal intervention session or a 15-min meditation. The setting was in Auckland, New Zealand. The participants were a convenience sample of the public with a score >29 on the Heights Interpretation Questionnaire (HIQ), a questionnaire validated against actual height exposure. The primary outcomes were the proportion of participants with a score <26 on the HIQ at eight weeks and difference between the HIQ scores between the two arms of the study. Results Ninety-eight participants (92%) returned their questionnaire and were included in the intention to treat analysis. The HIQ score <26 was 34.6% (18/52) in the intervention group and 15.2% (7/46) in the control group RR = 2.26, 95% CI (1.05, 4.95) and p = 0.028. The numbers needed to treat is six 95% CI (3 to 36). Participants with scores <26 report their fear of heights is very much improved. There was a 4.5-point difference in the HIQ score at eight weeks (p = 0.055) on the multiple regression analysis. Conclusions This is the first randomized trial of this novel imaginal intervention which is probably effective, brief, easily learnt, and safe. It may be worth considering doing this prior to some of the longer or more expensive exposure therapies. This study will be of interest to family doctors, psychiatrists, and psychologists.