Lisa Forsberg

An evaluation of a brief motivational interviewing training course for HIV/AIDS counsellors in Western Cape Province, South Africa

Abstract HIV/AIDS counselling in South Africa covers a range of areas of prevention and treatment with a commonly used model of lay counsellors trained by non-governmental organisations and working alongside professionals in public health settings. This study presents a single group evaluation of a six-session (12-hour) course of Motivational Interviewing (MI) delivered to 17 HIV/AIDS lay counsellors working in peri-urban settings in Western Cape Province, South Africa. Counsellors reported that they used MI techniques both at the start and at the end of the training. In addition, they reported confidence in their ability to influence their clients’ motivation at both time points. The results from the ratings of role play performance showed that there was a marked change in emphasis over the group of counsellors from MI non-adherent practice before training (with advice giving, directiveness, control and confrontation) to more MI adherent practice (asking permission before giving advice, emphasising client autonomy, affirming the client and stressing the clients responsibility to change) at the end of the training. Only a small proportion of the counsellors reached the level of beginning proficiency (according to the Motivational Interviewing Treatment Integrity code) on the measure of the ratio of MI adherent to non-adherent responses. The ratio of reflections to questions and the percentage of open questions also showed improvements in performance across the group but generally to levels below that suggesting beginning proficiency in MI. There was no evidence of any change on global therapist ratings (of empathy and the spirit of MI, i.e. collaboration, evocation and autonomy support) or the percentage of complex reflections across the group of counsellors. Possible explanations for the results and public health implications are discussed.

Motivational Interviewing in an ordinary clinical setting: A controlled clinical trial at the Swedish National Tobacco Quitline

INTRODUCTION The present study aimed to assess the effect of adding motivational interviewing (MI) to the first session of an effective smoking cessation treatment protocol in an ordinary clinical setting: the Swedish National Tobacco Quitline (SNTQ). METHOD The study was designed as a controlled clinical trial. Between September 2005 and October 2006, 772 clients accepted the invitation to participate in the study and were semi-randomised to either standard treatment (ST) or MI. The primary outcome measures were self-reported 7-day point prevalence abstinence and 6-month continuous abstinence. RESULTS At 12-month follow-up, the 772 clients were included in an intention to treat analysis. Of the clients allocated to MI, 57/296 (19%) reported 6-month continuous abstinence compared to 66/476 (14%) of the clients allocated to ST (OR 1.48, 95% CI 1.00-2.19; P=.047). CONCLUSIONS Integrating MI into a cognitive behavioural therapy-based smoking cessation counselling in an ordinary clinical setting at a tobacco quitline increased client 6-month continuous abstinence rates by 5%.

Neonatal Adaptation in Infants Prenatally Exposed to Antidepressants- Clinical Monitoring Using Neonatal Abstinence Score

Background Intrauterine exposure to antidepressants may lead to neonatal symptoms from the central nervous system, respiratory system and gastrointestinal system. Finnegan score (Neonatal Abstinence Score, NAS) has routinely been used to assess infants exposed to antidepressants in utero. Aim The purpose was to study neonatal maladaptation syndrome in infants exposed to selective serotonin reuptake inhibitors (SSRI) or serotonin-norepinephrine reuptake inhibitors (SNRI) in utero. Method Retrospective cohort study of women using antidepressants during pregnancy and their infants. Patients were identified from the electronic health record system at Karolinska University Hospital Huddinge containing pre-, peri- and postnatal information. Information was collected on maternal and infant health, social factors and pregnancy. NAS sheets were scrutinized. Results 220 women with reported 3rd trimester exposure to SSRIs or SNRIs and who gave birth between January 2007 and June 2009 were included. Seventy seven women (35%) used citalopram, 76 used (35%) sertraline, 34 (15%) fluoxetine and 33 (15%) other SSRI/SNRI. Twenty-nine infants (13%) were admitted to the neonatal ward, 19 were born prematurely. NAS was analyzed in 205 patients. Severe abstinence was defined as eight points or higher on at least two occasions (on a scale with maximum 40 points), mild abstinence as 4 points or higher on at least two occasions. Seven infants expressed signs of severe abstinence and 46 (22%) had mild abstinence symptoms. Hypoglycemia (plasma glucose <2.6 mmol/L) was found in 42 infants (19%). Conclusion Severe abstinence in infants prenatally exposed to antidepressants was found to be rare (3%) in this study population, a slightly lower prevalence than reported in previous studies. Neonatal hypoglycemia in infants prenatally exposed to antidepressant may however be more common than previously described.

How to Measure Motivational Interviewing Fidelity in Randomized Controlled Trials: Practical Recommendations

Many randomized controlled trials in which motivational interviewing (MI) is a key intervention make no provision for the assessment of treatment fidelity. This methodological shortcoming makes it impossible to distinguish between high- and low-quality MI interventions, and, consequently, to know whether MI provision has contributed to any intervention effects. This article makes some practical recommendations for the collection, selection, coding and reporting of MI fidelity data, as measured using the Motivational Interviewing Treatment Integrity Code. We hope that researchers will consider these recommendations and include MI fidelity measures in future studies.

Neonatal Morbidity After Maternal Use of Antidepressant Drugs During Pregnancy.

OBJECTIVES: To estimate the rate of admissions to NICUs, as well as infants’ morbidity and neonatal interventions, after exposure to antidepressant drugs in utero. METHODS: Data on pregnancies, deliveries, prescription drug use, and health status of the newborn infants were obtained from the Swedish Medical Birth Register, the Prescribed Drug Register, and the Swedish Neonatal Quality Register. We included 741 040 singletons, born between July 1, 2006, and December 31, 2012. Of the infants, 17 736 (2.4%) had mothers who used selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Infants exposed to an SSRI were compared with nonexposed infants, and infants exposed during late pregnancy were compared with those exposed during early pregnancy only. The results were analyzed with logistic regression analysis. RESULTS: After maternal use of an SSRI, 13.7% of the infants were admitted to the NICU compared with 8.2% in the population (adjusted odds ratio: 1.5 [95% confidence interval: 1.4–1.5]). The admission rate to the NICU after treatment during late pregnancy was 16.5% compared with 10.8% after treatment during early pregnancy only (adjusted odds ratio: 1.6 [95% confidence interval: 1.5–1.8]). Respiratory and central nervous system disorders and hypoglycemia were more common after maternal use of an SSRI. Infants exposed to SSRIs in late pregnancy compared with early pregnancy had a higher risk of persistent pulmonary hypertension (number needed to harm: 285). CONCLUSIONS: Maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU. The absolute risk for severe disease was low, however.

Challenges in developing primary care physicians' motivational interviewing skills

INTRODUCTION Motivational interviewing (MI) skills are relevant for primary care providers (PCPs) who are responsible for caring for patients with diseases affected by behavior. There are significant challenges associated with developing PCPs MI skills. We report on an effort to document the acquisition of MI skills by PCPs using an objective measure of MI competence, the Motivational Interviewing Treatment Integrity (MITI) coding system. METHOD Eleven PCPs volunteered to participate in 6 MI workshops over a period of 6 months and to submit work samples between each of these workshops to be assessed with the MITI coding system. RESULTS Thirteen of the expected 55 work samples were submitted before the final workshop. A revised approach was implemented in which each participant completed 2 simulated patient encounters. None of the providers reached the MITIs Beginning Proficiency threshold of MI skill. DISCUSSION Six MI workshops were not sufficient to help motivated PCPs achieve Beginning Proficiency as measured by the MITI. Participants failed to submit most of the work samples for feedback on their MI practice, which may have contributed to their limited acquisition of MI skills. Helping PCPs develop MI skills likely requires more than participation in a series of workshops totaling 18 h. Questions remain about the feasibility of training PCPs to be competent in MI. Approaches such as use of simulated patients, peer observation, or specific protected time for obtaining work samples may be required. (PsycINFO Database Record

636 Bipolar Disorder and Pregnancy - Neurodevelopmental Outcome of Children Exposed to Maternal Illness with or without Lithium during Pregnancy

Background and Aims Bipolar disorder (BD) is a chronic psychiatric condition. Lithium is the most common mood stabilizing drug during pregnancy. It is unknown whether lithium exposure in utero may have negative effects on neurodevelopment. This study aims to investigate the health and cognitive development of preschool children born to mothers with BD. Methods 10 women with BD who had given birth 2006 or 2007 were recruited from a psychiatric center. 4 of them had been medicating with lithium during pregnancy. 4 women without psychiatric illness were included. At age 4–5 the children were tested by a child psychologist, using Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and physically examined. The mental health and social situation of the mother was assessed by a psychiatric nurse or psychiatrist. Results WPPSI results were available for 9 children. Mean full scale IQ of children exposed to lithium during pregnancy (n=3) was 108 and for unexposed children (n=6) 111, no significant difference. One child, born to a mother with bipolar disease but not exposed to lithium, was born prematurely and tested in the lower normal range of the IQ scale. One child, not exposed to lithium, had been diagnosed with ADHD. All children were in good general health. Conclusions These preliminary results show that children to mothers with bipolar disorder, with or without intrauterine exposure to lithium, had a normal to high IQ at preschool age. 5 more children have been tested, results to be analyzed, and additional children will be recruited.

Long-term consequences after exposure to antiepileptic drugs in utero

Most pregnant women with epilepsy need pharmacological treatment during pregnancy. Children exposed to antiepileptic drugs have an increased risk of being born with major malformations. Some antiepileptic drugs seem to have negative effects on psychomotor or cognitive development in children exposed during foetal life. Neither carbamazepine nor lamotrigine in monotherapy seem to affect the cognition of exposed children. Several studies have shown negative effects on the long-term neurodevelopment of children prenatally exposed to valproic acid or polytherapy (two or more antiepileptic drugs during pregnancy). For most of the newer antiepileptic drugs there are insufficient data regarding long-term outcome.

MAGDALENA: study protocol of a randomised, placebo-controlled trial on cognitive development at 2 years of age in children exposed to SSRI in utero

Introduction Ten per cent of all pregnant women are depressed. Standard therapy of pregnant women with moderate depression is selective serotonin reuptakeinhibitors (SSRI). Observational studies on neurodevelopment after fetal SSRI exposure show conflicting results. Our primary objective is to compare the cognitive development in children exposed to sertraline and maternal depression with those exposed to maternal depression and placebo in utero. We hypothesise that there is a significant neurodevelopmental difference between the groups. As a secondary objective, we study the add-on effect of sertraline to internet-based cognitive behavioural therapy (ICBT) to treat moderate depression during pregnancy. Methods and analysis MAGDALENA is a randomised, placebo-controlled, double-blinded trial in Stockholm Healthcare Region with 2.3 million inhabitants. The women are recruited in weeks 9–21 of pregnancy either through Antenatal Health Clinics or through social media. They are to be diagnosed with moderate depression without ongoing antidepressive therapy or any serious comorbidity. The women in the intervention arm receive sertraline combined with a 12-week period of ICBT; the control arm is treated with placebo and ICBT. We assess the cognitive development in the offspring at the age of 2 years using Bayley Scales of Infant and Toddler Development, third edition (BSID-III). We aim at recruiting 200 women, 100 women in each treatment arm, to ensure statistical power to detect a clinically relevant difference between the groups. Ethics and dissemination This randomised trial will provide long-sought evidence about the effects of SSRI and maternal depression during pregnancy on the neurodevelopment in the offspring. The study is approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm and the Swedish Medical Products Agency. It is registered with the European Clinical Trials Database (EudraCT), Number: 2013-004444-31. Results will be disseminated at scientific conferences, published in peer-reviewed journals and made available to the public. Trial registration number EudraCT2013-004444-31; Pre-results.

Maternal mood disorders and lithium exposure in utero were not associated with poor cognitive development during childhood

This study evaluated whether maternal mood disorders (MMD), particularly bipolar disorder, and lithium treatment during pregnancy influenced the neonatal health and cognition of children born from 2006 to 2010.