“Is It Removed During Dialysis?”—Cognitive Dysfunction in Advanced Kidney Failure—A Review Article

Cognitive impairment is independently associated with kidney disease and increases in prevalence with declining kidney function. At the stage where kidney replacement therapy is required, with dialysis or transplantation, cognitive impairment is up to three times more common, and can present at a younger age. This is not a new phenomenon. The cognitive interactions of kidney disease are long recognized from historical accounts of uremic encephalopathy and so-called “dialysis dementia” to the more recent recognition of cognitive impairment in those undergoing kidney replacement therapy (KRT). The understanding of cognitive impairment as an extra-renal complication of kidney failure and effect of its treatments is a rapidly developing area of renal medicine. Multiple proposed mechanisms contribute to this burden. Advanced vascular aging, significant multi-morbidity, mood disorders, and sleep dysregulation are common in addition to the disease-specific effects of uremic toxins, chronic inflammation, and the effect of dialysis itself. The impact of cognitive impairment on people living with kidney disease is vast ranging from increased hospitalization and mortality to decreased quality of life and altered decision making. Assessment of cognition in patients attending for renal care could have benefits. However, in the context of a busy clinical service, a pragmatic approach to assessing cognitive function is necessary and requires consideration of the purpose of testing and resources available. Limited evidence exists to support treatments to mitigate the degree of cognitive impairment observed, but promising interventions include physical or cognitive exercise, alteration to the dialysis treatment and kidney transplantation. In this review we present the history of cognitive impairment in those with kidney failure, and the current understanding of the mechanisms, effects, and implications of impaired cognition. We provide a practical approach to clinical assessment and discuss evidence-supported treatments and future directions in this ever-expanding area which is pivotal to our patients' quality and quantity of life.

The implementation potential of a method to monitor empirically-supported children’s mental health treatment through claims data

Background The delivery of evidence-supported treatments (EST) in children’s mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system. Methods Implementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method’s acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State. Results The analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies’ mixed views regarding the accuracy and benefits of reporting. Conclusions Measurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

Good Psychiatric Management and Transference-Focused Psychotherapy for Borderline Personality Disorder: A Spectrum of Psychodynamically Informed Treatments

Good psychiatric management for borderline personality disorder (GPM) and transference-focused psychotherapy (TFP) are evidence-supported treatments that may be used in a complementary, flexible manner to provide a spectrum of psychodynamically informed care. In this article, we provide overviews of TFP and GPM, describing GPM's eclectic approach that includes psychodynamically informed supportive psychotherapy, case management, and medication management, informed by a model of hypersensitivity to rejection, comparing it with TFP's focus on identity integration and modification of standard psychodynamic techniques for use in treating patients with borderline personality disorder. We outline convergences and divergences between TFP and GPM in assessment, establishment of treatment goals and a treatment agreement, family involvement, and moment-to-moment psychotherapeutic interventions. The options for integration of TFP and GPM theoretical principles, as well as for models of treatment sequencing, are explored. Clinical vignettes are provided that illustrate sequential uses of GPM and TFP as part of psychodynamically informed long-term clinical management.

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal

Background Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation. Methods Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes. Results Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care. Conclusion Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.

Fidelity with Flexibility

Research has linked the use of evidence-supported treatments to effective, efficient therapeutic outcomes. Questions related to the best way to disseminate and implement evidence-supported treatments in the field has led to discussions about transportability of treatments from controlled to applied settings. Specifically, scholars have focused on issues related to treatment fidelity, acceptability, and adoption versus adaptation of evidence-based treatments in practice. Treatment fidelity, a multidimensional construct, pertains to how extensively a treatment is delivered to a client, and it may be affected by several variables. Although the relationship is complex, treatment fidelity is considered an important moderator of client outcomes. Furthermore, the acceptability of a treatment appears to be of importance. Simply, if a treatment is perceived to be acceptable, it is more likely to be implemented with high levels of fidelity, increasing the chances that successful therapeutic outcomes will result. Nevertheless data indicate that some clinicians are wary of using evidence-supported treatments; their chief concern is feasibility of implementation, which could affect treatment fidelity and acceptability. Thus, there is a debate about whether evidence-supported treatments should be adopted strictly as developed or whether they might be adapted to improve implementation and acceptability. In adaptation of a treatment, relevant clinician variables (e.g., training received, availability of resources) and client factors (e.g., cultural fit) might be considered to promote therapeutic outcomes. This chapter describes how the key to treatment success may be to strike a balance between fidelity and adaptation of evidence-based treatments and fidelity with flexibility.

Pharmacological Adjuncts and Evidence-Supported Treatments for Trauma

A large proportion of humans experienced a traumatic event in their lifetime, with more than 10% developing posttraumatic stress disorder (PTSD), panic disorder, phobias, and other fear/anxiety disorders. The neural circuitry of fear responses is highly conserved in humans as well as rodents, and this allows for translational research using animal models of fear. Fear/anxiety disorders in humans are most efficiently treated by exposure-based psychotherapy (i.e., cognitive behavioral therapy; CBT), the main aspects of which are closely modeled by extinction training in Pavlovian fear conditioning and extinction paradigms in rodents. To improve the efficacy of psychotherapy, pharmacological agents potent for enhancing learning and memory consolidation processing should be developed to combine with exposure-based therapy. The purpose of these adjunctive pharmacological agents is to promote fear memory erasure and the consolidation of extinction memories, thus providing a combined treatment of increased effectiveness. This review discusses established pharmacological adjuncts to behavioral therapeutic interventions for fear/anxiety disorders. The mechanisms of action of these adjuncts, as well as the evidence for and against the pharmacological treatment strategies and their limitations are discussed.