St. Patrick's Hospital

Personal recovery is increasingly important in service delivery. While personal recovery has been examined in relation to several mental health issues, it has yet to be reviewed in recovery from substance use disorders.This review of qualitative studies, which followed PRISMA guidelines, used a 'Best Fit' framework synthesis. To organise studies, the a-priori, transdiagnostic CHIME framework was employed.2885 papers were initially identified, with 3 added in updated searches; 13 papers were included for analysis. Findings show that CHIME captures many elements related to recovery from substance use. However, the original framework does not consider challenges associated with trauma, loss, and stigmatisation. Including a 'Difficulties' domain supports the use of the CHIME-D framework.Personal recovery from substance use is a complex and individual process. The CHIME-D framework emphasises the importance of professionals adopting a balanced approach to recovery, recognising both benefits and challenges.

Implementing technological innovations into practice can often be a challenge. In this article, Shane Kirwan and colleagues describe the successful implementation of a virtual reality exposure therapy intervention in a mental health setting, explaining key steps, such as needs assessment, stakeholder engagement and ensuring the appropriate standards.

Serial ketamine infusions are being increasingly adopted as off-label treatment for major depression in routine clinical practice, yet robust psychoactive placebo-controlled trial evidence for short- and long-term efficacy and safety remains limited. To assess antidepressant efficacy, safety, tolerability, cost-effectiveness, and quality of life during and after serial ketamine infusions compared with midazolam as an adjunct to usual inpatient care. The KARMA-Dep 2 trial was an investigator-led, double-blind, randomized, midazolam-controlled, pragmatic trial conducted at an academic center in Ireland between September 2021 and August 2024. Participants included adults (≥18 years) hospitalized with a DSM-5 major depressive episode (unipolar or bipolar) and baseline Montgomery-Åsberg Depression Rating Scale (MADRS) score ≥20. Participants were randomized 1:1 to receive up to 8 twice-weekly intravenous infusions of either ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) as an adjunct to usual-care pharmacotherapy and other aspects of routine inpatient psychiatric care. Participants were followed up for 6 months. The primary outcome was change in depression symptom severity measured by the observer-rated MADRS score from baseline to end of treatment. Secondary outcomes included self-reported depression severity, safety, tolerability, health care costs, and quality of life. Of 65 randomized participants (mean [SD] age, 53.5 [18.6] years; 37 [59.7%] male), 62 were included in the final analysis. In the analysis of primary outcome, end-of-treatment MADRS scores did not significantly differ between the ketamine and midazolam groups (adjusted mean difference, -3.16 points, 95% CI, -8.54 to 2.22; P = .25; Cohen d, -0.29). Similarly, there was no significant between-group difference between Quick Inventory of Depressive Symptoms, Self-Report, scores (adjusted mean difference, -0.002; 95% CI, -2.71 to 2.71; P > .99; Cohen d, -0.0004). There were no significant between-group differences on other secondary outcomes, including cognition, cost-effectiveness, or quality of life. Most patients and raters accurately guessed treatment allocation. Serial adjunctive ketamine infusions were not more effective than serial midazolam infusions in reducing depressive symptoms in inpatients receiving usual psychiatric care. ClinicalTrials.gov Identifier: NCT04939649.

Purpose The increasing demand for practice education placements in Ireland, driven by the growing need for allied health professionals, presents significant challenges. Over the past twenty years, the co-supervision model, which divides the supervision of a single student among two educators, has become more prevalent. This is largely due to its suitability for part-time therapists who wish to facilitate practice education placements. Despite its increasing use, the model has received less attention in occupational therapy than the one-to-one model, the two-to-one and the collaborative model. This paper aims to describe occupational therapy practice educators experiences of facilitating the co-supervision model of practice education. Design/methodology/approach Using a qualitative descriptive approach, semi-structured interviews were completed with nine occupational therapists to explore their experiences of using the co-supervision model. Data were analysed using Braun and Clarke’s six-phase reflexive thematic analysis. Rigour and trustworthiness were achieved through an audit trail, prolonged engagement with the data and ongoing team reflection on theme development. Findings Reflexive thematic analysis yielded five themes: (i) broad student learning opportunities in the co-supervision model, (ii) communication within collaborative relationships, (iii) co-supervision facilitates participation in the Practice Educator role, (iv) planning and self-preparation are essential and (v) the co-supervision model demands student self-management skills. Originality/value Providing contemporary nuanced evidence on practice educators’ perspectives of the co-supervision model in occupational therapy placements in an Irish context is essential in highlighting its potential as a promising alternative to other models in facilitating quality student placements.

Fumarate hydratase (FH), a key node of mitochondrial metabolism, is also a tumour suppressor. Despite its prominent roles in tumourigenesis and inflammation, its regulation remains poorly understood. Herein, we show that histone deacetylase 6 (HDAC6) regulates FH activity. In triple-negative breast cancer cells, HDAC6 inhibition or knockdown results in alterations to mitochondrial cristae structure, as detected by live-cell super-resolution STED nanoscopy and electron microscopy, along with the release of mitochondrial DNA. Mass-spectrometry immunoprecipitation reveals multiple mitochondrial HDAC6-interactors, with FH emerging as a top hit. Super-resolution 3D-STORM shows HDAC6 interactions with FH in mitochondrial networks, which increases after perturbation of HDAC6 activity with BAS-2. Treatment with BAS-2 leads to fumarate accumulation by 13C glucose labelling, along with downstream succination of proteins and cell death. Together, these results identify HDAC6 inhibition as a regulator of endogenous FH activity in tumour cells, and highlight it as a promising candidate for indirectly targeting tumour metabolism.

Relapse following electroconvulsive therapy (ECT) remains a significant clinical challenge despite continuation of pharmacotherapy. We performed a systematic review and meta-analysis (PROSPERO CRD420251000113) of the efficacy and acceptability of continuation ECT (cECT) combined with pharmacotherapy compared to pharmacotherapy alone for relapse prevention following an acute course of ECT for depression. We searched PubMed, Embase, Web of Science, and CENTRAL databases for randomized controlled trials enrolling adults diagnosed with a unipolar or bipolar major depressive episode, who met remission or response criteria after an acute course of ECT and who were subsequently randomized to cECT with pharmacotherapy versus pharmacotherapy alone. The efficacy outcome was the cumulative relapse rate at 6-month follow-up. Data were synthesized using random-effects meta-analyses with effect sizes expressed as relative risks (RRs) with 95% confidence intervals (CIs). Four trials (n = 254) met the inclusion criteria. cECT combined with pharmacotherapy significantly reduced relapse compared to pharmacotherapy alone (RR = 0.57, 95% CI = 0.37–0.88; I2 = 0%; number needed to treat = 7). Sensitivity analyses consistently supported the superiority of cECT under all examined dropout scenarios and analytic approaches. Acceptability, measured by all-cause dropout, was similar between the groups (RR = 1.12; 95% CI = 0.48–2.62; I2 = 0%). cECT combined with pharmacotherapy significantly reduces the RR of relapse by 43% compared to pharmacotherapy alone without compromising acceptability. These findings reinforce the role of cECT as a valuable relapse prevention strategy following successful acute ECT and highlight the need for larger, multicenter trials to further optimize post-ECT prophylaxis.

IntroductionOlder people (people aged 65 years and older) have high rates of death by suicide, and self-harm is a major risk factor for suicide. While rates of self-harm decrease with age, rates of suicide increase among this age group. The overall aim of this research project is to identify real-life evidence of the characteristics associated with older people who present with self-harm and suicidal ideation to emergency departments in Ireland. In examining the variables associated with self-harm, we may be better able to identify the characteristics of older adults who are at highest risk, including those presenting with high lethality attempts.Methods and analysisOur data are a cohort study of older people in Ireland involving two workstreams. The first will use a 5-year cohort of data from the National Clinical Programme for Self-Harm and Suicide-related Ideation (NCPSHI) which comprises over 70 000 presentations. The second workstream will use a 15-year cohort of electronic patient records from the Mater Misericordiae University Hospital (MMUH) comprising over 30 491 presentations (900 aged 65 years and older) to collect more detailed information on characteristics of older people presenting with self-harm and suicidal ideation.Ethics and disseminationThis study has received full ethical approval. The Clinical Research Ethics Committee of the MMUH approved the MMUH workstream—Reference number: 1/378/2327 TMR. Ethical approval for the NCPSHI workstream has been granted by the University College Dublin’s Office of Research Ethics.Our findings will be disseminated via peer-review publications and presentations to the scientific community, along with reports for clinicians and policymakers.

Shared decision-making (SDM) has yet to be successfully adopted into routine use in psychiatric settings amongst people living with severe mental illnesses. Suboptimal rates of SDM are particularly prominent amongst patients with psychotic illnesses during antipsychotic treatment choices. Many interventions have been assessed for their efficacy in improving SDM within this context, although results have been variable and inconsistent. To generate an in-depth understanding of how, why, for whom, and to what extent interventions facilitating the application of SDM during antipsychotic treatment choices work and the impact of contextual factors on intervention effectiveness. This review will use realist review methodology to provide a causal understanding of how and why interventions work when implementing SDM during antipsychotic treatment choices. The cohort of interest will be those experiencing psychosis where ongoing treatment with an antipsychotic is clinically indicated. The review will take place over five stages; (1) Locating existing theories, (2) Searching for evidence, (3) Selecting articles, (4) Extracting and organising data and (5) Synthesizing evidence and drawing conclusions. An understanding of how and why interventions work will be achieved by developing realist programme theories on intervention effectiveness through iterative literature reviews and engaging with various stakeholder groups, including patient, clinician and carer representatives. This is the first realist review aiming to identify generative mechanisms explaining how and why successful interventions aimed at improving SDM within the parameters outlined work and in which contexts desired outcomes are most likely to be achieved. Review findings will include suggestions for clinicians, policy and decision-makers about the most promising interventions to pursue and their ideal attributes.

Shane Kirwan and colleagues describe the virtual mental health inpatient wards implemented in Ireland in response to the COVID-19 pandemic and discuss the continuing development of this model of care delivery.