A new scale to assess the therapeutic relationship in community mental health care: STAR

Background. No instrument has been developed specifically for assessing the clinician-patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction. Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction. test-retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden. Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test-retest reliability was r = 0(.)76 for STAR-P and r = 0(.)68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit. Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care

How accessible and acceptable are current GP referral mechanisms for IAPT for low-income patients? Lay and primary care perspectives

Background: Improving Access to Psychological Therapies (IAPT) constitutes a key element of England’s national mental health strategy. Accessing IAPT usually requires patients to self-refer on the advice of their GP. Little is known about how GPs perceive and communicate IAPT services with patients from low-income communities, nor how the notion of self-referral is understood and responded to by such patients. Aims: This paper examines how IAPT referrals are made by GPs and how these referrals are perceived and acted on by patients from low-income backgrounds Method: Findings are drawn from in-depth interviews with low-income patients experiencing mental distress (n = 80); interviews with GPs (n = 10); secondary analysis of video-recorded GP-patient consultations for mental health (n = 26). Results: GPs generally supported self-referral, perceiving it an important initial step towards patient recovery. Most patients however, perceived self-referral as an obstacle to accessing IAPT, and felt their mental health needs were being undermined. The way that IAPT was discussed and the pathway for referral appears to affect uptake of these services. Conclusions: A number of factors deter low-income patients from self-referring for IAPT. Understanding these issues is necessary in enabling the development of more effective referral and support mechanisms within primary care

Cosmic microwave background multipole alignments in slab topologies

Several analyses of the microwave sky maps from the Wilkinson Microwave Anisotropy Probe (WMAP) have drawn attention to alignments amongst the low-order multipoles. Amongst the various possible explanations, an effect of cosmic topology has been invoked by several authors. We focus on an alignment of the first four multipoles (\ell = 2 to 5) found by Land and Magueijo (2005), and investigate the distribution of their alignment statistic for a set of simulated cosmic microwave background maps for cosmologies with slab-like topology. We find that this topology does offer a modest increase in the probability of the observed value, but that even for the smallest topology considered the probability of the observed value remains below one percent.Comment: 6 pages RevTex with 6 figures included. Minor changes to match version accepted as Physical Review D Rapid Communicatio

Use of the Patient Health Questionnaire (PHQ-9) in Practice: Interactions between patients and physicians

We analyze the use of nine-item Patient Health Questionnaire (PHQ-9), an instrument that is widely used in diagnosing and determining the severity of depression. Using conversation analysis, we show how the doctor deploys the PHQ-9 in response to the patient's doubts about whether she is depressed. Rather than relaying the PHQ-9 verbatim, the doctor deviates from the wording so that the response options are selectively offered to upgrade the severity of the patient's symptoms. This works in favor of a positive diagnosis and is used to justify a treatment recommendation that the patient previously resisted. This contrasted with the rest of the data set, where diagnosis was either not delivered (as patients are presenting with ongoing problems) or delivered without using the PHQ-9. When clinician-administered, the PHQ-9 can be influenced by how response items are presented. This can lead to either downgrading or upgrading the severity of depression

The non-unique Universe

The purpose of this paper is to elucidate, by means of concepts and theorems drawn from mathematical logic, the conditions under which the existence of a multiverse is a logical necessity in mathematical physics, and the implications of Godel's incompleteness theorem for theories of everything. Three conclusions are obtained in the final section: (i) the theory of the structure of our universe might be an undecidable theory, and this constitutes a potential epistemological limit for mathematical physics, but because such a theory must be complete, there is no ontological barrier to the existence of a final theory of everything; (ii) in terms of mathematical logic, there are two different types of multiverse: classes of non-isomorphic but elementarily equivalent models, and classes of model which are both non-isomorphic and elementarily inequivalent; (iii) for a hypothetical theory of everything to have only one possible model, and to thereby negate the possible existence of a multiverse, that theory must be such that it admits only a finite model

FAST: A multi-processed environment for visualization of computational fluid dynamics

Three-dimensional, unsteady, multi-zoned fluid dynamics simulations over full scale aircraft are typical of the problems being investigated at NASA Ames' Numerical Aerodynamic Simulation (NAS) facility on CRAY2 and CRAY-YMP supercomputers. With multiple processor workstations available in the 10-30 Mflop range, we feel that these new developments in scientific computing warrant a new approach to the design and implementation of analysis tools. These larger, more complex problems create a need for new visualization techniques not possible with the existing software or systems available as of this writing. The visualization techniques will change as the supercomputing environment, and hence the scientific methods employed, evolves even further. The Flow Analysis Software Toolkit (FAST), an implementation of a software system for fluid mechanics analysis, is discussed

General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal.

BACKGROUND: There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects. AIMS: To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms. METHOD: Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert. RESULTS: Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned. CONCLUSIONS: Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines

UNIFORMED MILITARY ACQUISITION OFFICER CAREER PATH DEVELOPMENT COMPARISON

The purpose of this research was to compare the career path development of the Navy, Marine Corps, Air Force, and Army acquisition officers and identify advantages and disadvantages from each service. After an analysis of the differences, recommended changes to establish greater efficiency and symmetry within the acquisition officer’s professional development to serve more effectively in a joint environment are proposed. The methodology included comparing U.S. Armed Forces processes and frameworks concerning career field education and training of uniformed acquisition officers in the contract management and program management fields. Each service’s methods were compared to identify milestones for career progression of acquisition officers within each service. Processes that would benefit other services were identified, such as serving in non-acquisition positions as junior officers and serving in back-to-back acquisitions tours once joining the acquisition workforce. These beneficial processes were used to create a Universal Acquisition Officer Career Path (UAOCP) that can be adopted by all services to better synchronize military and civilian education, training, and experience across the services for acquisition officers. The UAOCP would promote a level field of knowledge that could better serve the joint acquisition environment.Major, United States Marine CorpsLieutenant Commander, United States NavyLieutenant Commander, United States NavyApproved for public release. distribution is unlimite

The Topology of Branching Universes

The purpose of this paper is to survey the possible topologies of branching space-times, and, in particular, to refute the popular notion in the literature that a branching space-time requires a non-Hausdorff topology