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Generative AI in healthcare education: How AI literacy gaps could compromise learning and patient safety.
AIM: To examine the challenges and opportunities presented by generative artificial intelligence in healthcare education and explore how it can be used ethically to enhance rather than compromise future healthcare workforce competence. BACKGROUND: Generative artificial intelligence is fundamentally changing healthcare education, yet many universities and healthcare educators have failed to keep pace with its rapid development. DESIGN: A discussion paper. METHODS: Discussion and analysis of the challenges and opportunities presented by students' increasing use of generative artificial intelligence in healthcare education, with particular focus on assessment approaches, critical thinking development and artificial intelligence literacy. RESULTS: Students' widespread use of generative artificial intelligence threatens assessment integrity and may inhibit critical thinking, problem-solving skills and knowledge acquisition. Without adequate artificial intelligence literacy there is a risk of eroding future healthcare workforce competence and compromising patient safety and professional integrity. CONCLUSION: While generative artificial intelligence presents significant challenges to healthcare education, it offers great promise if used carefully with awareness of its limitations. The development of artificial intelligence literacy is crucial for maintaining professional standards and ensuring patient safety and mitigating its potentially negative impact on the formation of critical thinking skills.
Adversarial testing of global neuronal workspace and integrated information theories of consciousness.
Different theories explain how subjective experience arises from brain activity1,2. These theories have independently accrued evidence, but have not been directly compared3. Here we present an open science adversarial collaboration directly juxtaposing integrated information theory (IIT)4,5 and global neuronal workspace theory (GNWT)6-10 via a theory-neutral consortium11-13. The theory proponents and the consortium developed and preregistered the experimental design, divergent predictions, expected outcomes and interpretation thereof12. Human participants (n = 256) viewed suprathreshold stimuli for variable durations while neural activity was measured with functional magnetic resonance imaging, magnetoencephalography and intracranial electroencephalography. We found information about conscious content in visual, ventrotemporal and inferior frontal cortex, with sustained responses in occipital and lateral temporal cortex reflecting stimulus duration, and content-specific synchronization between frontal and early visual areas. These results align with some predictions of IIT and GNWT, while substantially challenging key tenets of both theories. For IIT, a lack of sustained synchronization within the posterior cortex contradicts the claim that network connectivity specifies consciousness. GNWT is challenged by the general lack of ignition at stimulus offset and limited representation of certain conscious dimensions in the prefrontal cortex. These challenges extend to other theories of consciousness that share some of the predictions tested here14-17. Beyond challenging the theories, we present an alternative approach to advance cognitive neuroscience through principled, theory-driven, collaborative research and highlight the need for a quantitative framework for systematic theory testing and building.
Modulation of alpha oscillations by attention is predicted by hemispheric asymmetry of subcortical regions
Evidence suggests that subcortical structures play a role in high-level cognitive functions such as the allocation of spatial attention. While there is abundant evidence in humans for posterior alpha band oscillations being modulated by spatial attention, little is known about how subcortical regions contribute to these oscillatory modulations, particularly under varying conditions of cognitive challenge. In this study, we combined MEG and structural MRI data to investigate the role of subcortical structures in controlling the allocation of attentional resources by employing a cued spatial attention paradigm with varying levels of perceptual load. We asked whether hemispheric lateralization of volumetric measures of the thalamus and basal ganglia predicted the hemispheric modulation of alpha-band power. Lateral asymmetry of the globus pallidus, caudate nucleus, and thalamus predicted attention-related modulations of posterior alpha oscillations. When the perceptual load was applied to the target and the distractor was salient caudate nucleus asymmetry predicted alpha-band modulations. Globus pallidus was predictive of alpha-band modulations when either the target had a high load, or the distractor was salient, but not both. Finally, the asymmetry of the thalamus predicted alpha band modulation when neither component of the task was perceptually demanding. In addition to delivering new insight into the subcortical circuity controlling alpha oscillations with spatial attention, our finding might also have clinical applications. We provide a framework that could be followed for detecting how structural changes in subcortical regions that are associated with neurological disorders can be reflected in the modulation of oscillatory brain activity.
Efficacy of a 6-month supported online programme (Feeling Safer) for the treatment of persecutory delusions: protocol for a randomised controlled trial.
INTRODUCTION: Persecutory delusions are very common in severe mental health disorders such as schizophrenia. Existing treatments often do not work well enough. We developed a face-to-face theory-driven psychological intervention, called Feeling Safe, that produces very large reductions in persistent persecutory delusions. The challenge now is to make Feeling Safe widely available. So, we developed a 6-month supported online version, called Feeling Safer. The aim is an intervention that patients can easily access and use, reduces persecutory delusions and can be supported by a range of mental health professionals in less contact time than face-to-face therapy. Initial proof of concept testing of Feeling Safer was very encouraging. In a randomised controlled trial, we now plan to test whether Feeling Safer is efficacious for patients and can be successfully delivered by any of three different mental health staff groups (peer-support workers, graduate psychologists and cognitive behavioural therapy (CBT) therapists). We will also test whether Feeling Safer works equally across gender, age, ethnicity and cognitive functioning (moderation) and whether Feeling Safer works via the targeted psychological processes (mediation). METHODS AND ANALYSIS: The study design is a multicentre, single-blind (outcome assessor), parallel, four-arm randomised controlled trial; 484 patients with persistent persecutory delusions will be randomised to one of the four conditions (1:1:1:1): Feeling Safer (added to treatment as usual (TAU)) supported by peer-support workers, or Feeling Safer (added to TAU) supported by graduate mental health workers including assistant psychologists, or Feeling Safer (added to TAU) supported by CBT therapists or TAU. Feeling Safer will be provided for 6 months with a staff member. Assessments will be conducted at 0, 3, 6 and 9 months by research assistants blind to group allocation. The primary outcome is severity of persecutory delusions at 6 months rated with the Psychotic Symptoms Rating Scale-Delusions. The secondary outcomes are other psychiatric symptoms (depression, anxiety, insomnia, agoraphobia and paranoia), psychological well-being, recovery, activity and health-related quality of life. Analysis will be conducted under a treatment policy strategy following the intention-to-treat principle, incorporating data from all participants including those who do not complete treatment. Moderation and mediation will be tested. A within-trial cost-effectiveness analysis will be conducted of Feeling Safer compared with TAU. ETHICS AND DISSEMINATION: The trial has received ethical approval from the NHS Health Research Authority (23/LO/0951). Informed consent will be obtained from all participants. A key output will be an open-access publication in a peer-reviewed journal reporting on the clinical effectiveness of a high-quality supported online programme for the treatment of persecutory delusions that has the potential to be used at scale in mental health services. TRIAL REGISTRATION NUMBER: ISRCTN93974770.
How do people recover from persecutory delusions? An interpretative phenomenological analysis
Background: Patient perspectives on recovery from psychosis have been studied. However, there are few studies on recovery from particular psychotic experiences. Persecutory delusions are common, often distressing, and can disrupt day-to-day life and relationships. We explored how patients report recovering from persecutory delusions. Methods: Semi-structured interviews were completed with 15 patients who had recovered from persecutory delusions. Interpretative Phenomenological Analysis was used. Results: Three superordinate themes were identified. The first was “Foundational background features set the context for recovery”. A range of features, including support and respect from others, routine, calm environments, and medication, provided the basis for recovery. The second superordinate theme was “Activity as a route for positivity and re-engagement with the world”. Engagement in activity was important to re-orient attention away from paranoid fears, and to improve mood. The third superordinate theme was “The effortful discovery of safety”. Generating, considering, and testing alternative explanations was a key route to learning safety. Discussion: Recovery from persecutory delusions can take many routes, which vary between individuals. Supporting individuals to reengage with activity and generate acceptable and sufficiently-evidenced alternatives to paranoid fears are potentially valuable treatment targets in the processes of recovery from paranoia.
Learning How to Improve the Treatment of Persecutory Delusions: Using a Principal Trajectories Analysis to Examine Differential Effects of Two Psychological Interventions (Feeling Safe, Befriending) in Distinct Groups of Patients.
BACKGROUND: A theory-driven cognitive therapy (Feeling Safe) has produced much better outcomes for patients with persecutory delusions. There are four distinct response classes: very high delusion conviction with large improvement, very high delusion conviction with no response, high delusion conviction with large improvement, and high delusion conviction with modest improvement. Our objective was to apply principal trajectories analysis, a novel statistical method, to original trial data to estimate whether these groups may have responded differently to a different intervention: befriending. DESIGN: One hundred and thirty patients with persistent persecutory delusions were randomised to six months of Feeling Safe or befriending. Baseline assessments were used to assign patients allocated to befriending (who did not receive Feeling Safe) into the four Feeling Safe response classes. The treatment effect, including on potential mediators, was then estimated for these classes. RESULTS: Patients in two treatment response classes (Very high conviction/large improvement, High conviction/large improvement) benefited more from Feeling Safe, patients in one group (Very high conviction/no improvement) benefited more from befriending, and patients in the remaining group (High conviction/moderate improvement) benefited equally from the interventions. Mechanism differences were detected when Feeling Safe was superior to befriending, but not when befriending was superior. CONCLUSIONS: There may be patients with psychosis who benefit more from one type of therapy than another, likely due to different change mechanisms. The application of principal trajectories has generated testable hypotheses and a potential step toward personalised treatment. We recommend an investigation of whether sequential provision of the treatment types could enhance patient outcomes. Keywords: persecutory, delusions, outcome trajectories, psychosis, cognitive therapy.
Developing a qualitative and quantitative ambulatory assessment-based feedback system within cognitive behavioural interventions for people with persecutory beliefs.
BACKGROUND: Although the application of self-monitoring (ambulatory assessment) and visual feedback in psychological interventions has yielded promising results, there are currently no reports on using self-monitoring and feedback during a complete therapy. The online m-Path platform provides a tailorable framework for integrating self-monitoring and visual feedback within different psychological interventions. METHODS: Therapy-specific questionnaires and visual feedback were developed within the online m-Path platform as part of the Feeling Safe-NL trial (registration number: ISRCTN25766661) for regular CBT for psychosis (CBTp) and the Feeling Safe Programme combined with peer counselling (the Feeling Safe-NL Programme). The design process involved people with lived experience, psychologists, peer counsellors, researchers, and software developers. The design principles included that the system should be 1) easy to use, 2) suitable for use during a six-month therapy, 3) focussed on positive and goal-aligned outcomes, 4) understandable by patients and professionals, and 5) informing, guiding, and promoting therapy. Design principles were evaluated using compliance data and a patient questionnaire. RESULTS: The system was used by 21 patients, of which nine completed the questionnaires for the full therapy period, 168 days on average. Usability data from patients revealed that the system was easy to use, well-explained, and suitable for use over six months of therapy. The patients also reported that the questions overall positively affected their emotions and that the feedback was insightful. CONCLUSION: The results support the successful application of the design principles to promote the integration of the self-monitoring and visual feedback system within specific CBTp interventions.
A counterweight model for understanding and treating persecutory delusions.
Direct challenge seldom leads to change in strongly held beliefs such as persecutory delusions. A better route is to develop an alternative belief that can coexist with the delusion. The best such beliefs function as counterweights to the delusion. Over time, the scales shift. The alternative belief becomes more powerful than the delusion. In this paper, we set out such a model of persecutory delusions (or severe paranoia) and describe how it inherently translates theoretical understanding into treatment routes. Severe paranoia occurs when the adaptive cognitive processes of deciding whether to trust become overly weighted to mistrust. An inaccurate threat belief is formed, and the person feels very unsafe. Hence, overcoming the delusion means developing a counterweighting belief. It means building the alternative view that the world is safe enough for the person now and going forward. This, in turn, is done by experiencing safety. However, the pull of paranoia is strong due to multiple factors such as past history, anxious arousal, hallucinations, feelings of vulnerability, use of defenses, withdrawal, worry, difficulties distancing from fears, and a sense of defeat. These factors can prevent the person from feeling safe in even the most benign environments. Therefore, counterweights must be developed for these factors. For instance, feeling vulnerable can be counterweighted by developing self-confidence. Excessive time spent worrying can be counterweighted by devoting more time to thinking about meaningful activities. The counterweight approach provides a non-confrontational, empathic, personalized way to lift the burden of paranoia from a patient with persecutory delusions.
Sleep disruption and its psychological treatment in young people at risk of psychosis: A peer methods qualitative evaluation.
OBJECTIVES: A recent randomized controlled feasibility trial showed that sleep problems in young people at risk of psychosis can be successfully treated with psychological therapy and that this may bring additional benefits such as reducing depression, anxiety and paranoia. Here we report participants' qualitative experience of sleep problems and therapy. DESIGN: A peer-methods qualitative study employing reflexive thematic analysis. METHODS: Semi-structured interviews, co-facilitated by peer researchers, were conducted with 16 young patients at risk of psychosis and having sleep problems who participated in the SleepWell Trial (ISRCTN85601537). Ten interviewees had received the 12-week sleep therapy. RESULTS: Four themes were generated: (1) the challenge to access mental health treatment ('bouncing between services'), (2) sleep problems and mental health difficulties are intertwined ('an obvious link'), (3) flexibility in therapy provision matters ('tailored to me as a person') and (4) improving sleep leads to wider benefits ('fixing the sleep helped everything else'). Participants described a frustrating journey to access mental health treatment, marked by rejection and invalidation, which resulted in hopelessness and often resignation. The interaction between sleep disruption and other mental health difficulties was seen as obvious. Treatment for sleep problems was highly valued. The clear focus, therapeutic style and flexible delivery of the treatment was seen to create patient ownership, active engagement and hope. Participants described transformative changes: better sleep, fewer voices and fears and improved mood and confidence. Improving sleep made a difference to everyday life. CONCLUSIONS: Treating sleep problems in people at risk of psychosis is highly valued and often brings rapid and widespread improvements across a range of domains.
A 6-month supported online program for the treatment of persecutory delusions: Feeling Safer.
BACKGROUND: Based on an efficacious face-to-face theory-driven psychological therapy for persecutory delusions in the context of psychosis, we set out to develop a scalable guided 6-month online program. The aim was an intervention that patients can easily access and use, produces large clinical effects, and can be supported by a range of mental health professionals in less contact time than face-to-face therapy. We report here the proof-of-concept testing. At least moderate-sized clinical effects were required to progress to a randomized controlled trial (RCT). METHODS: In the 6-month Feeling Safer online program, a certified medical device, patients complete a brief assessment and then are provided with up to 10 modules that match their difficulties. Regular remote meetings with a mental health professional also take place. These may be supplemented by in-person visits. A pre- to post-treatment cohort trial was conducted with 14 patients with persistent persecutory delusions. The primary outcome was the Psychotic Symptoms Rating Scale (PSYRATS)-Delusions. RESULTS: Satisfaction and usability ratings of the program were high. Very large reductions in persecutory delusions were observed (PSYRATS mean reduction = 7.1, 95% C.I. = 3.4, 10.8, n = 13, Cohen's d = 3.0). There were large improvements in paranoia, anxiety, depression, agoraphobic distress, psychological wellbeing, meaningful activity, personal recovery, recovering quality of life, and moderate improvements in insomnia, agoraphobic avoidance, and quality of life. CONCLUSIONS: The clinical effects associated with Feeling Safer were very high, comparable to those seen in the evaluations of the face-to-face therapy, and enable progression to an RCT.
Interoceptive and exteroceptive pregnant bodily experiences and postnatal well-being: A network analysis
Objectives: Pregnancy involves rapid physical and physiological changes that may affect feelings towards the bodily experience. This experience, including body dissatisfaction and interoceptive sensibility, is linked to antenatal attachment and maternal mental health. However, the long-term relationships between pregnant bodily experiences and postnatal outcomes remain unknown. This study aimed to explore the complex relationships between the perinatal bodily experience and postnatal variables. Design: Longitudinal observational study using online surveys at three time points. Methods: Longitudinal data were collected at three time points, during pregnancy (N = 253), and 3 (N = 137) and 6 (N = 107) months postpartum. Pregnancy-validated measures assessed body dissatisfaction and interoception, alongside measures of postnatal bonding, maternal anxiety and depression, breastfeeding behaviours, and infant birth weight and development. A partial correlation graphical lasso network analysis was used to explore the relationships between the bodily experience and these postnatal variables. Results: Antenatal bodily experiences linked to postnatal anxiety, body dissatisfaction and interoceptive trust, with poorer postnatal experiences going on to correlate with higher anxiety, depression and breastfeeding rates at 3 months. Antenatal body weight dissatisfaction was linked to increased breastfeeding and depression, less trust in bodily signals and a lower quality mother-infant bond at 6 months postpartum. Conclusions: The findings underscore the importance of pregnant bodily experiences for maternal postnatal health and mother-infant bonding, helping to identify mothers at risk of poorer postnatal outcomes.
Single neurons and networks in the mouse claustrum integrate input from widespread cortical sources.
The claustrum is thought to be one of the most highly interconnected forebrain structures, but its organizing principles have yet to be fully explored at the level of single neurons. Here, we investigated the identity, connectivity, and activity of identified claustrum neurons in Mus musculus to understand how the structure's unique convergence of input and divergence of output support binding information streams. We found that neurons in the claustrum communicate with each other across efferent projection-defined modules which were differentially innervated by sensory and frontal cortical areas. Individual claustrum neurons were responsive to inputs from more than one cortical region in a cell-type and projection-specific manner, particularly between areas of frontal cortex. In vivo imaging of claustrum axons revealed responses to both unimodal and multimodal sensory stimuli. Finally, chronic claustrum silencing specifically reduced animals' sensitivity to multimodal stimuli. These findings support the view that the claustrum is a fundamentally integrative structure, consolidating information from around the cortex and redistributing it following local computations.
Temporal Network of Depressive Symptoms across College Students with Distinct Depressive Trajectories during the COVID-19 Pandemic.
BACKGROUND: There are marked differences in how individuals respond and adapt to depressive symptoms over time during the strain of public health emergencies; however, few studies have examined the interrelations between depressive symptoms in distinct depressive trajectories from the COVID-19 outbreak period to the COVID-19 control period. Therefore, this study conducted cross-lagged panel networks to investigate the temporal relationships between depressive symptoms across distinct depressive trajectories from the COVID-19 outbreak period (T1) to the COVID-19 control period (T2). METHODS: A total of 35,516 young participants from the College Students' Behavior and Health Cohort during the COVID-19 pandemic were included in the current study. Depressive symptoms were self-reported using the nine-item Patient Health Questionnaire. Unique longitudinal relationships between symptoms during the COVID-19 pandemic were estimated using a cross-lagged panel network. RESULTS: Longitudinal relationships across distinct depressive trajectories were unique during the COVID-19 pandemic. Specifically, suicidal ideation at T1 in the chronic- and delayed-dysfunction groups was most predictive of other symptoms at T2, whereas "sleep" at T1 in the recovery group and "lack of energy" at T1 in the resistance group may be strongly related to the remission of other depressive symptoms at T2. CONCLUSIONS: These exploratory findings demonstrate the directionality of relationships underlying individual symptoms in the youth and highlight suicidal ideation, sleep, and energy as potential influencers of other depressive symptoms across distinct depressive trajectories. Targeting those symptoms during the outbreak period of COVID 19 would theoretically have been beneficial in preventing and/or reducing the likelihood of spontaneous depression during the subsequent control period.