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Background Mental health problems are highly prevalent in people with type 1 diabetes mellitus (T1DM), which adversely impact physical health and quality of life. This study aimed to explore the experiences of people with T1DM who had completed the Mental health IN DiabeteS Optimal Health Program (MINDS OHP), a novel intervention developed to bridge the gap between physical and mental health care. Method Participants with T1DM were invited to take part in a focus group or semi-structured interviews. Participants were recruited from outpatient and community settings. The focus group and interviews were audio-recorded and transcribed verbatim. Thematic content analysis was used and identified themes were cross-validated by researchers and member-checked by participants. Results Ten people with T1DM were included. Two key themes emerged: ‘MINDS OHP experiences’ and ‘lived experiences of diabetes’. MINDS OHP experiences included five sub-themes: program benefits, follow-up and timing, suggested improvements, collaborative partners, and materials suitability. Lived experiences also included five sub-themes: bridging the gap between mental and physical health, support networks, stigma and shame, management intrusiveness, and adolescence and critical life points. Conclusions The MINDS OHP for people with T1DM was generally well received, though study findings suggest a number of improvements could be made to the program, such as including family members, and consideration being given to its routine early inclusion in diabetes management, ideally in primary care.

Introduction To assess the effects of alcohol and illicit drug use in young adults (age 18–35) with type 1 diabetes (T1D) on flash glucose monitor sensor glucose (SG) readings. Methods Twenty young adults with T1D were enrolled from a tertiary referral hospital outpatient department in Melbourne, Australia for a 6‐week prospective observational study using flash glucose monitoring (FGM). Glucometrics comparing substance using days (SUEDs) to those without substance use (non‐SUEDS) were analysed. The primary outcomes were the difference in mean SG values, its standard deviation and minutes/24‐h period out of range (SG 10.0 mmol/L) between matched SUEDs vs non‐SUEDs. An interaction model with the primary effect of HbA1c on SG values was also performed. Results There were no differences in the primary outcome measures between SUEDS and non‐SUEDs. However, there were differences in the regression coefficients for HbA1c and glucometrics between non‐SUEDs and SUEDs for mean SG, time out of range and time with SG > 10 mmol/L. This difference was also identified between non‐SUEDS and days of ≥40 g alcohol for mean SG. Conclusions While there was no difference between glucometrics for SUEDs and non‐SUEDs on primary outcomes, HbA1C was found to be a less reliable predictor of glucose patterns in the 24‐h period following substance use than control days. Young adults with T1D need to monitor and respond to their glucose levels following substance use and engage in harm minimisation practices irrespective of baseline glucose control., Using FGM, we found no difference in glucometrics in young adults with type 1 diabetes following days of substance use than those without. However, HbA1C values were less predictive of glucometrics on days of substance use than those without substance use. Young adults with T1D, even those with adequate glucose control, need to engage in harm reduction measures, including closer monitoring of their glucose levels, should they choose to consume alcohol or illicit drugs.

Aims Alcohol and recreational drug use is common in young adults with type 1 diabetes (T1DM) and may account for increased morbidity and mortality. This study explores the motivations and experiences unique to this population while using alcohol and recreational drugs. Methods Semi-structured interviews focusing on substance use were performed with 16 young adults aged 18–35 with T1DM who drink alcohol (at least 50 g, 5 Australian standard drinks, in a single session) and/or used recreational drugs. A qualitative interpretative phenomenological analysis (IPA) of the interview data was performed by three clinicians with differing expertise (a psychologist, endocrinologist and addiction medicine specialist). Results A range of motivations, experiences and harm reduction strategies regarding substance use were described specific to young adults with T1DM with most aimed at mitigating the risk of hypoglycaemia. Clinicians remained the most trusted resources, however, substance use was rarely discussed at clinical encounters. Currently available information, especially for illicit drugs, was described as inadequate. Conclusions This analysis identified experiences unique to young adults with T1DM when using alcohol and other drugs. Understanding these experiences and how these young adults attempt to mitigate the risks of substance use may lead to improved clinical interactions and management strategies.

Alcohol and other recreational drug use reaches peak prevalence in young adulthood, including for those with chronic medical conditions such as type 1 diabetes. This review summarises the current literature on the patterns of substance use amongst young adults with type 1 diabetes and the mechanisms through which alcohol and recreational drugs may affect diabetes related health outcomes. These include the direct physical effect of intoxication, as well as the effects of alcohol and drugs on mental health and glucose metabolism. Evidence for increased associated mortality and morbidity is also presented, and current guidelines, management strategies and directions for further research are discussed.

Background: Health care provider experiences of the carer have been researched, but little is written about how these can inform development of support programs. Objectives: This study aimed to (1) explore health care provider perceptions of stroke carer roles and support needs and (2) examine carer needs across the stroke care trajectory to assist with development of an Optimal Health Program (OHP) to support carers. This study is part of a staged program of research that will evaluate and refine the OHP. Methods: Four dual-moderated semi-structured focus groups of stroke health care providers across acute, subacute, and community rehabilitation services were conducted. Facilitators used a semi-structured focus group schedule to guide discussion. Sessions were recorded, transcribed, and analyzed using thematic and content analysis. Results: Three key themes emerged: transition, information, and impact of stroke. A number of subthemes highlighted the distinct roles of health care providers and carers. Specific elements of the OHP were identified as having the potential to advance support for carers across the stroke care trajectory. Discussion: Findings support the integration of an OHP for carers within existing stroke care services in Australian public hospital and community settings. Conclusion: This study suggests how health care provider experiences could inform a self-management OHP to assist carers in navigating stroke services and to address their health-related concerns.

Background: After a diagnosis of diabetes mellitus, people not only have to cope with the physical aspects and common complications that require daily self-management, they are also faced with ongoing psychosocial challenges. Subsequently they find themselves having to navigate the health system to engage multidisciplinary supports; the combination of these factors often resulting in reduced health-related quality of life. To maintain optimal diabetes control, interventions need to incorporate psychosocial supports and a skill base for disease management. Therefore, our aim was to evaluate an 'Optimal Health Program' that adopts a person-centred approach and engages collaborative therapy to educate and support the psychosocial health of people diagnosed with type I or II diabetes. Methods: This prospective randomised controlled trial will include 166 people diagnosed with diabetes: 83 in the intervention (Optimal Health Program) and 83 in the control (usual care) group. Participants with type diabetes mellitus will be recruited through hospital outpatient clinics and diabetes community organisations. Participants in the intervention group will receive nine (8 + 1 booster session) sequential sessions, based on a structured treatment manual emphasising educational and psychosocial support self-efficacy and skills building. The primary outcome measures will be generalised self-efficacy (GSE) and health-related quality of life (AQoL-6D and EQ-5D). Secondary measures will be anxiety and depression (HADS), social and workplace functioning (WSAS), diabetes-related quality of life (DQoL), diabetes-related distress (PAID), and type of coping strategies (Brief COPE). In addition, a health economic cost analysis and process evaluations will be performed to assess the economic cost and efficacy of the program's operations, implementation and service delivery. Discussion: We envisage that the Optimal Health Program's emphasis on self-efficacy and self-management will provide participants with the skills and knowledge to achieve increased empowerment and independence in aspects of health, which in turn, will help participants deal more effectively with the physical and psychosocial complexities of diabetes. Trial registration:ACTRN12614001085662. Registered on 10 October 2014.

Background: Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers. Methods: This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted. Discussion: We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management. Trial registration:ACTRN12615001046594. Registered on 7 October 2015.

A clinical fellowship provides opportunities for health professionals to learn specialist skills from experienced mentors in “real-world” environments. In 2010–2011, I had the opportunity to complete a palliative care and psycho-oncology clinical fellowship in a public hospital. I found ways to integrate academic training into my practice and become a more independent psychologist. In this essay, I aim to share my experience with others and highlight key learnings and challenges I encountered. In providing psychosocial care, I learned to adapt my psychological practice to a general hospital setting, learning about the medical concerns, and life stories of my patients. I faced challenges navigating referral processes and had opportunities to strengthen my psychotherapy training. In the fellowship, I engaged in educational activities from the more familiar psychological skills to observing surgical teams at work. I also developed confidence facilitating groups and an interest in group psychological support for young adult offspring of people with cancer. I was able to engage participants with haematological cancer in qualitative research about their experiences of corticosteroid treatment. In this process, I came to understand the complexity of chemotherapy regimens. Overseeing my development were multiple supervisors, offering unique insights that I could take in and integrate with my personal practice and worldview. Throughout this process I became increasingly tuned into my own process, the impact of the work, and developed self-care routines to help disconnect from my day. I also reflected on my experiences of loss and grief and developed a deeper understanding of myself as a person. I use the metaphor of a parachuting journey to illustrate various aspects of my learning.

DOI: 10.1200/JCO.2013.54.7323 “I’ve always wanted to draw the human body. Can you teach me?” Paul asked before I had the chance to put down my sketchbook and pencils. “It’s the most difficult thing to draw” he continued, leaving me to hurriedly introduce myself as the art therapy student in the psycho-oncology department. The psychologist in our department had referred Paul in the hope that art therapy might offer him a way to express how he felt about his recent paralysis, feelings that he had only hinted at during their sessions. Art therapy is a powerful process that uses visual symbols created in the therapy to work through feeling states and experiences not easily articulated. It is especially helpful for those limited by language or held back by the ferocity of their distress. A growing body of evidence in cancer care reveals improvements in symptoms such as depression, anxiety, pain and fatigue, the benefits particularly apparent where the treatment is delivered by a qualified art therapist. Moreover, art therapy can reestablish a connection with oneself as coherent and enduring, a process described in the qualitative literature as “meaning making” and of special importance in cancer care where a disorienting sense of personal disintegration frequently accompanies diagnosis. My position in the psycho-oncology service acknowledged these benefits to patient care, and I was keen to meet Paul after I heard his story. Paul was a single man in his fifties who worked as a health professional. He had a strongwilled and resilient personality bolstered by his athletic physique, which he had mobilized in his battle against lymphoma 9 years earlier. After many years of good health, he had been admitted to the hospital with relapsed lymphoma complicated by lower limb paralysis. In keeping with his usual coping strategy, he threw himself into his rehabilitation, insisting on “double doses” of physical therapy. He similarly embraced a psycho-oncology referral when his treating team anticipated he might need support adjusting to his paralysis. At our first meeting, Paul struck me as friendly and approachable. His casual clothes and collegial manner suggested that he saw himself as a fellow professional rather than a patient. The process of art therapy privileges the patient’s voice in guiding the work and understanding the symbols created. At Paul’s bidding we began with technical aspects, using light and shadow to sketch real-life objects (Fig 1). After several quite structured sessions in which little emotionally salient material surfaced, Paul admitted to some frustration that his drawings did not emerge as he imagined. This dissatisfaction with the work he produced was apparent in his repetitive titling of each piece with “practice.” Our first sessions coincided with a plateau in his physical progress where his paralysis seemed permanent. In team discussion it became clear that Paul greatly valued achievement and saw himself as able to overcome any adversity with enough effort. This led him to become anxious with tasks he could not easily master, and now, confronted with an apparent stalemate in the presence of fellow health professionals, his attitude was one of self-reproach. To address Paul’s frustration with artistic realism, I led him towards more abstract and spontaneous art making using less constraining materials. During our eighth art therapy session, Paul experimented with acrylic paints and took pleasure in the ensuing mess, a process that can bring people into contact with the child-like aspects of themselves where emotions are less guarded. The colors and shapes evoked childhood memories of earning his place among his older brothers through his sporting prowess, and he lamented the loss of this physical connection through the cancer. Another piece observed from a distance symbolized a shield (Fig 2), and Paul quietly admitted “I want this shield to protect me from my illness, but......I think that I may just have to live with it.” Holding this protective visual metaphor in mind, Paul was able to safely explore his feelings about the irreversible nature of his illness, a process Moon described as “arting out” that empowers the patient to reframe their story by altering or even painting over certain aspects. Paul’s art helped to connect the cancer to his life story while offering a buffer against intolerable feelings that his body, and thus he himself, had failed in some way. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 19 JULY 1 2014