Search the source libraries

Omega-3 polyunsaturated fatty acids protect against inflammation through production of LOX and CYP450 lipid mediators: relevance for major depression and for human hippocampal neurogenesis.

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) can exert antidepressant, anti-inflammatory and neuroprotective properties, but the exact molecular mechanism underlying their effects is still not fully understood. We conducted both in vitro and clinical investigations to test which EPA or DHA metabolites are involved in these anti-inflammatory, neuroprotective and antidepressant effects. In vitro, we used the human hippocampal progenitor cell line HPC0A07/03C, and pre-treated cells with either EPA or DHA, followed by interleukin 1beta (IL1β), IL6 and interferon-alpha (IFN-α). Both EPA and DHA prevented the reduction in neurogenesis and the increase in apoptosis induced by these cytokines; moreover, these effects were mediated by the lipoxygenase (LOX) and cytochrome P450 (CYP450) EPA/DHA metabolites, 5-hydroxyeicosapentaenoic acid (HEPE), 4-hydroxydocosahexaenoic acid (HDHA), 18-HEPE, 20-HDHA, 17(18)-epoxyeicosatetraenoic acid (EpETE) and 19(20)-epoxydocosapentaenoic acid (EpDPA), detected here for the first time in human hippocampal neurones using mass spectrometry lipidomics of the supernatant. In fact, like EPA/DHA, co-treatment with these metabolites prevented cytokines-induced reduction in neurogenesis and apoptosis. Moreover, co-treatment with 17(18)-EpETE and 19(20)-EpDPA and the soluble epoxide hydroxylase (sEH) inhibitor, TPPU (which prevents their conversion into dihydroxyeicosatetraenoic acid (DiHETE)/ dihydroxydocosapentaenoic acid (DiHDPA) metabolites) further enhanced their neurogenic and anti-apoptotic effects. Interestingly, these findings were replicated in a sample of n = 22 patients with a DSM-IV Major Depressive Disorder, randomly assigned to treatment with either EPA (3.0 g/day) or DHA (1.4 g/day) for 12 weeks, with exactly the same LOX and CYP450 lipid metabolites increased in the plasma of these patients following treatment with their precursor, EPA or DHA, and some evidence that higher levels of these metabolites were correlated with less severe depressive symptoms. Overall, our study provides the first evidence for the relevance of LOX- and CYP450-derived EPA/DHA bioactive lipid metabolites as neuroprotective molecular targets for human hippocampal neurogenesis and depression, and highlights the importance of sEH inhibitors as potential therapeutic strategy for patients suffering from depressive symptoms.

Molecular psychiatry · randomised controlled trial · 170 citationsread the source →

A randomised pilot trial for bedtime procrastination: Examining the efficacy and feasibility of the Reducing Evening Screen Time online intervention (REST-O).

Bedtime procrastination is associated with inadequate sleep and is a novel intervention target to improve sleep health. Formative work indicates that pre-sleep electronic device use, a ubiquitous bedtime procrastination behaviour, may be targeted using a behaviour change approach. This pilot study aimed to examine (1) the acceptability and feasibility of the Reducing Evening Screen Time online program (REST-O) in new career starters, and (2) the preliminary effect of the program on daily pre-sleep electronic device use and sleep duration, as well as weekly measures of bedtime procrastination, excessive device use, and sleep quality and duration. Participants (N = 55) were randomised into three arms; an active Control (n = 19), Prevent (n = 18) and Substitute (n = 18), who used behavioural substitution at different times of day. Daily assessments were conducted for two weeks, and weekly measures at baseline, pre-intervention, post-intervention, and follow-up (end of Week Three). All groups experienced a reduction in daily pre-sleep device use (M = 23.4 min per day) and an increase in daily sleep duration (M = 12.7 min per day) post-intervention. Continued reductions in bedtime procrastination, excessive device use, and improvements in sleep quality and duration were observed at follow-up. The program appears feasible and acceptable to participants with a high daily completion rate (M = 84.7 %). Reductions in habit strength and hedonic motivation suggest potential mechanisms of change. Findings provide preliminary evidence for behaviour change interventions in targeting pre-sleep electronic device use and bedtime procrastination, with broader implications for sleep health.

Sleep medicine · randomised controlled trial · 2 citationsread the source →

Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood: Evidence From a Birth Cohort Supporting a Late-Onset Syndrome.

Importance: The requirement of a childhood onset has always been a key criterion for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults, but recently this requirement has become surrounded by controversy. Objective: To investigate whether impaired young adults with ADHD symptoms always have a childhood-onset disorder in a population-based longitudinal study. Design, setting, and participants: Participants belonged to the 1993 Pelotas Birth Cohort Study, including 5249 individuals born in Pelotas, Brazil, in 1993. They were followed up to 18 to 19 years of age, with 81.3% retention. The data analysis was performed between August 8, 2015, and February 5, 2016. Main outcomes and measures: The ADHD status was first ascertained at 11 years of age using a screening instrument (hyperactivity subscale of the Strength and Difficulties Questionnaire) calibrated for a DSM-IV ADHD diagnosis based on clinical interviews with parents using the Development and Well-Being Assessment. At 18 to 19 years of age, ADHD diagnosis was derived using DSM-5 criteria, except age at onset. We estimated the overlap between these groups assessed at 11 and 18 to 19 years of age and the rates of markers of impairment in these 2 groups compared with those without ADHD. Results: At 11 years of age, childhood ADHD (C-ADHD) was present in 393 individuals (8.9%). At 18 to 19 years of age, 492 individuals (12.2%) fulfilled all DSM-5 criteria for young adult ADHD (YA-ADHD), except age at onset. After comorbidities were excluded, the prevalence of YA-ADHD without comorbidities decreased to 256 individuals (6.3%). Children with C-ADHD had a male preponderance not observed among children without ADHD (251 [63.9%] vs 1930 [47.9%] male, P < .001), whereas the YA-ADHD group had a female preponderance (192 [39.0%] vs 1786 [50.4%] male, P < .001). Both groups had increased levels of impairment in adulthood, as measured by traffic incidents, criminal behavior, incarceration, suicide attempts, and comorbidities. However, only 60 children (17.2%) with ADHD continued to have ADHD as young adults, and only 60 young adults (12.6%) with ADHD had the disorder in childhood. Conclusions and relevance: The findings of this study do not support the assumption that adulthood ADHD is necessarily a continuation of childhood ADHD. Rather, they suggest the existence of 2 syndromes that have distinct developmental trajectories.

JAMA psychiatry · 219 citationsread the source →

Towards integration of palliative care in patients with chronic heart failure and chronic obstructive pulmonary disease: a systematic literature review of European guidelines and pathways.

Background: Despite the positive impact of Palliative Care (PC) on the quality of life for patients and their relatives, the implementation of PC in non-cancer health-care delivery in the EU seems scarcely addressed. The aim of this study is to assess guidelines/pathways for integrated PC in patients with advanced Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) in Europe via a systematic literature review. Methods: Search results were screened by two reviewers. Eligible studies of adult patients with CHF or COPD published between 01/01/1995 and 31/12/2013 in Europe in 6 languages were included. Nine electronic databases were searched, 6 journals were hand-searched and citation tracking was also performed. For the analysis, a narrative synthesis was employed. Results: The search strategy revealed 26,256 studies without duplicates. From these, 19 studies were included in the review; 17 guidelines and 2 pathways. 18 out of 19 focused on suffering reduction interventions, 13/19 on a holistic approach and 15/19 on discussions of illness prognosis and limitations. The involvement of a PC team was mentioned in 13/19 studies, the assessment of the patients' goals of care in 12/19 and the advance care planning in 11/19. Only 4/19 studies elaborated on aspects such as grief and bereavement care, 7/19 on treatment in the last hours of life and 8/19 on the continuation of goal adjustment. Conclusion: The results illustrate that there is a growing awareness for the importance of integrated PC in patients with advanced CHF or COPD. At the same time, however, they signal the need for the development of standardized strategies so that existing barriers are alleviated.

BMC palliative care · systematic review · 79 citationsread the source →

Mindfulness-based interventions for weight loss: a systematic review and meta-analysis.

Background: An increasing number of studies are investigating the efficacy of mindfulness-based interventions (MBIs) for weight loss and obesity-related eating behaviours. However, the results of past reviews are inconsistent. Objective: To clarify these inconsistencies, we conducted a comprehensive effect-size analysis to evaluate the efficacy of MBIs on weight loss and eating behaviours. Data source: Data sources were identified through a systematic review of studies published in journals or as dissertations in PsychINFO, PubMed, CINAHL, Web of Science, Medline and Scopus, ProQuest or OATD from the first available date to March 10, 2017. Review methods: A total of 18 publications (19 studies, n = 1,160) were included. Results: Mean weight loss for MBIs at post-treatment was 6.8 and 7.5 lb at follow-up. In pre-post comparisons, effect-size estimates suggest that MBIs are moderately effective for weight loss (n = 16; Hedge's g = .42; 95% CI [.26, .59], p < .000001) and largely effective in reducing obesity-related eating behaviours (n = 10; Hedge's g = .70; CI 95% [.36, 1.04], p < .00005). Larger effects on weight loss were found in studies that used a combination of informal and formal meditation practice (n = 6; Hedge's g = .55; CI 95% [.32, .77], p < .00001) compared with formal meditation practice alone (n = 4; Hedge's g = .46; CI [.10, .83], p < .05). Conclusion: Results suggest that MBIs are effective in reducing weight and improving obesity-related eating behaviours among individuals with overweight and obesity. Further research is needed to examine their efficacy for weight loss maintenance.

Obesity reviews : an official journal of the International Association for the Study of Obesity · meta-analysis · 118 citationsread the source →

Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Effectiveness of these delivery modalities through 4-year follow-up.

Objective: Independent trials have found that the dissonance-based Body Project eating disorder prevention program is efficacious and effective; the present trial provided the first test of whether delivery could be task-shifted from clinician-delivery to peer educator-delivery or Internet-delivery without loss of effectiveness through 4-year follow-up. Method: Young women at high-risk for eating disorders because of body image concerns (N = 680, Mage = 22.2) recruited at 3 colleges were randomized to clinician-led Body Project groups, peer-led Body Project groups, the Internet-based eBody Project, or educational video control. Results: Participants in clinician- and peer-led Body Project groups and the eBody Project generally showed larger reductions in risk factors and eating disorder symptoms versus controls through 1- and 2-year follow-up (d = .16-.59), with some effects persisting through 3- and 4-year follow-ups (d = .28-.58). Peer-led Body Project participants showed greater reductions in some risk factors than eBody Project participants (d = .18-.19), but no other contrasts between Body Project interventions differed. Eating disorder onset over 4-year follow-up was significantly lower for peer-led Body Project participants (8.1%) than control participants (17.6%) and clinician-led Body Project participants (19.3%), and marginally lower than eBody Project participants (15.5%). Conclusions: The evidence that all three Body Project interventions outperformed educational video controls, peer-led groups outperformed the Internet-based intervention, and peer-led groups showed lower eating disorder onset over 4-year follow-up than the other conditions are novel. Results imply that it might be optimal to task-shift Body Project delivery to peer-leaders to address implementation barriers associated with clinician-led delivery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Journal of consulting and clinical psychology · randomised controlled trial · 68 citationsread the source →

Effects of a combined nature-based and audio-based virtual mindfulness intervention on stress and wellbeing of COVID-19 healthcare workers: a randomized controlled trial.

Background: The global COVID-19 pandemic and its subsequent transition to an endemic phase has highly increased psychosocial distress among healthcare workers. This chronic stress may culminate into burnout, which has been associated with impaired patient care and increased medical errors. Exposure to nature-based programs have been shown to reduce levels of perceived stress and promote well-being. However, benefits derived from nature programs can be short-lived. Mindfulness-based interventions represent a promising additive option to enhance benefit. The present study proposes to combine a nature-based program with an audio-based mindfulness intervention to address stress and promote psychosocial-spiritual wellbeing in COVID-19 healthcare workers. Methods: Between June 2021 and October 2023, 78 healthcare workers were randomized into a Nature only group (Nature), a Combined Nature-Mindfulness group (Combined), and a control group (Control), with 19, 16, and 18 subjects completing the study, respectively (23-46 years, mean = 35, SD = 6). The nature program was a three or five-day retreat during which participants engaged in rock climbing, surfing or kayaking. The virtual audio mindfulness intervention was a 10-day program offered online and included mindful breathing, body scan, and loving-kindness meditation. Participants completed self-administered assessments at three or four time points during the study, including at baseline and following study procedures. Assessments included a measure of stress, the Perceived Stress Scale, and a measure of wellbeing, the National Institute of Health Healing Experience of All Life Stressors (NIH-HEALS). Results: The mean baseline Perceived Stress Scale score was 21.2 ± 3.2 in the Combined group, 22.3 ± 2.8 in the Nature group, and 23.2 ± 3.3 in the Control group. Perceived Stress Scale levels did not change following nature-based and mindfulness-based interventions. The mean baseline NIH-HEALS score was 123.1 ± 19.4 in the Combined group, 118.1 ± 17.1 in the Nature group, and 114.3 ± 17.8 in the Control groups. NIH-HEALS scores increased in both the Nature and Combined groups when compared to the Control group. At follow-up, the Combined group maintained improvements in wellbeing when compared to the Nature group. Conclusions: Findings suggest that nature-based programs can be used to improve overall wellbeing among COVID-19 healthcare workers. Additionally, integrating audio-based mindfulness practices to these programs may enhance their benefits. Notably however, these interventions may not effectively reduce perceived stress among COVID-19 healthcare workers. Due to diminished power of the present study, further research is needed to validate and refine the present findings.

PeerJ · randomised controlled trialread the source →

COVID-19 pandemic and mental health consequences: Systematic review of the current evidence.

Background: During the COVID-19 pandemic general medical complications have received the most attention, whereas only few studies address the potential direct effect on mental health of SARS-CoV-2 and the neurotropic potential. Furthermore, the indirect effects of the pandemic on general mental health are of increasing concern, particularly since the SARS-CoV-1 epidemic (2002-2003) was associated with psychiatric complications. Methods: We systematically searched the database Pubmed including studies measuring psychiatric symptoms or morbidities associated with COVID-19 among infected patients and among none infected groups the latter divided in psychiatric patients, health care workers and non-health care workers. Results: A total of 43 studies were included. Out of these, only two studies evaluated patients with confirmed COVID-19 infection, whereas 41 evaluated the indirect effect of the pandemic (2 on patients with preexisting psychiatric disorders, 20 on medical health care workers, and 19 on the general public). 18 of the studies were case-control studies/compared to norm, while 25 of the studies had no control groups. The two studies investigating COVID-19 patients found a high level of post-traumatic stress symptoms (PTSS) (96.2%) and significantly higher level of depressive symptoms (p = 0.016). Patients with preexisting psychiatric disorders reported worsening of psychiatric symptoms. Studies investigating health care workers found increased depression/depressive symptoms, anxiety, psychological distress and poor sleep quality. Studies of the general public revealed lower psychological well-being and higher scores of anxiety and depression compared to before COVID-19, while no difference when comparing these symptoms in the initial phase of the outbreak to four weeks later. A variety of factors were associated with higher risk of psychiatric symptoms and/or low psychological well-being including female gender, poor-self-related health and relatives with COVID-19. Conclusion: Research evaluating the direct neuropsychiatric consequences and the indirect effects on mental health is highly needed to improve treatment, mental health care planning and for preventive measures during potential subsequent pandemics.

Brain, behavior, and immunity · systematic review · 1974 citationsread the source →

Peer support interventions for parents and carers of children with complex needs.

Background: Parents and family carers of children with complex needs experience a high level of pressure to meet children's needs while maintaining family functioning and, as a consequence, often experience reduced well-being and elevated psychological distress. Peer support interventions are intended to improve parent and carer well-being by enhancing the social support available to them. Support may be delivered via peer mentoring or through support groups (peer or facilitator led). Peer support interventions are widely available, but the potential benefits and risks of such interventions are not well established. Objectives: To assess the effects of peer support interventions (compared to usual care or alternate interventions) on psychological and psychosocial outcomes, including adverse outcomes, for parents and other family carers of children with complex needs in any setting. Search methods: We searched the following resources. • Cochrane Central Register of Controlled Trials (CENTRAL; latest issue: April 2014), in the Cochrane Library. • MEDLINE (OvidSP) (1966 to 19 March 2014). • Embase (OvidSP) (1974 to 18 March 2014). • Journals@OVID (22 April 2014). • PsycINFO (OvidSP) (1887 to 19 March 2014). • BiblioMap (EPPI-Centre, Health Promotion Research database) (22 April 2014). • ProQuest Dissertations and Theses (26 May 2014). • metaRegister of Controlled Trials (13 May 2014). We conducted a search update of the following databases. • MEDLINE (OvidSP) (2013 to 20 February 2018) (search overlapped to 2013). • PsycINFO (ProQuest) (2013 to 20 February 2018). • Embase (Elsevier) (2013 to 21 February 2018). We handsearched the reference lists of included studies and four key journals (European Child and Adolescent Psychiatry: 31 March 2015; Journal of Autism and Developmental Disorders: 30 March 2015; Diabetes Educator: 7 April 2015; Journal of Intellectual Disability Research: 13 April 2015). We contacted key investigators and consulted key advocacy groups for advice on identifying unpublished data. We ran updated searches on 14 August 2019 and on 25 May 2021. Studies identified in these searches as eligible for full-text review are listed as "Studies awaiting classification" and will be assessed in a future update. Selection criteria: Randomised and cluster randomised controlled trials (RCTs and cluster RCTs) and quasi-RCTs were eligible for inclusion. Controlled before-and-after and interrupted time series studies were eligible for inclusion if they met criteria set by the Cochrane Effective Practice and Organisation of Care Review Group. The comparator could be usual care or an alternative intervention. The population eligible for inclusion consisted of parents and other family carers of children with any complex needs. We applied no restriction on setting. Data collection and analysis: Inclusion decisions were made independently by two  authors, with differences resolved by a third  author. Extraction to data extraction templates was conducted independently by two authors and cross-checked. Risk of bias assessments were made independently by two authors and were reported according to Cochrane guidelines. All measures of treatment effect were continuous and were analysed in Review Manager version 5.3. GRADE assessments were undertaken independently by two review authors, with differences resolved by discussion. Main results: We included 22 studies (21 RCTs, 1 quasi-RCT) of 2404 participants. Sixteen studies compared peer support to usual care; three studies compared peer support to an alternative intervention and to usual care but only data from the usual care arm contributed to results; and three studies compared peer support to an alternative intervention only. We judged risk of bias as moderate to high across all studies, particularly for selection, performance, and detection bias. Included studies contributed data to seven effect estimates compared to usual care: psychological distress (standardised mean difference (SMD) -0.10, 95% confidence interval (CI) -0.32 to 0.11; 8 studies, 864 participants), confidence and self-efficacy (SMD 0.04, 95% CI -0.14 to 0.21; 8 studies, 542 participants), perception of coping (SMD -0.08, 95% CI -0.38 to 0.21; 3 studies, 293 participants), quality of life and life satisfaction (SMD 0.03, 95% CI -0.32 to 0.38; 2 studies, 143 participants), family functioning (SMD 0.15, 95% CI -0.09 to 0.38; 4 studies, 272 participants), perceived social support (SMD 0.31, 95% CI -0.15 to 0.77; 4 studies, 191 participants), and confidence and skill in navigating medical services (SMD 0.05, 95% CI -0.17 to 0.28; 4 studies, 304 participants). In comparisons to alternative interventions, one pooled effect estimate was possible: psychological distress (SMD 0.2, 95% CI -0.38 to 0.79; 2 studies, 95 participants). No studies reported on adverse outcomes. All narratively synthesised data for psychological distress (compared to usual care - 2 studies), family functioning (compared to usual care - 1 study; compared to an alternative intervention - 1 study), perceived social support (compared to usual care - 2 studies), and self-efficacy (compared to alternative interventions - 1 study) were equivocal. Comparisons with usual care showed no difference between intervention and control groups (perceived social support), some effect over time for both groups but more effect for intervention (distress), or mixed effects for intervention (family function). Comparisons with alternative interventions showed no difference between the intervention of interest and the alternative. This may indicate similar effects to the intervention of interest or lack of effect of both, and we are  uncertain which option is likely. We found no clear evidence of effects of peer support interventions on any parent outcome, for any comparator; however, the certainty of evidence for each outcome was low to very low, and true effects may differ substantially from those reported here. We found no evidence of adverse events such as mood contagion,  negative group interactions, or worsened psychological health. Qualitative data suggest that parents and carers value peer support interventions and appreciate emotional support. Authors' conclusions: Parents and carers of children with complex needs perceive peer support interventions as valuable, but this review found no evidence of either benefit or harm. Currently, there is uncertainty about the effects of peer support interventions for parents and carers of children with complex needs. However, given the overall low to very low certainty of available evidence, our estimates showing no effects of interventions may very well change with further research of higher quality.

The Cochrane database of systematic reviews · systematic review · 51 citationsread the source →

Factors predisposing women to chronic pelvic pain: systematic review.

Objective: To evaluate factors predisposing women to chronic and recurrent pelvic pain. DESIGN, DATA SOURCES, AND METHODS: Systematic review of relevant studies without language restrictions identified through Medline, Embase, PsycINFO, Cochrane Library. SCISEARCH, conference papers, and bibliographies of retrieved primary and review articles. Two reviewers independently extracted data on study characteristics, quality, and results. Exposure to risk factors was compared between women with and without pelvic pain. Results were pooled within subgroups defined by type of pain and risk factors. Results: There were 122 studies (in 111 articles) of which 63 (in 64,286 women) evaluated 54 risk factors for dysmenorrhoea, 19 (in 18,601 women) evaluated 14 risk factors for dyspareunia, and 40 (in 12,040 women) evaluated 48 factors for non-cyclical pelvic pain. Age < 30 years, low body mass index, smoking, earlier menarche (< 12 years), longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse, and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise, and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety, and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic inflammatory disease, previous caesarean section, pelvic pathology, abuse, and psychological comorbidity were associated with an increased risk of non-cyclical pelvic pain. Conclusion: Several gynaecological and psychosocial factors are strongly associated with chronic pelvic pain. Randomised controlled trials of interventions targeting these potentially modifiable factors are needed to assess their clinical relevance in chronic pelvic pain.

BMJ (Clinical research ed.) · meta-analysis · 302 citationsread the source →

REFOCUS-PULSAR recovery-oriented practice training in specialist mental health care: a stepped-wedge cluster randomised controlled trial.

Background: Recovery-oriented practice promotes the strengths and recovery potential of individuals. We aimed to establish whether individuals who access mental health services where staff have received the REFOCUS-PULSAR intervention, an adaptation of the UK's REFOCUS recovery-oriented staff intervention for use in Australia, show increased recovery compared with people using non-intervention services. Methods: We did a pragmatic, two-step, stepped-wedge, randomised controlled trial at 18 sites grouped into 14 clusters across public mental health services and mental health community support services in Victoria, Australia. Eligible staff were working part-time or full-time in a direct service role at one of the 18 sites and had consumers being recruited for this study. Eligible consumers were receiving care from a participating cluster, with contact in the 3 months before data collection; aged 18-75 years; and not imprisoned. Clusters were randomly assigned with a web-based randomisation tool to receive the REFOCUS-PULSAR intervention in either the first year (step one) or second year (step two). Consumers, but not staff, were masked to treatment assignment. The primary outcome was the Questionnaire about the Process of Recovery (QPR), for which cross-sectional data were collected across three timepoints (baseline [T0], year 1 [T1], and year 2 [T2]). The primary analysis was done by intention to treat. This trial is registered with ANZCTR, number ACTRN12614000957695. Findings: 190 staff (111 from public mental health services and 79 from mental health community support services) received the REFOCUS-PULSAR recovery-oriented training intervention. Between Sept 18, 2014, and May 19, 2017, 942 consumers were recruited across the three timepoints (T0: n=301; T1: n=334; T2: n=307). The mean QPR score was 53·6 (SD 16·3) in the control group and 54·4 (16·2) in the intervention group (adjusted difference 3·7, 95% CI 0·5-6·8; p=0·023). The Cohen's d value for the intervention effect was small (d=0·23). Interpretation: The REFOCUS-PULSAR intervention had a small but significant effect on the QPRs of individuals using community mental health services and might be effective in promotion of recovery-oriented practice across sectors. Funding: Victorian Government Mental Illness Research Fund.

The lancet. Psychiatry · randomised controlled trial · 39 citationsread the source →

Efficacy and safety of the muscarinic receptor agonist KarXT (xanomeline-trospium) in schizophrenia (EMERGENT-2) in the USA: results from a randomised, double-blind, placebo-controlled, flexible-dose phase 3 trial.

Background: New treatments with new mechanisms are urgently needed for people with schizophrenia. Xanomeline is a dual M1 and M4-preferring muscarinic receptor agonist that does not block D2 dopamine receptors, unlike all currently approved treatments for schizophrenia. Xanomeline-trospium (KarXT) combines xanomeline with the peripherally restricted muscarinic receptor antagonist trospium chloride with the goal of ameliorating xanomeline-related adverse events associated with peripheral muscarinic receptors. The EMERGENT-2 trial aimed to assess the efficacy and safety of KarXT in people with schizophrenia experiencing acute psychosis. Methods: EMERGENT-2 was a randomised, double-blind, placebo-controlled, flexible-dose, 5-week, inpatient, phase 3 trial in people with schizophrenia. Participants were adults aged 18-65 years with a diagnosis of schizophrenia who had a recent worsening of psychosis warranting hospital admission, a Positive and Negative Syndrome Scale (PANSS) score of 80 or higher, and a Clinical Global Impression-Severity score of 4 or higher. The participants were recruited from 22 inpatient sites in the USA, and were randomly assigned (1:1) to KarXT or placebo twice per day. Participants randomly assigned to KarXT received 50 mg xanomeline and 20 mg trospium twice per day for the first 2 days and then 100 mg xanomeline and 20 mg trospium twice per day for days 3-7. Beginning on day 8, KarXT dosing was flexible with an optional increase to 125 mg xanomeline and 30 mg trospium twice per day and the option to return to 100 mg xanomeline and 20 mg trospium based on tolerability. The primary endpoint was change from baseline to week 5 in PANSS total score. Efficacy analyses used the modified intention-to-treat population (all randomly assigned participants who received at least one trial medication dose and had at least one post-baseline PANSS assessment). Least squares mean change from baseline, SE, and least squares mean difference between the KarXT and placebo groups at week 5, along with the 95% CI and two-sided p values were calculated for the primary and secondary continuous efficacy endpoints. Safety analyses included all participants receiving at least one trial medication dose and used descriptive statistics. This trial is registered with ClinicalTrials.gov (NCT04659161). Findings: From Dec 16, 2020, to April 13, 2022, of 407 people who were screened, 252 participants meeting enrolment criteria were randomly assigned to the KarXT (n=126) or placebo (n=126). Baseline PANSS total scores were 98·3 (KarXT; n=126) and 97·9 (placebo; n=125). The trial met the primary endpoint with a mean change from baseline to week 5 in PANSS total score that favoured KarXT (-21·2 points, SE 1·7) versus placebo (-11·6 points, 1·6; least squares mean difference -9·6; 95% CI -13·9 to -5·2; p<0·0001, Cohen's d effect size=0·61). All secondary endpoints were also met, and favoured KarXT versus placebo (p<0·05). The most common adverse events with KarXT versus placebo were constipation (27 [21%] vs 13 [10%]), dyspepsia (24 [19%] vs 10 [8%]), headache (17 [14%] vs 15 [12%]), nausea (24 [19%] vs seven [6%]), vomiting (18 [14%] vs one [1%]), hypertension (12 [10%] vs one [1%]), dizziness (11 [9%] vs four [3%]), gastro-oesophageal reflux disease (eight [6%] vs zero [0%]), and diarrhoea (seven [6%] vs four [3%]). Treatment-emergent adverse event rates of extrapyramidal motor symptoms (KarXT, zero [0%] vs placebo, zero [0%]), akathisia (one [1%] vs one [1%]), weight gain (zero [0%] vs one [1%]), and somnolence (six [5%] vs five [4%]) were similar between the KarXT and placebo groups, as were adverse event-related discontinuation rates (nine [7%] vs seven [6%]). Interpretation: In the EMERGENT-2 trial, KarXT was effective in reducing positive and negative symptoms and was generally well tolerated. These results support the potential for KarXT to represent a new class of effective and well tolerated antipsychotic medicines based on activating muscarinic receptors, not the D2 dopamine receptor-blocking mechanism of all current antipsychotic medications. Results from additional trials, including the identical EMERGENT-3 trial and the 52-week, open-label EMERGENT-4 and EMERGENT-5 trials, will provide additional information on the efficacy and safety of KarXT in people with schizophrenia. Funding: Karuna Therapeutics.

Lancet (London, England) · randomised controlled trial · 144 citationsread the source →

Kleine-Levin syndrome: a systematic review of 186 cases in the literature.

Kleine-Levin syndrome (KLS) is a rare disorder with symptoms that include periodic hypersomnia, cognitive and behavioural disturbances. Large series of patients are lacking. In order to report on various KLS symptoms, identify risk factors and analyse treatment response, we performed a systematic review of 195 articles, written in English and non-English languages, which are available on Medline dating from 1962 to 2004. Doubtful or duplicate cases, case series without individual details and reviews (n = 56 articles) were excluded. In addition, the details of 186 patients from 139 articles were compiled. Primary KLS cases (n = 168) were found mostly in men (68%) and occurred sporadically worldwide. The median age of onset was 15 years (range 4-82 years, 81% during the second decade) and the syndrome lasted 8 years, with seven episodes of 10 days, recurring every 3.5 months (median values) with the disease lasting longer in women and in patients with less frequent episodes during the first year. It was precipitated most frequently by infections (38.2%), head trauma (9%), or alcohol consumption (5.4%). Common symptoms were hypersomnia (100%), cognitive changes (96%, including a specific feeling of derealization), eating disturbances (80%), hypersexuality (43%), compulsions (29%), and depressed mood (48%). In 75 treated patients (213 trials), somnolence decreased using stimulants (mainly amphetamines) in 40% of cases, while neuroleptics and antidepressants were of poor benefit. Only lithium (but not carbamazepine or other antiepileptics) had a higher reported response rate (41%) for stopping relapses when compared to medical abstention (19%). Secondary KLS (n = 18) patients were older and had more frequent and longer episodes, but had clinical symptoms and treatment responses similar to primary cases. In conclusion, KLS is a unique disease which may be more severe in female and secondary cases.

Brain : a journal of neurology · systematic review · 166 citationsread the source →

Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial.

Background: Internet-based interventions for smoking cessation could help millions of people stop smoking at very low unit costs; however, long-term biochemically verified evidence is scarce and such interventions might be less effective for smokers with low socioeconomic status than for those with high status because of lower online literacy to engage with websites. We aimed to assess a new interactive internet-based intervention (StopAdvisor) for smoking cessation that was designed with particular attention directed to people with low socioeconomic status. Methods: We did this online randomised controlled trial between Dec 6, 2011, and Oct 11, 2013, in the UK. Participants aged 18 years and older who smoked every day were randomly assigned (1:1) to receive treatment with StopAdvisor or an information-only website. Randomisation was automated with an unseen random number function embedded in the website to establish which treatment was revealed after the online baseline assessment. Recruitment continued until the required sample size had been achieved from both high and low socioeconomic status subpopulations. Participants, and researchers who obtained data and did laboratory analyses, were masked to treatment allocation. The primary outcome was 6 month sustained, biochemically verified abstinence. The main secondary outcome was 6 month, 7 day biochemically verified point prevalence. Analysis was by intention to treat. Homogeneity of intervention effect across the socioeconomic subsamples was first assessed to establish whether overall or separate subsample analyses were appropriate. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN99820519. Findings: We randomly assigned 4613 participants to the StopAdvisor group (n=2321) or the control group (n=2292); 2142 participants were of low socioeconomic status and 2471 participants were of high status. The overall rate of smoking cessation was similar between participants in the StopAdvisor and control groups for the primary (237 [10%] vs 220 [10%] participants; relative risk [RR] 1·06, 95% CI 0·89-1·27; p=0·49) and the secondary (358 [15%] vs 332 [15%] participants; 1·06, 0·93-1·22; p=0·37) outcomes; however, the intervention effect differed across socioeconomic status subsamples (1·44, 0·99-2·09; p=0·0562 and 1·37, 1·02-1·84; p=0·0360, respectively). StopAdvisor helped participants with low socioeconomic status stop smoking compared with the information-only website (primary outcome: 90 [8%] of 1088 vs 64 [6%] of 1054 participants; RR 1·36, 95% CI 1·00-1·86; p=0·0499; secondary outcome: 136 [13%] vs 100 [10%] participants; 1·32, 1·03-1·68, p=0·0267), but did not improve cessation rates in those with high socioeconomic status (147 [12%] of 1233 vs 156 [13%] of 1238 participants; 0·95, 0·77-1·17; p=0·61 and 222 [18%] vs 232 [19%] participants; 0·96, 0·81-1·13, p=0·64, respectively). Interpretation: StopAdvisor was more effective than an information-only website in smokers of low, but not high, socioeconomic status. StopAdvisor could be implemented easily and made freely available, which would probably improve the success rates of smokers with low socioeconomic status who are seeking online support. Funding: National Prevention Research Initiative.

The Lancet. Respiratory medicine · randomised controlled trial · 99 citationsread the source →

What Factors Are Most Closely Associated With Mood Disorders in Adolescents During the COVID-19 Pandemic? A Cross-Sectional Study Based on 1,771 Adolescents in Shandong Province, China.

Background and Aims: COVID-19 has been proven to harm adolescents' mental health, and several psychological influence factors have been proposed. However, the importance of these factors in the development of mood disorders in adolescents during the pandemic still eludes researchers, and practical strategies for mental health education are limited. Methods: We constructed a sample of 1,771 adolescents from three junior high middle schools, three senior high middle schools, and three independent universities in Shandong province, China. The sample stratification was set as 5:4:3 for adolescent aged from 12 - 15, 15 - 18, 18 - 19. We examined the subjects' anxiety, depression, psychological resilience, perceived social support, coping strategies, subjective social/school status, screen time, and sleep quality with suitable psychological scales. We chose four widely used classification models-k-nearest neighbors, logistic regression, gradient-boosted decision tree (GBDT), and a combination of the GBDT and LR (GBDT + LR)-to construct machine learning models, and we utilized the Shapley additive explanations value (SHAP) to measure how the features affected the dependent variables. The area under the curve (AUC) of the receiver operating characteristic (ROC) curves was used to evaluate the performance of the models. Results: The current rates of occurrence of symptoms of anxiety and depression were 28.3 and 30.8% among the participants. The descriptive and univariate analyses showed that all of the factors included were statistically related to mood disorders. Among the four machine learning algorithms, the GBDT+LR algorithm achieved the best performance for anxiety and depression with average AUC values of 0.819 and 0.857. We found that the poor sleep quality was the most significant risk factor for mood disorders among Chinese adolescents. In addition, according to the feature importance (SHAP) of the psychological factors, we proposed a five-step mental health education strategy to be used during the COVID-19 pandemic (sleep quality-resilience-coping strategy-social support-perceived social status). Conclusion: In this study, we performed a cross-sectional investigation to examine the psychological impact of COVID-19 on adolescents. We applied machine learning algorithms to quantify the importance of each factor. In addition, we proposed a five-step mental health education strategy for school psychologists.

Frontiers in psychiatry · 43 citationsread the source →

Prevalence of Domestic Violence Among Trauma Patients.

Importance: Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. Objective: To assess the reported prevalence of domestic violence among trauma patients. Design, setting, and participants: A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. Participants: Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. Main outcomes and measures: To assess the reported prevalence of domestic violence among trauma patients. Results: A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per 1000 discharges in 2012; P = .001) over the 6-year period and remained unchanged for elderly patients (0.8 cases per 1000 discharges in 2007 to 0.96 cases per 1000 discharges in 2012; P = .09). On subanalysis of adults and elderly patients, the prevalence of domestic violence increased among both female (4.6 cases per 1000 discharges in 2007 to 5.3 cases per 1000 discharges in 2012; P = .001) and male patients (1.5 cases per 1000 discharges in 2007 to 2.8 cases per 1000 discharges in 2012; P = .001). Conclusions and relevance: Domestic violence is prevalent among trauma patients. Over the years, the reported prevalence of domestic violence has been increasing among children and adults, and continues to remain high among female trauma patients. A robust mandatory screening for evaluating domestic violence among trauma patients, along with a focused national intervention, is warranted.

JAMA surgery · cohort or longitudinal · 27 citationsread the source →

A co-designed mHealth programme to support healthy lifestyles in Māori and Pasifika peoples in New Zealand (OL@-OR@): a cluster-randomised controlled trial.

Background: The OL@-OR@ mobile health programme was co-designed with Māori and Pasifika communities in New Zealand, to support healthy lifestyle behaviours. We aimed to determine whether use of the programme improved adherence to health-related guidelines among Māori and Pasifika communities in New Zealand compared with a control group on a waiting list for the programme. Methods: The OL@-OR@ trial was a 12-week, two-arm, cluster-randomised controlled trial. A cluster was defined as any distinct location or setting in New Zealand where people with shared interests or contexts congregated, such as churches, sports clubs, and community groups. Members of a cluster were eligible to participate if they were aged 18 years or older, had regular access to a mobile device or computer, and had regular internet access. Clusters of Māori and of Pasifika (separately) were randomly assigned (1:1) to either the intervention or control condition. The intervention group received the OL@-OR@ mHealth programme (smartphone app and website). The control group received a control version of the app that only collected baseline and outcome data. The primary outcome was self-reported adherence to health-related guidelines, which were measured with a composite health behaviour score (of physical activity, smoking, alcohol intake, and fruit and vegetable intake) at 12 weeks. The secondary outcomes were self-reported adherence to health-related behaviour guidelines at 4 weeks; self-reported bodyweight at 12 weeks; and holistic health and wellbeing status at 12 weeks, in all enrolled individuals in eligible clusters; and user engagement with the app, in individuals allocated to the intervention. Adverse events were not collected. This study is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12617001484336. Findings: Between Jan 24 and Aug 14, 2018, we enrolled 337 Māori participants from 19 clusters and 389 Pasifika participants from 18 clusters (n=726 participants) in the intervention group and 320 Māori participants from 15 clusters and 405 Pasifika participants from 17 clusters (n=725 participants) in the control group. Of these participants, 227 (67%) Māori participants and 347 (89%) Pasifika participants (n=574 participants) in the intervention group and 281 (88%) Māori participants and 369 (91%) Pasifika participants (n=650 participants) in the control group completed the 12-week follow-up and were included in the final analysis. Relative to baseline, adherence to health-related behaviour guidelines increased at 12 weeks in both groups (315 [43%] of 726 participants at baseline to 329 [57%] of 574 participants in the intervention group; 331 [46%] of 725 participants to 369 [57%] of 650 participants in the control group); however, there was no significant difference between intervention and control groups in adherence at 12 weeks (odds ratio [OR] 1·13; 95% CI 0·84-1·52; p=0·42). Furthermore, the proportion of participants adhering to guidelines on physical activity (351 [61%] of 574 intervention group participants vs 407 [63%] of 650 control group participants; OR 1·03, 95% CI 0·73-1·45; p=0·88), smoking (434 [76%] participants vs 501 [77%] participants; 1·12, 0·67-1·87; p=0·66), alcohol consumption (518 [90%] participants vs 596 [92%] participants; 0·73, 0·37-1·44; p=0·36), and fruit and vegetable intake (194 [34%] participants vs 196 [30%] participants; 1·08, 0·79-1·49; p=0·64) did not differ between groups. We found no significant differences between the intervention and control groups in any secondary outcome. 147 (26%) intervention group participants engaged with the OL@-OR@ programme (ie, set at least one behaviour change goal online). Interpretation: The OL@-OR@ mobile health programme did not improve adherence to health-related behaviour guidelines amongst Māori and Pasifika individuals. Funding: Healthier Lives He Oranga Hauora National Science Challenge.

The Lancet. Digital health · randomised controlled trial · 45 citationsread the source →

Reduced dorsal anterior cingulate cortical activity during emotional regulation and top-down attentional control in generalized social phobia, generalized anxiety disorder, and comorbid generalized social phobia/generalized anxiety disorder.

Background: Generalized social phobia (GSP) and generalized anxiety disorder (GAD) are both associated with emotion dysregulation. Research implicates dorsal anterior cingulate cortex in both explicit emotion regulation (EER) and top-down attentional control (TAC). Although studies have examined these processes in GSP or GAD, no work compares findings across the two disorders or examines functioning in cases comorbid for both disorders (GSP/GAD). Here we compare the neural correlates of EER and TAC in GSP, GAD, and GSP/GAD. Methods: Medication-free adults with GSP (EER n = 19; TAC n = 18), GAD (EER n = 17; TAC n = 17), GSP/GAD (EER n = 17; TAC n = 15), and no psychopathology (EER n = 18; TAC n = 18) participated. During EER, individuals alternatively viewed and upregulated and downregulated responses to emotional pictures. During TAC, they performed an emotional Stroop task. Results: For both tasks, significant group × condition interactions emerged in dorsal anterior cingulate cortex and parietal cortices. Healthy adults showed significantly increased recruitment during emotion regulation, relative to emotion-picture viewing. GAD, GSP, and GSP/GAD subjects showed no such increases, with all groups differing from healthy adults but not from each other. Evidence of emotion-related disorder-specificity emerged in medial prefrontal cortex and amygdala. This disorder-specific responding varied as a function of emotion content but not emotion-regulatory demands. Conclusions: GSP and GAD both involve reduced capacity for engaging emotion-regulation brain networks, whether explicitly or via TAC. A reduced ability to recruit regions implicated in top-down attention might represent a general risk factor for anxiety disorders.

Biological psychiatry · cohort or longitudinal · 132 citationsread the source →

Text Messaging-Based Interventions for Smoking Cessation: A Systematic Review and Meta-Analysis.

Background: Tobacco use is one of the leading preventable global health problems producing nearly 6 million smoking-related deaths per year. Interventions delivered via text messaging (short message service, SMS) may increase access to educational and support services that promote smoking cessation across diverse populations. Objective: The purpose of this meta-analysis is to (1) evaluate the efficacy of text messaging interventions on smoking outcomes, (2) determine the robustness of the evidence, and (3) identify moderators of intervention efficacy. Methods: Electronic bibliographic databases were searched for records with relevant key terms. Studies were included if they used a randomized controlled trial (RCT) to examine a text messaging intervention focusing on smoking cessation. Raters coded sample and design characteristics, and intervention content. Summary effect sizes, using random-effects models, were calculated and potential moderators were examined. Results: The meta-analysis included 20 manuscripts with 22 interventions (N=15,593; 8128 (54%) women; mean age=29) from 10 countries. Smokers who received a text messaging intervention were more likely to abstain from smoking relative to controls across a number of measures of smoking abstinence including 7-day point prevalence (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.22, 1.55, k=16) and continuous abstinence (OR=1.63, 95% CI=1.19, 2.24, k=7). Text messaging interventions were also more successful in reducing cigarette consumption relative to controls (d+=0.14, 95% CI=0.05, 0.23, k=9). The effect size estimates were biased when participants who were lost to follow-up were excluded from the analyses. Cumulative meta-analysis using the 18 studies (k=19) measuring abstinence revealed that the benefits of using text message interventions were established only after only five RCTs (k=5) involving 8383 smokers (OR=1.39, 95% CI=1.15, 1.67, P<.001). The inclusion of the subsequent 13 RCTs (k=14) with 6870 smokers did not change the established efficacy of text message interventions for smoking abstinence (OR=1.37, 95% CI=1.25, 1.51, P<.001). Smoking abstinence rates were stronger when text messaging interventions (1) were conducted in Asia, North America, or Europe, (2) sampled fewer women, and (3) recruited participants via the Internet. Conclusions: The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well-established. Using text messaging to support quitting behavior, and ultimately long-term smoking abstinence, should be a public health priority.

JMIR mHealth and uHealth · review · 169 citationsread the source →

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic.

Background: The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order. Methods: A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses. Results: Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618). Conclusion: This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s). Level of evidence: Epidemiological, level IV.

The journal of trauma and acute care surgery · cohort or longitudinal · 80 citationsread the source →

The algorithm of dissatisfaction: social media and body image crisis among university students.

Introduction: To map and critically synthesize evidence (2020-2025) on the relationship between social media use/exposure and body image among university students, we conducted a scoping review guided by Arksey and O'Malley's methodological framework and reported according to PRISMA-ScR. A descriptive numerical summary and qualitative thematic synthesis were produced; meta-analysis was not conducted due to heterogeneity in study designs and outcome measures. Methodology: Seven databases (PubMed/MEDLINE, PsycINFO, Embase, CINAHL, Scopus, Web of Science, and Google Scholar) were searched using controlled vocabulary and free-text terms related to body image constructs, social media platforms/content, and higher education populations. Eligible peer-reviewed studies (quantitative, qualitative, mixed-methods, and systematic/scoping reviews) included samples with ≥ 70% university students and assessed a body image outcome in relation to social media exposure. Results: A total of 81 studies (N = 19,947; ages predominantly 18-25; ~70% women) met inclusion criteria: 55.6% were cross-sectional, 18.5% experimental, 14.8% mixed-methods, and 11.1% longitudinal or EMA-based. Discussion: Six non-exclusive thematic groups were identified: [1] body dissatisfaction/shame/low physical self-esteem (63.0%); [2] eating disorders and weight control behaviours (32.1%); [3] cosmetic procedure seeking and probable body dysmorphic disorder (BDD) (11.1%); [4] protective/positive content (body positivity/neutrality, self-compassion), including brief "social media breaks" (16.0%); [5] psychological mediators/moderators (including self-objectification) (33.3%); and (6) methodological contributions (e.g., EMA designs, longitudinal and experimental approaches, and social media-specific measurement advances) (3.7%). Across all designs, the emotional the emotional valence, degree of idealization, and appearance-focused or stigmatizing nature of contentconsistently predicted outcomes more strongly than time-based exposure metrics. Brief, theory-based, digitally delivered interventions showed modest short-term improvements, although questions remain about their scalability and long-term efficacy. Conclusion: Despite methodological advances, the evidence base is still constrained by cross-sectional self-report data, varied measurement tools, and underrepresentation of male and gender-diverse populations. Universities are encouraged to incorporate media literacy, comparison reappraisal, and self-compassion into student wellbeing programs, while future research should prioritize harmonized effect size reporting, mechanism-focused trials, and ethically governed digital trace methodologies.

BMC psychology · reviewread the source →

Exercise is more effective than health education in reducing fatigue in fatigued cancer survivors.

Introduction: Cancer-related fatigue is a most debilitating side effect reported by survivors, often lasting years following treatment. Purpose: To determine the effects of a 10-week exercise intervention compared with a health education intervention on fatigue, quality of life outcomes and functional fitness in cancer survivors with documented fatigue. Methods: This quasi-experimental study allocated 37 post-treatment fatigued cancer survivors (33 female, 30 breast cancer, aged 55 ± 2 years, time since treatment 2.3 ± 0.3 years; mean ± SEM) to an exercise group (EX, n = 19) or health education comparison group (HE, n = 18). The EX intervention emphasised brisk walking with progressive increments, stretching, exercise education and self-efficacy enhancement. The HE intervention emphasised sleep management, nutrition and cognitive behavioural therapy. All participants were evaluated at pre- and post-intervention with EX followed up at 26 W. Results: The intervention effect on fatigue (FACT-F) in EX was greater (p < 0.05) than that in HE, the difference being 4 times the recognised clinically important difference. The intervention also increased (p < 0.05) cognitive function, global quality of life and functional fitness scores. It reduced (p < 0.05) insomnia and fear of physical activity. All intervention effects were maintained to 26 W. The intervention effect on fatigue in EX was largely achieved by week 4. There was 100% retention rate at 10 W and no adverse events reported. Conclusions: There is a reduction of considerable magnitude in cancer fatigue from group-based exercise training, that is sustainable and attributable to exercise per se. Implications for cancer survivors: Exercise training is feasible for fatigued cancer survivors and should form part of tailored rehabilitation programmes.

Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer · clinical trial · 23 citationsread the source →

Early liver transplantation for severe alcohol-related hepatitis not responding to medical treatment: a prospective controlled study.

Background: Early liver transplantation for severe alcohol-related hepatitis is an emerging treatment option. We aimed to assess the risk of alcohol relapse 2 years after early liver transplantation for alcohol-related hepatitis compared with liver transplantation for alcohol-related cirrhosis after at least 6 months of abstinence. Methods: We conducted a multicentre, non-randomised, non-inferiority, controlled study in 19 French and Belgian hospitals. All participants were aged 18 years or older. There were three groups of patients recruited prospectively: patients with severe alcohol-related hepatitis who did not respond to medical treatment and were eligible for early liver transplantation according to a new selection scoring system based on social and addiction items that can be quantified in points (early transplantation group); patients with alcohol-related cirrhosis listed for liver transplantation after at least 6 months of abstinence (standard transplantation group); patients with severe alcohol-related hepatitis not responding to medical treatment not eligible for early liver transplantation according to the selection score (not eligible for early transplantation group), this group did not enter any further liver transplantation processes. We also defined a historical control group of patients with severe alcohol-related hepatitis unresponsive to medical therapy and non-transplanted. The primary outcome was the non-inferiority of 2-year rate of alcohol relapse after transplantation in the early transplantation group compared with the standard transplantation group using the alcohol timeline follow back (TLFB) method and a prespecified non-inferiority margin of 10%. Secondary outcomes were the pattern of alcohol relapse, 2-year survival rate post-transplant in the early transplantation group compared with the standard transplantation group, and 2-year overall survival in the early transplantation group compared with patients in the not eligible for early transplantation group and historical controls. This trial is registered with ClinicalTrials.gov, NCT01756794. Findings: Between Dec 5, 2012, and June 30, 2016, we included 149 patients with severe alcohol-related hepatitis: 102 in the early transplantation group and 47 in the not eligible for early transplantation group. 129 patients were included in the standard transplantation group. 68 patients in the early transplantation group and 93 patients in the standard transplantation group received a liver transplant. 23 (34%) patients relapsed in the early transplantation group, and 23 (25%) patients relapsed in the standard transplantation group; therefore, the non-inferiority of early transplantation versus standard transplantation was not demonstrated (absolute difference 9·1% [95% CI -∞ to 21·1]; p=0·45). The 2-year rate of high alcohol intake was greater in the early transplantation group than the standard transplantation group (absolute difference 16·7% [95% CI 5·8-27·6]) The time spent drinking alcohol was not different between the two groups (standardised difference 0·24 [95% CI -0·07 to 0·55]), but the time spent drinking a large quantity of alcohol was higher in the early transplantation group than the standard transplantation group (standardised difference 0·50 [95% CI 0·17-0·82]). 2-year post-transplant survival was similar between the early transplantation group and the standard transplantation group (hazard ratio [HR] 0·87 [95% CI 0·33-2·26]); 2-year overall survival was higher in the early transplantation group than the not eligible for early transplantation group and historical controls (HR 0·27 [95% CI 0·16-0·47] and 0·21 [0·13-0·32]). Interpretation: We cannot conclude non-inferiority in terms of rate of alcohol relapse post-transplant between early liver transplantation and standard transplantation. High alcohol intake is more frequent after early liver transplantation. This prospective controlled study confirms the important survival benefit related to early liver transplantation for severe alcohol-related hepatitis; and this study provides objective data on survival and alcohol relapse to tailor the management of patients with severe alcohol-related hepatitis. Funding: The present study has been granted by the French Ministry of Health-Programme Hospitalier de Recherche Clinique 2010.

The lancet. Gastroenterology & hepatology · randomised controlled trial · 103 citationsread the source →

Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.

Background: Before the COVID-19 pandemic, coronaviruses caused two noteworthy outbreaks: severe acute respiratory syndrome (SARS), starting in 2002, and Middle East respiratory syndrome (MERS), starting in 2012. We aimed to assess the psychiatric and neuropsychiatric presentations of SARS, MERS, and COVID-19. Methods: In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature databases (from their inception until March 18, 2020), and medRxiv, bioRxiv, and PsyArXiv (between Jan 1, 2020, and April 10, 2020) were searched by two independent researchers for all English-language studies or preprints reporting data on the psychiatric and neuropsychiatric presentations of individuals with suspected or laboratory-confirmed coronavirus infection (SARS coronavirus, MERS coronavirus, or SARS coronavirus 2). We excluded studies limited to neurological complications without specified neuropsychiatric presentations and those investigating the indirect effects of coronavirus infections on the mental health of people who are not infected, such as those mediated through physical distancing measures such as self-isolation or quarantine. Outcomes were psychiatric signs or symptoms; symptom severity; diagnoses based on ICD-10, DSM-IV, or the Chinese Classification of Mental Disorders (third edition) or psychometric scales; quality of life; and employment. Both the systematic review and the meta-analysis stratified outcomes across illness stages (acute vs post-illness) for SARS and MERS. We used a random-effects model for the meta-analysis, and the meta-analytical effect size was prevalence for relevant outcomes, I2 statistics, and assessment of study quality. Findings: 1963 studies and 87 preprints were identified by the systematic search, of which 65 peer-reviewed studies and seven preprints met inclusion criteria. The number of coronavirus cases of the included studies was 3559, ranging from 1 to 997, and the mean age of participants in studies ranged from 12·2 years (SD 4·1) to 68·0 years (single case report). Studies were from China, Hong Kong, South Korea, Canada, Saudi Arabia, France, Japan, Singapore, the UK, and the USA. Follow-up time for the post-illness studies varied between 60 days and 12 years. The systematic review revealed that during the acute illness, common symptoms among patients admitted to hospital for SARS or MERS included confusion (36 [27·9%; 95% CI 20·5-36·0] of 129 patients), depressed mood (42 [32·6%; 24·7-40·9] of 129), anxiety (46 [35·7%; 27·6-44·2] of 129), impaired memory (44 [34·1%; 26·2-42·5] of 129), and insomnia (54 [41·9%; 22·5-50·5] of 129). Steroid-induced mania and psychosis were reported in 13 (0·7%) of 1744 patients with SARS in the acute stage in one study. In the post-illness stage, depressed mood (35 [10·5%; 95% CI 7·5-14·1] of 332 patients), insomnia (34 [12·1%; 8·6-16·3] of 280), anxiety (21 [12·3%; 7·7-17·7] of 171), irritability (28 [12·8%; 8·7-17·6] of 218), memory impairment (44 [18·9%; 14·1-24·2] of 233), fatigue (61 [19·3%; 15·1-23·9] of 316), and in one study traumatic memories (55 [30·4%; 23·9-37·3] of 181) and sleep disorder (14 [100·0%; 88·0-100·0] of 14) were frequently reported. The meta-analysis indicated that in the post-illness stage the point prevalence of post-traumatic stress disorder was 32·2% (95% CI 23·7-42·0; 121 of 402 cases from four studies), that of depression was 14·9% (12·1-18·2; 77 of 517 cases from five studies), and that of anxiety disorders was 14·8% (11·1-19·4; 42 of 284 cases from three studies). 446 (76·9%; 95% CI 68·1-84·6) of 580 patients from six studies had returned to work at a mean follow-up time of 35·3 months (SD 40·1). When data for patients with COVID-19 were examined (including preprint data), there was evidence for delirium (confusion in 26 [65%] of 40 intensive care unit patients and agitation in 40 [69%] of 58 intensive care unit patients in one study, and altered consciousness in 17 [21%] of 82 patients who subsequently died in another study). At discharge, 15 (33%) of 45 patients with COVID-19 who were assessed had a dysexecutive syndrome in one study. At the time of writing, there were two reports of hypoxic encephalopathy and one report of encephalitis. 68 (94%) of the 72 studies were of either low or medium quality. Interpretation: If infection with SARS-CoV-2 follows a similar course to that with SARS-CoV or MERS-CoV, most patients should recover without experiencing mental illness. SARS-CoV-2 might cause delirium in a significant proportion of patients in the acute stage. Clinicians should be aware of the possibility of depression, anxiety, fatigue, post-traumatic stress disorder, and rarer neuropsychiatric syndromes in the longer term. Funding: Wellcome Trust, UK National Institute for Health Research (NIHR), UK Medical Research Council, NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London.

The lancet. Psychiatry · meta-analysis · 1531 citationsread the source →

AIDS as a chronic illness: psychosocial implications

Introduction Early in the epidemic, the public perception of AIDS as a highly fatal acute illness with a rapid downward trajectory was crystallized. Nevertheless, as early as 1991 in the nursing and medical sociology literature, a few investigators were already discussing HIV/AIDS as a chronic illness (for example [1,2]). Shortly thereafter, a number of psychosocial investigations of small groups of long-term AIDS survivors appeared in the literature, although these cases were still seen as infrequent exceptions (see [3] for a review). It was not until the advent of protease inhibitors in 1996, which ushered in the era of highly active antiretroviral therapy (HAART), that the view of AIDS as a chronic illness became widely accepted. These medications were touted in the mass media as ‘miraculous’ because they reduced the risk of opportunistic infections and extended survival by suppressing viral replication and increasing CD4 cell counts. Their availability was said to have “reinserted the word ‘hope’ into the discussion about AIDS for the first time in a decade of treatment trials” [4] (p. 161), and to have offered infected individuals the opportunity for a “second life” [5]. Among those at advanced stages of the disease, recoveries have often been so dramatic that the phenomenon has been dubbed the ‘Lazarus Syndrome’, referring to the seeming rising from the dead made possible by these new medications [6]. While in the United States recent treatment advances have had a profound impact on the illness trajectory and thus life expectancy of many infected individuals [7], AIDS-related mortality continues to rise unabated in parts of the world where access to the new therapies is limited. The prohibitively high prices of antiretrovirals coupled with inadequate and inefficient health delivery systems have allowed AIDS to reach catastrophic levels in many developing countries [8]. Even in the United States, however, not all infected persons have access to or choose to adopt the new treatments. Some physicians are less likely to offer HAART to patients they assume to be at risk for poor adherence, such as those with a history of drug use, the homeless, and the mentally ill [9–11], although the evidence supporting their actions remains inconclusive [12, 13]. Other research indicates that women, African-Americans, and those with low levels of education are less likely to have ever used the new therapies [14–17]. These findings have been attributed not only to a lack of access to these medications among these socio-economically disadvantaged groups, but also to their own reluctance to use them due to such factors as fear of medication side-effects and distrust of physicians. Similar issues were identified as barriers to antiretroviral use and medication adherence before HAART became available [18,19]. Chronic illness and AIDS Chronic illnesses are typically incurable, and thus the goals of medical care are usually containment, slowing disease progression and symptom management rather than cure. Beyond this, chronic diseases tend to share a variety of characteristics [20–23]. Frequently, they have an uncertain course or disease trajectory often characterized by alternating periods of remission and recurrence, or stable periods interrupted by episodic exacerbations of symptoms. Most require adherence to a treatment regimen, although these differ significantly across diseases in complexity and efficacy. Chronic disease also typically requires considerable self-care (including self-monitoring of symptoms) on the patient's part, since most of the day-to-day management of the illness takes place outside formal health institutions or facilities. As illness is a form of deviance and thus an undesirable state, chronic conditions also carry some degree of stigma. However, this varies greatly across diseases and depends on a variety of factors, such as whether the individual is perceived as being responsible for having acquired the illness, whether the illness is contagious and whether there is visible disfigurement. In addition, changes in roles and relationships are common. Illness almost always necessitates some degree of dependency, at least at the more advanced stages of a disease. Roles and responsibilities in relationships and families typically must be re-negotiated in light of the patient's limitations or disabilities. Finally, chronic diseases often bring about identity changes as the patient attempts to integrate the illness into his/her life and self-perception over the long haul. Psychological distress is a prevalent concomitant of living with chronic conditions, because of the uncertainty inherent in many of these illness characteristics. Each of these aspects of chronic disease posses an adaptive task or challenge (e.g., tolerating uncertainty, managing stigma, adhering to treatment) that is stressful for the individual to confront. How well the chronically ill individual will adapt to one's disease will depend in large part on his/her ability to master, or at least successfully manage, these tasks. Today, AIDS meets the criteria for a chronic illness [24]. While available treatments can render a viral load undetectable, they cannot fully eradicate it from the body and, left untreated, the viral load will rebound. Consequently, there is still no cure for the disease. Furthermore, while the natural history of the disease has been delineated, the course of HIV disease progression varies considerably among individuals [25]. Current multi-drug regimens remain complex, often requiring that many pills be taken on a rigid schedule while following strict dietary guidelines. Yet, similar to many other chronic illnesses, the regimens for HIV infection are not equally effective for all patients [26]. It is also well recognized that HIV/AIDS has a profound impact on intimate and social relationships. The fact that the disease can be transmitted through sexual behaviors renders intimate relationships fraught with anxiety and ambivalence. Moreover, infected adults often feel that others are unwilling to enter into long-term relationships with them for fear of having to assume care-giving responsibilities when the disease progresses. Additionally, self-care is a component of living with HIV. Many patients engage in self-initiated strategies (e.g., diet, relaxation exercises, stress avoidance) aimed at managing illness or treatment-related symptoms, boosting their immune system, or alleviating stress. In the present paper, we discuss several of the principal characteristics of chronic illnesses, reviewing in each case the relevant available literature. In each section, we attempt to highlight continuities and discontinuities between the pre-HAART and the HAART eras. In addition, we discuss prevention in the context of AIDS as a chronic illness. We conclude with some suggestions for future research in the field of HIV/AIDS and chronic illness. Emotional distress From the outset of the AIDS epidemic, there has been considerable documentation of the adverse psychological consequences of knowing one is infected. When AIDS was viewed as a highly fatal illness with an inexorable downhill course, much of this work focused on assessing depression (depressive symptomatology or clinical depression) and suicidal ideation or acts. While the findings of studies sometimes differed, the preponderance of evidence from the pre-HAART era suggested that depression was prevalent and that suicidal ideation and risk were elevated [27–30]. Infected individuals seemed particularly emotionally vulnerable shortly after diagnosis, when HIV-related symptoms first appeared, in the later stages of the disease, and after suffering multiple AIDS-related losses in their social network. It is a widely held, although largely unexamined, assumption that the experience of living with HIV infection in the HAART era is significantly less distressing compared with the past because of the prospects for extended survival and enhanced quality of life offered by the new treatments. Only recently, however, has this issue begun to be empirically investigated. Rabkin et al. [31] followed a sample of gay and bisexual men with symptomatic illness over a period that included the time before and after the availability of protease inhibitors. On all measures of psychological distress employed, the sample as a whole showed a statistically significant, although clinically modest, decline over time (when CD4 cell count, HIV symptoms, physical limitations, and social support were included as co-variates). However, when they further compared subjects whose status on medical markers had improved and had not improved, no significant differences in decline in hopelessness or improvement in quality of life were observed. In another study [32], changes in depressive symptomatology were investigated among 456 HIV-infected individuals (433 men) receiving antiretroviral treatment who were asked to complete a self-administered questionnaire annually. All study participants had completed at least one survey before and one after using protease inhibitors. The investigators found that, between assessment points, the percentage of individuals with a score indicative of probable clinical depression declined from 52 to 46%. While this change was not statistically significant, there were improvements in the total score of the Center for Epidemiological Studies—Depression scale, as well as on the depressive mood, positive affect and somatic symptom subscales. Similarly, in another study [33], changes in depressive symptomatology among 125 HIV-infected adults (most homosexual/bisexual males) assessed at 6-month intervals over a 2-year period were examined. The investigators found a pattern of declining scores on the Beck Depression Inventory over time, especially after the third assessment (12 months after baseline), when 51% of study participants were receiving HAART. There was, however, substantial drop-out before the 6-month assessment, and the number of cases included at each assessment point varied. It thus seems that the evidence on whether living with HIV infection is less psychologically distressing since the availability of HAART remains inconclusive. If ultimately it is shown to be so, this could have implications for needed mental health services. Catalan et al. [34], for example, suggest that as AIDS becomes a more manageable disease there will be a diminished need for acute mental health services (e.g., psychiatric hospitalization, crisis intervention), and a greater need for interventions assisting individuals in adjusting long-term to chronic-illness-related psychosocial stressors. While this may be true among gay and bisexual men and drug users who can recall infected individuals’ bleaker prospects in the pre-HAART era, the need for acute psychiatric services may grow among more recently impacted populations, such as infected adults living in rural America, adolescents, and heterosexual women without a history of drug use. Members of these populations often do not recognize that they were at risk for infection, making diagnosis a more psychologically disruptive event. Uncertainty Individuals living with HIV/AIDS have always confronted uncertainty. Early in the epidemic, this uncertainty revolved around issues such as when one had become infected, where one was in the disease trajectory, how long one was likely to survive, and whether any effective treatments for slowing or halting progression of one's disease would be developed. With the advent of zidovudine and other drugs of the pre-HAART era, uncertainty centered on issues such as whether to get tested, when to initiate treatment, and whether one would have a positive response to treatment. With the availability of HAART, new uncertainties have emerged [35] while old ones persist. For example, many infected individuals who realize extended survival as a result of new treatment regimens may confront emerging opportunistic infections that, in the past, patients did not live long enough to experience. Also, because these medications are new, there is uncertainty about their long-term safety. There is also a lack of clarity about how functional a restored immune system is likely to be [36,37]. The meaning of an improved CD4 cell count, a fundamental disease marker, is also ambiguous. For instance, is an individual who was diagnosed earlier as having AIDS solely on the basis of a CD4 cell count below 200 and who now has a count above that threshold still considered as having AIDS [35]? Those with advanced disease who had expected to die, but have now experienced a ‘reprieve’ on protease inhibitors, may feel insecure about their new-found well-being. While no longer imminently facing death, and possibly they recognize that they could experience a at any time, and The of many is by the fact that they have been to significant in their Finally, as in the pre-HAART era, and uncertainty to the of the time to initiate medication use Those who have not HAART recognize that not or can the Furthermore, those who have experienced recognize that they may be over an extended period of time adherence to the [26]. another of uncertainty is the risk of developing drug with Roles and relationships health has allowed infected individuals to the assumption of new social roles or the to old ones (e.g., For example, the in that zidovudine treatment could significantly of the from an infected to allowed infected women to more With the advent of HAART, more may now as a significant in viral load further the risk of survival and improved health due to HAART may also earlier about not being to or long enough to a However, the adverse of on their health to be of HIV-infected women the and of in the HAART Many infected individuals from HAART are also to work to their to become more to feel more and to however, uncertainty the impact of the stress of work their their after a long period of and their ability to their their health decline Many also about and in the Moreover, not all those using the new treatments feel to but may feel to do so the public perception of the new therapies as infected persons may that others view them as The of extended survival has also many infected individuals to the they have made their relationships Those a many of the confronted before HAART, the anxiety of one's HIV one's and Moreover, in an era of viral the of and may a considerable in relationships. The of living longer and may those who have in relationships because of about health and to the of these relationships Furthermore, the of of and sexual relationships may be anxiety when infected individuals do not feel for these changes The diagnosis of a chronic illness typically necessitates identity work Infected individuals differ in how they integrate their illness in their one are those who their life around their illness. These individuals may work or for AIDS are in or social on of infected and largely their social to other infected the other are those who have to and their illness while as much as possible with their to the illness from a in their In the era, many living with HIV/AIDS now have the opportunity to as living with a chronic illness rather than from a disease. Furthermore, new treatments have patients to feel and to their for longer periods of time, thus the and of the illness and the of the patient However, patients may feel their medication regimens are a of their patient From the outset of the epidemic, infected individuals have been and by have been to and social among physicians and in the United States to care for HIV-infected individuals has been well since early in the reluctance to care for these patients between 1991 and in HIV-related in the United States some but also some of stigma, support for (e.g., had significantly in almost of the that those with AIDS were responsible for the illness. Furthermore, significant they would be or having their with a with AIDS or having an with AIDS or at a where the had AIDS substantial also in that HIV could be transmitted through with AIDS on the a with them and using public all likely to be with to and HIV-infected has also that AIDS is on the it may be and at infected groups and of infected individuals may be greater in developing countries where there has been public education about the disease study of HIV-infected women in rural their that the to them at the time of delivery because of their infected that the medical were infected patients to the were also by study and so was their fear that their would or them Many infected individuals and the and feel and however, the and the and to public patients to remain for longer periods of time, the new treatments have made it possible for them to their illness longer and to as Their social identity as is thus and the many infected individuals experience with their distressing consequences are Yet, they may the psychological of having to a identity and possibly needed adherence The by of the of protease inhibitors was by the that adherence to these and regimens was often a task has been attributed to the to medication fear of the high that medication use will to of illness, and the of For these many individuals treatment or have been unwilling to use protease inhibitors from their physicians to do so While the of the recently regimens for treatment are being the impact of these of treatment on adherence remains to be While the of intervals may adherence because patients can to these treatment they also may adherence by patients to initiate their own who are to adherence to treatment regimens may engage in and have a of Those adhering to but not the dramatic health that early media with the ‘miraculous’ new medications may experience a of anxiety and fear and have also that, before HAART, all infected individuals a from the illness. However, now that some from treatment while others do of and has been by one of as becomes more that can be by and individual but also the to and (p. Finally, because many will not from HAART, those who do may experience a of similar to that in gay men who and to AIDS earlier in the care an part of the management of most chronic Many individuals living with HIV/AIDS engage in a variety of self-care to their immune system, to disease to stress and to symptoms. may be as as that their in a that for periods of so as to manage, for instance, remains a although we have an study infected individuals’ self-initiated for managing symptoms that they to the illness or to antiretroviral The research has focused on the use of and the of the new treatment use by HIV-infected persons has not diminished in the HAART era and and and or are used by infected adults in an to their immune system, to symptoms or medication and to stress. However, as most research has been on gay men with high levels of these findings may not be to other more disadvantaged populations, such as and In own we have found that infected adults often to when they cannot the side-effects of antiretrovirals or they Furthermore, most as than treatments. to these therapies is also by since the of many of are not by health in the era of HAART There is a that the of the new HAART and the availability of may to an in for a variety of the that AIDS is a chronic illness may significantly the of infection that has the of risk with considerably extended for may be a task for especially they feel well and become in relationships. some that having an viral load the of the to a on the impact of the new therapies on infected and although that the new treatments are about the of and sometimes also behaviors In a study of women and of heterosexual were asked about their and sexual behaviors the of viral and the new treatments. While many study that they were not as about being HIV positive because of the improved and they viewed AIDS as a less illness in the protease inhibitors era, they also that viral load and the new therapies (including have not them from Other however, evidence that the new treatments are in of sexual especially among gay and bisexual In one investigators found that, among active gay and bisexual those having sexual were more likely to the that having a who protease inhibitors or whose viral load is is less Additionally, a study of and heterosexual found that gay and bisexual men were more likely to sexual with or status in the HAART era while the sexual of heterosexual Finally, in a study of men and women who were and in more since the new therapies became available for future research for future research are suggested by the present that in survival and quality of life made possible by HAART can only be by those to these we must the treatment are the characteristics and of infected individuals who choose to remain antiretroviral to to their disease through or some other form or The phenomenon of long-term survivors be a one as treatments to the life expectancy of infected How is the of of later impacted by this illness. How HIV/AIDS or In the United States, HIV/AIDS has been a health in rural however, the of research on the disease has been on where health and social are more available and infected individuals may be more research whether the of living with HIV/AIDS in rural the rapid into rural among adolescents, heterosexual women, and future prevention and studies need to these more recently of risk behaviors and interventions behaviors were from work with gay and often these and interventions are in and long-term adherence to among the more recently populations be investigated. The of the epidemic, extended and new of AIDS as a manageable chronic illness may the of new prevention of the consequences that the new of AIDS as a manageable disease will have on and active of HIV-infected individuals is also As the treatment advances the and the health of will the fear and with the disease and, will social of those infected The issue of also be examined. HIV-infected individuals feel less about their illness, and are they more to their HIV status to in light of recent treatment advances and their consequences for those living with the As the present there are many continuities as well as discontinuities in the experience of living with HIV/AIDS over the past There is to feel by the that has been made since the of the in the diagnosis, treatment and clinical management of this disease. however, are still many of the psychosocial as in the pre-HAART era, in While we AIDS as a chronic illness, we to and we have about to with the illness, since many of the issues remain as the

AIDS · review · 178 citationsread the source →

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries.

Background: Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap. Objectives: To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies. Selection criteria: Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review). Data collection and analysis: Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect. Main results: The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care. Authors' conclusions: Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.

The Cochrane database of systematic reviews · meta-analysis · 353 citationsread the source →

Effectiveness of the Stand More AT (SMArT) Work intervention: cluster randomised controlled trial.

Objectives: To evaluate the impact of a multicomponent intervention (Stand More AT (SMArT) Work) designed to reduce sitting time on short (three months), medium (six months), and longer term (12 months) changes in occupational, daily, and prolonged sitting, standing, and physical activity, and physical, psychological, and work related health. Design: Cluster two arm randomised controlled trial. Setting: National Health Service trust, England. Participants: 37 office clusters (146 participants) of desk based workers: 19 clusters (77 participants) were randomised to the intervention and 18 (69 participants) to control. Interventions: The intervention group received a height adjustable workstation, a brief seminar with supporting leaflet, workstation instructions with sitting and standing targets, feedback on sitting and physical activity at three time points, posters, action planning and goal setting booklet, self monitoring and prompt tool, and coaching sessions (month 1 and every three months thereafter). The control group continued with usual practice. Main outcome measures: The primary outcome was occupational sitting time (thigh worn accelerometer). Secondary outcomes were objectively measured daily sitting, prolonged sitting (≥30 minutes), and standing time, physical activity, musculoskeletal problems, self reported work related health (job performance, job satisfaction, work engagement, occupational fatigue, sickness presenteeism, and sickness absenteeism), cognitive function, and self reported psychological measures (mood and affective states, quality of life) assessed at 3, 6, and 12 months. Data were analysed using generalised estimating equation models, accounting for clustering. Results: A significant difference between groups (in favour of the intervention group) was found in occupational sitting time at 12 months (-83.28 min/workday, 95% confidence interval -116.57 to -49.98, P=0.001). Differences between groups (in favour of the intervention group compared with control) were observed for occupational sitting time at three months (-50.62 min/workday, -78.71 to -22.54, P<0.001) and six months (-64.40 min/workday, -97.31 to -31.50, P<0.001) and daily sitting time at six months (-59.32 min/day, -88.40 to -30.25, P<0.001) and 12 months (-82.39 min/day, -114.54 to -50.26, P=0.001). Group differences (in favour of the intervention group compared with control) were found for prolonged sitting time, standing time, job performance, work engagement, occupational fatigue, sickness presenteeism, daily anxiety, and quality of life. No differences were seen for sickness absenteeism. Conclusions: SMArT Work successfully reduced sitting time over the short, medium, and longer term, and positive changes were observed in work related and psychological health. Trial registration: Current Controlled Trials ISRCTN10967042.

BMJ (Clinical research ed.) · randomised controlled trial · 140 citationsread the source →

Deficits in docosahexaenoic acid and associated elevations in the metabolism of arachidonic acid and saturated fatty acids in the postmortem orbitofrontal cortex of patients with bipolar disorder.

Previous antemortem and postmortem tissue fatty acid composition studies have observed significant deficits in the omega-3 fatty acid docosahexaenoic acid (DHA, 22:6n-3) in red blood cell (RBC) and postmortem cortical membranes of patients with unipolar depression. In the present study, we determined the fatty acid composition of postmortem orbitofrontal cortex (OFC, Brodmann area 10) of patients with bipolar disorder (n=18) and age-matched normal controls (n=19) by gas chromatography. After correction for multiple comparisons, DHA (-24%), arachidonic acid (-14%), and stearic acid (C18:0) (-4.5%) compositions were significantly lower, and cis-vaccenic acid (18:1n-7) (+12.5%) composition significantly higher, in the OFC of bipolar patients relative to normal controls. Based on metabolite:precursor ratios, significant elevations in arachidonic acid, stearic acid, and palmitic acid conversion/metabolism were observed in the OFC of bipolar patients, and were inversely correlated with DHA composition. Deficits in OFC DHA and arachidonic acid composition, and elevations in arachidonic acid metabolism, were numerically (but not significantly) greater in drug-free bipolar patients relative to patients treated with mood-stabilizer or antipsychotic medications. OFC DHA and arachidonic acid deficits were greater in patients plus normal controls with high vs. low alcohol abuse severity. These results add to a growing body of evidence implicating omega-3 fatty acid deficiency as well as the OFC in the pathoaetiology of bipolar disorder.

Psychiatry research · cohort or longitudinal · 99 citationsread the source →

Pregnancy in Adolescence - A Challenge Beyond Public Health Policies

Recent Sustainable Development Goals were established by the United Nations (2015–2030), including the broad goal of “good health and wellbeing” for all. Good health and wellbeing (item 3), quality education (item 4), gender equality (item 5) and reduced inequalities (item 10) are among the 17 items of the list.[ 1 ] These four cited goals are directly linked to the unresolved issue of pregnancy during adolescence, and point to fact that well-directed work needs to be done in this area. According to the United Nations Population Fund (UNFPA), around 16 million girls between the ages of 15 and 19, and 1 million girls under the age of 15, give birth every year around the world. In addition, ∼ 95% of these deliveries are concentrated in developing countries, and it is estimated that by 2035 births will be ∼ 20 million, making pregnancy in adolescence one of the major public health problems.[ 2 ] [ 3 ] In Brazil, the 2015 National Household Sample Program (PNAD, in the Portuguese acronym) compared the specific fertility rate of women aged 15 to 19 between the years of 2004 and 2014, and this indicator changed from 78.8 to 60.5 children per thousand women in this age group. The participation of adolescents in the total fertility rate remained high, going from 18.4 to 17.4% in the same period.[ 4 ] Maternity during adolescence draws attention to political debates and issues that have been studied in different areas of knowledge. In the area of public health, teenage pregnancy is considered a major problem due to the high prevalence and perinatal risks. Adolescent pregnancies may be considered high risk, especially those of adolescents under the age of 15, and they often fall outside the statistics data.[ 5 ] Childbirth and complications of pregnancy are the leading causes of hospitalization and death among adolescent women in developing countries. Anemia, preeclampsia and postpartum hemorrhage may occur in greater proportions than in adult pregnant women.[ 6 ] A recent study among pregnant Brazilian adolescents found that 42% of them suffered from anemia.[ 7 ] Preterm birth, low birth weight, low Apgar score and perinatal mortality are also more frequent among the children of teenagers.[ 6 ] The nutritional aspects should also be considered a problem in the association of gestation with adolescence, since these are two periods of great metabolic transformations overlapping. Adolescents in general present an accelerated increase in their overall metabolism, and often have poor nutritional habits and make poor food choices, a behavior that generates deficiencies in the intake of some micronutrients, higher rates of overweight and obesity, in addition to a greater frequency of pathological eating disorders, such as bulimia and anorexia.[ 8 ] Obesity may be associated with early menarche, which is one of the risk factors for early pregnancy. During pregnancy, teenagers can experiment excessive gestational weight gain, and that may result in post-pregnancy weight retention and obesity in adult life. Overweightness and obesity affect ∼ 30–40% of Brazilian women in reproductive age with physical and psychological repercussions leading to an increased risk of non-communicable diseases and a cycle of morbidity and poor health condition in the broadest sense.[ 9 ] [ 10 ] [ 11 ] [ 12 ] Besides the aforementioned medical risks, there is an increase in the social risk related to the physical, emotional, economic, and social dependence of these girls. There is also a greater risk of violence, in all its forms, associated with the lack of autonomy of these mothers in making their own decisions. Lack of autonomy can compromise the aspects related to the evolution of the gestation, as well as various aspects of the mother's future life. Examples of this condition include the later onset of prenatal follow-up,[ 6 ] and the higher prevalence of “delays” in obstetric care, related to the occurrence of maternal near miss, both of which are higher among adolescents.[ 13 ] Unwanted pregnancy is an important cause of morbidity in adolescence, and the use of effective contraception is one of the fundamental pillars that prevent the occurrence of this problem.[ 14 ] In the United States, teenage pregnancy rates are the highest among high-income countries.[ 15 ] However, there has been a reduction since 1990, which could be associated with educational programs that address responsible sexuality and contraceptive use among adolescents. Such educational programs would have been responsible for 86% of this decline.[ 16 ] The use of a “double method” or “double protection,” which consists of the use of a condom associated with another effective method, and a more widespread use of long-acting reversible contraceptives (LARCs) accompanied this reduction.[ 17 ] Any reversible method of contraception can be used for adolescents. Neither the age nor the number of previous pregnancies constitutes a medical reason to contraindicate any of them. It is important to remember that, whatever the choice, it should be based on current scientific information, respecting the eligibility criteria of each method established by the World Health Organization (WHO) and the recommendations of the Brazilian Ministry of Health.[ 18 ] [ 19 ] A Brazilian study shows that after childbirth, the most used contraceptive method was depot medroxyprogesterone acetate (DMPA). To improve contraception and reduce the chance of unintended pregnancies among adolescents, we should promote the use of LARCs.[ 20 ] A recent systematic review of the Cochrane Library compiled studies with a higher quality of information elaboration and consistency, and concluded that it is necessary to integrate educational interventions and offer contraceptive methods in order to reduce the phenomenon of teenage pregnancy.[ 21 ] The abstention from formal education among adolescent pregnant women is relevant, and many of them do not have the opportunity to resume their education once they give birth due to the time they spend in the care of their newborns.[ 22 ] The lower schooling of adolescents at the time of their first pregnancy can be attributed to this serious condition of social deprivation (dropping out of school), and could be one of the reasons behind the etiology of the problem, being the cause, and not the consequence. Disruption of studies in the puerperal period are often unavoidable due to lack of support for these girls and their babies. This all adds to the negative social and economic impact on the adolescents, their families, and society as a whole, for it hinders them from using their potential to invest in their education, find a job and ear an income. The absence from school also increases the chances of a recurring pregnancy still during adolescence. On the other hand, adolescents who do not become pregnant are more likely to finish high school.[ 22 ] In addition to formal education, adolescent sexual education is required. It is widely quoted by the WHO / and The Joint United Nations Program on HIV/AIDS (UNAIDS) that “Sexual education does not lead to increased sexual activity or stimulation of early sexual activity,” and a sexual orientation and education policy is necessary to enable “educated and empowered women and girls to make decisions about their own health,” thereby ensuring their reproductive rights, according to Dr. Margaret Chan, Director-General of the WHO. In this context, the role of the gynecologist-obstetrician is to guide and ensure safe and effective contraception and protection from sexually transmitted diseases. For pregnant teenagers, they could perform prenatal care, preferably with a multidisciplinary team composed of motivated professionals aiming at pregnancy care, as well as health promotion in the general sense. In the puerperal period, it is necessary to pay special attention to contraception, because the risk of another pregnancy is greater then. It is also important to recruit all possible support, so that these young mothers can resume their life plans. More than an organic look at the risks involved in gestation among adolescents, the meaning of pregnancy varies according to the social context in which the teenager is inserted. The restricted perspective of personal growth by these young women, the lack of educational incentive and labor market, make them find in pregnancy and in the social role of being a mother a life goal. In this sense, it is perceived that dealing with the reality of pregnancy in adolescence involves dealing with contradictions and ethical dilemmas that go beyond the clinical protocols of care. Adolescent pregnancy requires critical insight. It is a public health problem, and it presents different dimensions as a human and social phenomenon in different cultures, but its occurrence can often disrupt personal growth and development, and jeopardize future opportunities for many girls. Finally, it is a question of gender and vulnerability that reflects all kinds of inequity.

Revista Brasileira Ginecologia e Obstetrícia · editorial or comment · 27 citationsread the source →

Decision-Making and Cognitive Strategies

“I think, therefore I am” - Rene Descartes “He who knows most, knows best how little he knows.” - Thomas Jefferson The past decade has seen a considerable increase in interest in understanding the cognitive underpinnings of medical decision making in dynamic acute care arenas. Errors caused by faulty thought processes more than faulty knowledge are called “cognitive errors” and may be caused by bias, heuristic, emotion, and other nonrational cognitive elements.1,2 Although a few groups (including both authors of this article) have been studying cognition and problem solving in dynamic arenas such as emergency medicine, intensive care, or anesthesiology—including some going back more than 20 years3—these concepts are not yet well-known to many clinicians and simulation educators. Moreover, the literature on these topics exists in many different kinds of journals and indices and under a variety of key words, which may make finding salient information more challenging. Murray et al4 deserve congratulations for their work described in this issue of Simulation in Healthcare that uses simulation to understand more fully such decision making by individuals and teams.4 “Decision Making in Trauma Settings: Simulation to Improve Diagnostic Skills” highlights critical questions about clinical decision making in a dynamic arena. The study design, assumptions, and conclusions can serve as the basis for an important discussion about many facets of this complex process. One issue highlighted in the article of Murray et al is whether people are, in general, prone to certain kinds of foibles in decision making when a situation has some elements consistent with a simple explanation, along the lines of what they expect, but is actually more complex. Another is the interplay between individual decision and group decision making because health care quality and safety are known to be properties of teams rather than just of individuals. At issue as well is the contribution of clinical experience to “expertise” and to “performance.” Are experts and novices prone to different kinds of decision error in their application of knowledge (even when their “book knowledge” is equal)? We must also consider how accurately inferences can be made about thought process from observing surface behaviors. If making accurate inferences is difficult, how else might we better assess thought processes? Ultimately, one of the key goals in answering such questions is to determine how best to train new clinicians in these arenas of complex decision making to implement optimal decision-making strategies. HOW CAN WE DEFINE “SIMPLE” OR “COMPLEX”? DOES A “COMPLEX” PROBLEM NECESSARILY RESULT IN ANALYSIS OR A “SIMPLE” ONE IN USE OF HEURISTICS? In medicine, any case could appear to be a simple one if the available data seem to fit well within a recognized “illness script” or pattern. An illness script is a specific type of memory schema that represents generalized patient-oriented clinical events as a unit, in a precompiled knowledge structure. These scripts are stored in long-term memory and are the result of repeated direct or vicarious experiences.5 Use of illness scripts and pattern recognition are examples of intuitive decision strategy shortcuts, also called heuristics. Heuristics and other cognitive biases are widely discussed in the literature as potential sources of compromise to decision making.1,6–10 Heuristics may be applied implicitly, as when we believe that we recognize a pattern and therefore do not engage in any formal reasoning, or deliberately, as when we consciously abandon detailed abstract analysis of the available data and “go with our gut” (sometimes described as “analysis paralysis”). In dynamic settings, some degree of heuristic decision making is inevitable—thinking through in detail every single action would be impossible. Importantly, it is always possible to abandon heuristic or pattern-matching strategies in favor of analysis even when faced with a simple problem; likewise, analysis may be abandoned in a complex situation to go with an intuitively appealing solution or when the need to act becomes pressing. No strategy works perfectly all the time. As well, problems in highly dynamic areas of medicine are often ill-defined (ie, there is no clear single correct or best solution, and the quality of decision making is subject to judgment that often varies considerably even among content experts in the same domain). Unfortunately, patients do not come with a little flag that says what is really wrong with them. Failure to rapidly identify and treat problems can be just as deleterious as premature closure on the wrong, but early, identification of the problem. Either with classic situations (that do actually match a typical patterns) or with situations that demand quick action on the most serious possible etiology (eg, start cardiopulmonary resuscitation on an unresponsive patient without a quickly palpable pulse), waiting for analysis can be a mistake. Clinicians are thus thrust between the horns of a dilemma—whether to act quickly, risking that the early impression could be wrong, or whether to wait for certainty. Indeed, in many clinical emergencies, “correct” actions that are not implemented quickly become ineffective, and the decision to delay action in favor of analysis is itself an incorrect decision (eg, delayed defibrillation while causes are considered increases mortality11). However, it has also been posited that acting too rashly accounts for more patient harm than a few moments of planning and deliberation.12 Many models of decision making posit a “dual process” of heuristic (or “precompiled”) reasoning along with deliberate analysis (“abstract reasoning”). Croskerry13 reviews the clinical application of the dual-process model of reasoning in emergency medicine (“Type I vs. Type II”). This categorization may be traced to early work from Wason in196014 and decades of research since, recently popularized by Kahneman's book Thinking, Fast and Slow.15 A parallel set of approaches comes from a school of thought termed naturalistic decision making,16,17 in which one well-known model is called recognition-primed decision making (RPD).18,19 In RPD, the key decision maker assembles information to recognize a typical pattern, which then calls up typical solution strategies (this is quite consistent with the “illness script” model mentioned earlier). According to Klein,16 the first solution entertained by experienced decision makers is often satisfactory—that is, the decider quickly selects the first workable solution rather than the best possible solution (“satisficing”), and this is an advantage when faster decisions are better decisions. However, a key analytic feature of RPD is that decision maker then undertakes a brief “mental simulation” of how the solution would work, enabling her or him to see pros, cons, and barriers to the use of that solution for the particular problem (or to question whether the situation does in fact conform to the imagined pattern). Klein points out that this kind of analysis is not comparing potential solutions against each other but simply comparing the favored solution against the context at hand to assess likelihood of success. Also implicit in RPD and explicit in other models (including our own model of decision making in anesthesiology and other dynamic medical domains20–22) is the need for a process of constant reevaluation that can shift from one type of reasoning to another or adjust diagnoses and treatments to match an evolving situation. All of these models are based on the well-established fact that the capacity for conscious thought is very limited compared with subconscious or automatic and that that vast majority of our waking time is characterized by relative inattention, automaticity, and routine.23 Because such intuitive decision making draws from a repertoire of scripts and patterns that have been experienced either personally or vicariously, we can predict that clinicians with more experience will have a larger repertoire. However, the specific scripts and patterns in that repertoire will by necessity vary among individuals because of at least 2 distinct features: the content of experiences and the availability8 of the experiences. Availability refers to the degree of “memorableness”—the ease with which an experience comes consciously to mind. Availability may be influenced by recent events, emotionally charged events, novelty, and other factors that are distinct from the actual probability of that event occurring. As well, perception that a situation is recognized depends on the data streams that are present, and within those streams, which data are emphasized. In other words, “recognizing” a pattern is not an objective process. Instead, it is a subjective experience, influenced by allocation of attention, availability/memorableness, previous experience, strength of data signals within simultaneous streams, distraction, and so on. Hence, “recognition” is a key step, but it can be faulty itself. If one is initially incorrect in making such a recognition, the potential value of RPD or of using heuristics can be compromised. Thus, when a complex situation has presenting elements that fit recognizable scripts or patterns, particularly when the pattern or script is expected in the context (eg, hypotension on induction of anesthesia), lack of deliberate analysis may result in a rapid but not especially thoughtful temporizing maneuver, or it may result in the decision to take no action at all, expecting a self-limited course. Because “common things are common,” such lack of deliberate analysis is often quick and correct, thus reinforcing the automatic behavior. Only when the perturbation exceeds the expected duration or proves refractory to initial measures will it become apparent that the situation is actually more complex. In such cases, there may be a delayed or missed diagnosis or treatment of the unexpected etiology. Although such errors are sometimes described as an “overreliance” on heuristics,7 we would argue that it is impossible to make such judgments because (a) intuitive, heuristic, decision making is largely conducted subconsciously and (b) the decision of whether a decision was “good” is highly influenced by hindsight. Consequently, for a variety of reasons, we have some skepticism of whether the cases used in the study of Murray et al can reliably be categorized dichotomously in advance as “standard/heuristic” versus “complex/analytic.” Data that might readily match a script for one clinician might require analysis for another, even at the same level of training or experience. Moreover, the “application of knowledge”—whether via intuitive or analytic means—cannot be separated completely from knowledge itself. How can we be sure that the failure to diagnose a situation is really caused by heuristic thinking versus analytic approaches as opposed to other causes such as just plain lack of knowledge7 or the failure to perceive the data that suggest a complex etiology? WHAT IS THE ROLE OF EXPERIENCE IN DECISION ERROR? DO EXPERTS MAKE THE SAME MISTAKES AS NOVICES? It is known that experts have sufficient attentional resources to perform tasks and monitor information concurrently without hindering performance,24 and cognitive load theory and “chunking” explain how experts handle large volumes of information concurrently.25 However, less is known about exactly how medical decision making differs between more and less experienced clinicians. We largely agree with the core ideas Murray et al proposed to explain why juniors performed better in cases marked as “analytic” (less overconfidence by juniors, more use of pattern-matching strategies by seniors). Indeed, many of the cognitive processes discussed earlier (illness scripts, pattern matching, chunking data, and heuristics that minimize cognitive load) form through hard-won experience and are integral to the efficiency and accuracy often demonstrated by experts. This gain comes at the tradeoff price of a (generally subconscious) vulnerability to a kind of error that may not be seen with analytic thinking. In other words, when one finds a problem to be complex or challenging at the outset, it is hard to be overconfident and easy to be careful in determining what is going on. However, it is impossible to simultaneously perceive a problem to be easy or obvious, and also have insight into error of that perception. The literature on illness scripts suggests that seemingly small variations in the presentation or perception of a situation can radically change things. According to cognitive load theory,26 experience allows experts to “chunk” data into schema, thereby allowing them to monitor a larger volume of data. The compiling of elements and chunking of data with associated contextual cues play a significant role in the accuracy of experts. In contrast, when situation contravenes the script structure, for example, if information is presented in a random temporal order, rather than in the “script” order, experts' performances are affected much more than novices'. This is true even to the point where experts no longer benefit from their expertise and do not outperform novices.5 It is generally thought that experts solve many problems primarily via intuitive thinking, in contrast to deliberate analysis by nonexperts. Although such intuitive thinking is often highly effective and efficient, it is possible that it is also perhaps more susceptible to bias-induced error.27–30 The conclusions of Murray et al that “unexpectedly, the teams led by more junior residents received higher scores in the complex scenarios” is then not unexpected at all but just bolsters a view already in the literature. The explanation of Murray et al that more experienced team leaders are potentially more reliant on heuristic diagnostic approaches and often overconfident is consistent with prevailing theories as discussed earlier. It might also be true that experts can detect and integrate barely-above-threshold stimuli (a phenomenon variously described as a part of “situation awareness,”31 “gestalt,” or “sixth sense”) and that experts are generally better at using these subtle cues to recognize complexity or severity earlier than novices. Some such cues are difficult to simulate, and this is a known limitation of simulation education and research. Nonetheless, although a lack of such cues could potentially confuse those expecting to see them, this alone should not seriously derail expert decision making across the board. INDIVIDUAL AND TEAM DECISION MAKING Decision making by teams is extremely complex because of an extensive array of features including attention and information and A treatment of these is the of this but we will a few important In by other team can or individual errors of decision making by does this too but it has also been that sometimes groups rather than on are more prone to overconfidence than individual may their to a of and may be more influenced by It is not known to what degree this is true in health care because these data come from and and have not been in medical It has been well that to correct potential errors is a safety problem in health care, and individual biases may not be at the group This is thought to be caused by different and In there is to the first or early information or by rather than into critical information by one or a few In a may be missed when one or both their the other is In people of often to the or other or is also more when a higher is to have the often than an decision to the most to gain for even when the group (or the In health care, may sometimes be for a or out important that However, we we their even when those out to be wrong or not to the situation. CAN WE Murray et al events for the basis of their of which to patterns of which could be by of Trauma with no The other cases to be refractory to initial because of or This study simply because a case was not recognized by the care team does not that or lack of sufficient reevaluation as to why the diagnosis and treatment and or The are of reasoning that can even with an analytic In there is no to the it is a of this the problems would be and accurately by the study or by clinicians in simulation to understand the decision-making process is making inferences about that process based on the in on the 2 of without studying the reasoning process in on too many about of the In to other we have on to the of Murray et if the teams implemented to the presenting or whether they the diagnosis they would This a the the for the has a However, in the we would argue that a diagnostic error is and the fact that the is “good” is the same and to be to a different the long-term would be seriously As well, a decision to on a patient could a reevaluation of diagnostic is the of the study or it could than in which a action is even if not to what degree can of decision making be from and actions without detailed to and understand the actual processes of decisions may be as the action for the action for the wrong wrong action for the or wrong action for the wrong a specific into decision even we believe it is important for both simulation research and with correct action is to or even incorrect action with a may be in the used by Murray et too much may be about thought process without them We agree with Murray et al that more research is to how individuals and teams come to their decisions. and have been the for studying decision although these have in team as earlier. As well, these have and specific In for example, are not to about their thought for of decisions while clinicians are tasks is is, the act of in (sometimes for the to their a is less to change and a of thought Another of all such is to them to where in can increase time to of and where a is to have more than can be One to this problem might be to the simulation and a brief about the understanding of the situation. Another is to into the an into this One to do this is via the of or into the that may to the Another such that we have is to use as an explicit on the thinking of the in time. In a case or a when the clinician must with a expert (eg, or for the or OR one can and the discussion between the This their thinking more and than it might be if there was no or even if they in the same Some approaches use completely about decision processes of cases just or to one or more cases from the are easy to implement with a large of but they may be difficult to because of bias, bias, and Moreover, whether conducted in time or such as decision or cognitive each require a deliberate and for and then cognition in a clinicians about their thinking can also be used for education rather than for research. use might to use the more of for for as a to the potential potential value of the that uses simulation as a to study clinical care processes and individual and teams is as important as or more important than studying simulation is a need for more research about decision-making the to which we can and consciously our thinking (ie, and the in which some processes may be to research might on strategies to or of decision One might be on the and of different of to specific decision-making strategies or how training can itself cognitive These could be from those of other from and to or Another might be on one of the of decision making in dynamic medical decision that can cognitive errors to biases (eg, premature or a of other Importantly, such decision would need to key in that have been to clinicians are not at whether and when they need decision decisions are often made even people are consciously of them may then the of the with a or with a decision and the decision may not actually change the decisions and actions One of is the of such via simulation In Murray et al do a to our clinical and to the simulation by the for understanding of clinical decision making using the of Because and thought is complex and health care decision making is perhaps even more complex in the of and care, there is much to as we our knowledge on these In health care, the areas for research can be to what degree do automatic factors our decisions and which such factors are most which thought strategies are in which and what decision can best such strategies to decision be it will be a but to understand the of these research Murray et al have made an important in these questions into

Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · editorial or comment · 30 citationsread the source →

The effectiveness of mindfulness-based interventions on menopausal symptoms: A systematic review and meta-analysis of randomized controlled trials.

Background: Menopause, a crucial transitioning stage for women, can significantly impact mood and wellbeing. We aimed to systematically examine the effectiveness of Mindfulness-based interventions (MBIs) on health outcomes, including menopausal symptoms, quality of life (QOL), sleep quality, anxiety, depressive symptoms, stress, mindfulness levels, and female sexual function index. Methods: Eight databases were searched from inception to November 4, 2024 for randomized controlled trials. Two researchers independently selected, extracted, and appraised trials using the Cochrane Collaboration's 'risk of bias' tool. Meta-analysis, subgroup analysis, leave-one-out sensitivity analysis, and meta-regression were performed using Stata 18.0. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence. Results: A total of 19 studies (1670 participants) published between 2011 and 2024 were identified. Of these, 18 studies were included in the meta-analysis. Compared with control group, The pooled analysis demonstrated that MBIs had statistically significant effects on menopausal symptoms (SMD, -2.10; 95 % CI, -3.49 to -0.70), QOL (SMD, -0.88; 95 % CI, -1.67 to -0.09), sleep quality (SMD, -0.92; 95 % CI, -1.65 to -0.20), anxiety (SMD, -1.03; 95 % CI, -1.42 to -0.66), depressive symptoms (SMD, -0.91; 95 % CI, -1.30 to -0.53), stress (SMD, -0.85; 95 % CI, -1.55 to -0.15), and mindfulness levels (SMD, 1.19; 95 % CI, 0.35 to 2.02). The overall quality of evidence for all pooled estimates were graded as low and moderate due to methodological limitations and small sample size. The low attrition rate (6 %) and relatively high adherence rate (79 %) highlight the acceptability of MBIs. Conclusions: This systematic review and meta-analysis support using of MBIs to improve health outcomes in menopausal women. Rigorous randomized controlled trials with extended follow-up are needed to elucidate the mechanisms linking MBIs to menopausal health and strengthen evidence for clinical application.

Journal of affective disorders · meta-analysisread the source →

Experiences of dialectical behaviour therapy for adolescents: A qualitative analysis.

Objectives: To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful. Design: From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study. Methods: Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented. Results: Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings. Conclusion: A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized.

Psychology and psychotherapy · 5 citationsread the source →

Breastfeeding and Childhood Leukemia Incidence: A Meta-analysis and Systematic Review.

Importance: Childhood cancer is a leading cause of mortality among children and adolescents in the developed world and the incidence increases by 0.9% each year. Leukemia accounts for about 30% of all childhood cancer but its etiology is still mostly unknown. Objective: To conduct a meta-analysis of available scientific evidence on the association between breastfeeding and childhood leukemia. Data sources: A thorough search for articles published between January 1960 and December 2014 researching the association between breastfeeding and childhood leukemia was conducted on PubMed, the Cochrane Library, and Scopus (performed in July and December 2014), supplemented by manual searches of reference lists. Study selection: To be included in the meta-analyses, studies had to be case control; include breastfeeding as a measured exposure and leukemia as a measured outcome; include data on breastfeeding duration in months; and be published in a peer-reviewed journal with full text available in English. Data extraction and synthesis: The search identified 25 relevant studies, 18 of which met all inclusion criteria. No publication bias or heterogeneity among these 18 studies were detected. The quality of each study that met the inclusion criteria was assessed using the Newcastle-Ottawa Scale. Multiple meta-analyses were conducted using the random effect model on raw data in the StatsDirect statistical program. Main outcomes and measures: No or short duration of breastfeeding and the incidence of childhood leukemia. Results: The meta-analysis of all 18 studies indicated that compared with no or shorter breastfeeding, any breastfeeding for 6 months or longer was associated with a 19% lower risk for childhood leukemia (odds ratio, 0.81; 95% CI, 0.73-0.89). A separate meta-analysis of 15 studies indicated that ever breastfed compared with never breastfed was associated with an 11% lower risk for childhood leukemia (odds ratio, 0.89; 95% CI, 0.84-0.94), although the definition of never breastfed differed between studies. All meta-analyses of subgroups of the 18 studies showed similar associations. Based on current meta-analyses results, 14% to 19% of all childhood leukemia cases may be prevented by breastfeeding for 6 months or more. Conclusions and relevance: Breastfeeding is a highly accessible, low-cost public health measure. This meta-analysis that included studies not featured in previous meta-analyses on the subject indicates that promoting breastfeeding for 6 months or more may help lower childhood leukemia incidence, in addition to its other health benefits for children and mothers.

JAMA pediatrics · meta-analysis · 145 citationsread the source →

The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis.

Background: Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. Methods: We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. Findings: Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohen's d=1·11; p<0·0001), paranoia (-2·22, -2·98 to -1·45, Cohen's d=0·19; p<0·0001), and hallucinations (-1·58, -1·98 to -1·18, Cohen's d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. Interpretation: To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. Funding: Wellcome Trust.

The lancet. Psychiatry · randomised controlled trial · 460 citationsread the source →

Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies.

Promotion of good mental health, prevention, and early intervention before/at the onset of mental disorders improve outcomes. However, the range and peak ages at onset for mental disorders are not fully established. To provide robust, global epidemiological estimates of age at onset for mental disorders, we conducted a PRISMA/MOOSE-compliant systematic review with meta-analysis of birth cohort/cross-sectional/cohort studies, representative of the general population, reporting age at onset for any ICD/DSM-mental disorders, identified in PubMed/Web of Science (up to 16/05/2020) (PROSPERO:CRD42019143015). Co-primary outcomes were the proportion of individuals with onset of mental disorders before age 14, 18, 25, and peak age at onset, for any mental disorder and across International Classification of Diseases 11 diagnostic blocks. Median age at onset of specific disorders was additionally investigated. Across 192 studies (n = 708,561) included, the proportion of individuals with onset of any mental disorders before the ages of 14, 18, 25 were 34.6%, 48.4%, 62.5%, and peak age was 14.5 years (k = 14, median = 18, interquartile range (IQR) = 11-34). For diagnostic blocks, the proportion of individuals with onset of disorder before the age of 14, 18, 25 and peak age were as follows: neurodevelopmental disorders: 61.5%, 83.2%, 95.8%, 5.5 years (k = 21, median=12, IQR = 7-16), anxiety/fear-related disorders: 38.1%, 51.8%, 73.3%, 5.5 years (k = 73, median = 17, IQR = 9-25), obsessive-compulsive/related disorders: 24.6%, 45.1%, 64.0%, 14.5 years (k = 20, median = 19, IQR = 14-29), feeding/eating disorders/problems: 15.8%, 48.1%, 82.4%, 15.5 years (k = 11, median = 18, IQR = 15-23), conditions specifically associated with stress disorders: 16.9%, 27.6%, 43.1%, 15.5 years (k = 16, median = 30, IQR = 17-48), substance use disorders/addictive behaviours: 2.9%, 15.2%, 48.8%, 19.5 years (k = 58, median = 25, IQR = 20-41), schizophrenia-spectrum disorders/primary psychotic states: 3%, 12.3%, 47.8%, 20.5 years (k = 36, median = 25, IQR = 20-34), personality disorders/related traits: 1.9%, 9.6%, 47.7%, 20.5 years (k = 6, median = 25, IQR = 20-33), and mood disorders: 2.5%, 11.5%, 34.5%, 20.5 years (k = 79, median = 31, IQR = 21-46). No significant difference emerged by sex, or definition of age of onset. Median age at onset for specific mental disorders mapped on a time continuum, from phobias/separation anxiety/autism spectrum disorder/attention deficit hyperactivity disorder/social anxiety (8-13 years) to anorexia nervosa/bulimia nervosa/obsessive-compulsive/binge eating/cannabis use disorders (17-22 years), followed by schizophrenia, personality, panic and alcohol use disorders (25-27 years), and finally post-traumatic/depressive/generalized anxiety/bipolar/acute and transient psychotic disorders (30-35 years), with overlap among groups and no significant clustering. These results inform the timing of good mental health promotion/preventive/early intervention, updating the current mental health system structured around a child/adult service schism at age 18.

Molecular psychiatry · meta-analysis · 2420 citationsread the source →

Perinatal stressors and sleep quality in adolescents: a Brazilian birth cohort study.

OBJECTIVE: To investigate whether perinatal stressors (gestational weight gain, maternal age, marital status, and maternal body composition) exert a direct effect on sleep quality in adolescence; whether these effects are mediated by socioeconomic factors, lifestyle, and comorbidities; and whether depression, screen time, and physical activity have a direct effect on adolescents’ sleep quality. METHODS: Longitudinal cohort study was nested within a Brazilian birth cohort including 527 participants aged 18–19 years. Structural equation modeling was used to examine pathways linking perinatal stressors to sleep quality. Sleep quality was assessed using the Pittsburgh Sleep Quality Index. Explanatory variables included perinatal maternal characteristics, socioeconomic factors, lifestyle, and adolescent comorbidities. RESULTS: Among perinatal stressors, only maternal marital status at birth showed a direct effect on adolescents’ sleep quality (coef = 0.14; p = 0.027). Depression (coef = 0.38; p = 0.001) and asthma (coef = 0.19; p = 0.030) were directly associated with poorer sleep quality. No evidence of mediation by socioeconomic status, lifestyle, or comorbidities was found. Other perinatal stressors, screen time, and physical activity were not associated with sleep quality. CONCLUSIONS: Maternal marital instability during the perinatal period may have lasting consequences for adolescents’ sleep quality, possibly through direct neurobiological mechanisms. Depression and asthma emerged as predictors of poor sleep quality, underscoring the need for integrated early screening and intervention strategies. CURRENT KNOWLEDGE/STUDY RATIONALE: Perinatal adversities can dysregulate the hypothalamic–pituitary–adrenal (HPA) axis and circadian brain structures, leading to alterations in sleep patterns. However, the long-term consequences of perinatal stressors on sleep quality remain poorly understood, particularly during adolescence. The scarcity of longitudinal data limits our understanding of the neurobiological mechanisms underlying these associations. STUDY IMPACT: This study identifies maternal marital status at birth as a predictor of sleep quality in adolescence, suggesting long-term neurobiological effects. The findings underscore the importance of maternal support programs and early, integrated interventions addressing mental health, respiratory conditions, and sleep disorders—approaches that may yield lasting benefits for adolescents’ cognitive, emotional, and physical development.

Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicineread the source →

Gender differences in drinking behavior among Latino/a heavy drinkers.

Background: In the United States (U.S.), higher levels of acculturation have been associated with higher rates of heavy alcohol use more consistently among Latino women than among Latino men. This paper explores mechanisms underlying the link between acculturation and alcohol use among Latino/as in the U.S. We examine alcohol use expectancies and motives from the perspectives of the social cognitive theory of gender development. Methods: Qualitative narratives data from six focus groups of individuals (total n = 37), who met criteria for heavy drinking (4/5 drinks/occasion for females/males), were examined separately by gender (18 females; 19 males). Coded narratives data were analyzed using a framework that compared lives in Latin America and in the U.S. Emergent themes were analyzed for their consistency across genders. Gender-specific themes were identified. Results: Changes in family structure and the loss of social networks prompted divergent patterns of drinking among men and women, such that relative to patterns in their countries of origin, drinking among Latino women increased while it decreased among Latino men. Men and women reported drinking to replace missing social bonds, a motive not frequently reported in the literature on drinking motives. Women who engaged in heavy-drinking nonetheless described traditional gender role expectations after U.S. arrival. Only men endorsed positive alcohol expectancies in Latin America. Women reported drinking to alleviate psychological distress in the U.S. Conclusions: Pre and post-immigration comparisons revealed different drinking trajectories among men and women after immigration to the U.S. These patterns appeared to be influenced by new social contexts and changes in familial expectations regarding women's roles. Future inquiry that examines gender-specific themes in alcohol expectancies and motives unique to the experience of immigration, is warranted.

The International journal on drug policy · 22 citationsread the source →

Maintenance treatment with varenicline for smoking cessation in patients with schizophrenia and bipolar disorder: a randomized clinical trial.

Importance: It is estimated that more than half of those with serious mental illness smoke tobacco regularly. Standard courses of pharmacotherapeutic cessation aids improve short-term abstinence, but most who attain abstinence relapse rapidly after discontinuation of pharmacotherapy. Objective: To determine whether smokers diagnosed with schizophrenia and bipolar disease have higher rates of prolonged tobacco abstinence with maintenance pharmacotherapy than with standard treatment. Design, setting, and participants: Randomized, double-blind, placebo-controlled, parallel-group, relapse-prevention clinical trial conducted in 10 community mental-health centers. Of 247 smokers with schizophrenia or bipolar disease recruited from March 2008-April 2012, 203 received 12-weeks' open-label varenicline and cognitive behavioral therapy and 87 met abstinence criteria to enter the relapse prevention intervention. Interventions: Participants who had 2 weeks or more of continuous abstinence at week 12 of open treatment were randomly assigned to receive cognitive behavioral therapy and double-blind varenicline (1 mg, 2 per day) or placebo from weeks 12 to 52. Participants then discontinued study treatment and were followed up to week 76. Main outcomes and measures: Seven-day rate of continuous abstinence at study week 52, the end of the relapse-prevention phase, confirmed by exhaled carbon monoxide. Secondary outcomes were continuous abstinence rates for weeks 12 through 64 based on biochemically verified abstinence and weeks 12 through 76, based on self-reported smoking behavior. Results: Sixty-one participants completed the relapse-prevention phase; 26 discontinued participation (7 varenicline, 19 placebo) and were considered to have relapsed for the analyses; 18 of these had relapsed prior to dropout. At week 52, point-prevalence abstinence rates were 60% in the varenicline group (24 of 40) vs 19% (9 of 47) in the placebo group (odds ratio [OR], 6.2; 95% CI, 2.2-19.2; P < .001). From weeks 12 through 64, 45% (18 of 40) among those in the varenicline group vs 15% (7 of 47) in the placebo group were continuously abstinent (OR, 4.6; 95% CI, 1.5-15.7; P = .004), and from weeks 12 through 76, 30% (12 of 40) in the varenicline group vs 11% (5 of 47) in the placebo group were continuously abstinent (OR, 3.4; 95% CI, 1.02-13.6; P = .03). There were no significant treatment effects on psychiatric symptom ratings or psychiatric adverse events. Conclusions and relevance: Among smokers with serious mental illness who attained initial abstinence with standard treatment, maintenance pharmacotherapy with varenicline and cognitive behavioral therapy improved prolonged tobacco abstinence rates compared with cognitive behavioral therapy alone after 1 year of treatment and at 6 months after treatment discontinuation. Trial registration: clinicaltrials.gov Identifier: NCT00621777.

JAMA · randomised controlled trial · 157 citationsread the source →

Cohort Profile: The National Longitudinal Study of Adolescent to Adult Health (Add Health)

The National Longitudinal Study of Adolescent Health (Add Health) was developed in the 1990s in response to a mandate from the United States Congress to fund a study of adolescent health, and was designed by a team of multidisciplinary investigators from the social, behavioural and biomedical sciences. The original purpose of Add Health was to understand the causes of adolescent health and health behaviour, with special emphasis on the multiple contexts of adolescent life. To achieve this scientific goal, Add Health sampled the school and family environments in which young people live their lives, which included data on peer relationship dyads, parents, siblings, neighbourhoods and communities, and provides independent and direct measurement of these complex environments over time. As the cohort transitioned into adulthood, research objectives turned to understanding how adolescent experiences, behaviours and contexts are linked to health and achievement outcomes in adulthood, and the name of the study was officially changed to The National Longitudinal Study of Adolescent to Adult Health in 2014. Add Health is housed at the Carolina Population Center at the University of North Carolina (UNC) and has been led by two principal investigators and project directors: J Richard Udry from 1994–2004; and Kathleen Mullan Harris from 2004 to the present. Add Health is a nationally representative cohort study of more than 20 000 adolescents in grades 7–12 (aged 12–19) in the USA in 1994–95, who have been followed through adolescence and into adulthood with five in-home interviews in 1995 (Wave I), 1996 (Wave II), 2001–02 (Wave III), 2008–09 (Wave IV) and 2016–18 (Wave V).1Figure 1 displays the sampling design for selecting the original cohort. A school-based design selected 80 high schools and a paired feeder school from a list of all high schools in the USA in 1994. An in-school questionnaire was administered to more than 90 000 students in grades 7–12, who attended these schools during the 1994–95 school year, and school administrators also filled out a questionnaire about the school. Sampling structure. School rosters from the 1993–94 school year provided the sampling frame for a second level of sampling for a 90-min in-home interview with an adolescent and a 30-min interview with one parent. A grade- and gender-stratified core sample was selected from each school pair, representing a self-weighting nationally representative sample of 12 105 American adolescents in grades 7–12 in 1995. Based on responses to the in-school survey, specific subpopulations were oversampled for purposes of providing sufficient numbers for research on vulnerable and otherwise rare populations, including ethnic (Cuban, Puerto Rican and Chinese), genetic relatedness to siblings (identical/fraternal twins, full/half siblings and unrelated adolescents living in the same household), adoption status and disability samples. Black adolescents with highly educated parents were also oversampled. For two large schools and fourteen small schools, interviews with all enrolled students were attempted to create a special saturation sample. The core sample plus the special samples yield a total of 20 745 adolescents. This Wave I in-home sample represents the national cohort of adolescents in grades 7–12 in the USA in 1995, which is followed prospectively. Because school rosters from the year preceding sample selection were used as the sampling frame for the prospective cohort, high school dropouts over 2 years (e.g. 1993–94; 1994–95) were eligible for sample selection, resulting in little bias due to high school dropouts.2 For more details on design, see Harris 2010 and Harris et al., 2013.3,4 Figure 2 shows the longitudinal design of Add Health. The Wave I in-home adolescent cohort has been followed up with four subsequent waves spanning 20+ years. In 1996, all adolescents in grades 7 through 11 in Wave I (plus 12th graders who were part of the genetic and adopted sample) were re-interviewed for Wave II (n = 14 738); the decision not to follow up the seniors who were in grade 12 at Wave I was design-based. The Wave II sample were in grades 8 through 12. A follow-up school administrator interview measured change in school context from 1995 to 1996. Longitudinal design. The original cohort was followed through their transition to early adulthood with a Wave III in-home interview in 2001–02 when the sample was aged 18–26 years (n = 15 197). A sample of 1507 partners were randomly selected during the in-home interview and interviewed, filling quota samples of about 500 married, 500 cohabiting and 500 dating partners. Wave IV re-interviewed the original cohort as they settled into young adulthood in 2008–09 when the cohort was aged 24–32 years (n = 15 701). Wave V followed the cohort to the end of young adulthood when they were aged 32–42, with continuous interviewing using a mixed-mode protocol during 2016–18. Finally, the Add Health Parent Study completed a 20-year follow-up of a subset of the parents of Add Health respondents during 2015–17 (n = 3006). Add Health uses state-of-the-art methods and techniques for panel maintenance and tracing to locate and schedule an interview with all living eligible respondents, including those who may have been non-responsive in a preceding wave. Table 1 presents response rates for the eligible sample at each completed wave of interviews. Response rates have been quite high, highest when the interval between interview waves is short but remarkably high even when the interval is over 5 years at Waves III and IV. The transition from adolescence to early adulthood and the young adult period is an especially transient phase of the life course and it is difficult to track and locate young people. Add Health has done exceptionally well, with response rates of 77.4% and 80.3% at Waves III and IV. Response rates in Add Health for the eligible sample at each wave of in-home interviews By design, respondents who were in the 12th grade at Wave I and who were not part of the genetic sample were not interviewed at Wave II. Response rate at Wave III is based on 15 170 respondents who had data at Wave I. An additional 27 respondents without Wave I data were included at Wave III as part of the genetic subsample. Wave V response rates are not provided because data collection is ongoing, and only a subset of Wave V respondents completed in-home interviews. Response rates in Add Health for the eligible sample at each wave of in-home interviews By design, respondents who were in the 12th grade at Wave I and who were not part of the genetic sample were not interviewed at Wave II. Response rate at Wave III is based on 15 170 respondents who had data at Wave I. An additional 27 respondents without Wave I data were included at Wave III as part of the genetic subsample. Wave V response rates are not provided because data collection is ongoing, and only a subset of Wave V respondents completed in-home interviews. There has been differential attrition by gender, age, socioeconomic status, urban residence, immigrant status and race across time, with higher response rates for female, younger, higher socioeconomic status, urban, native-born and White respondents at Waves III and IV. These attrition patterns are consistent with most longitudinal cohort studies. Add Health response rates exceed other national studies with multiple year intervals between waves (e.g. National Survey of Families and Households 2001–03 wave had a 55% response rate; Midlife in the United States 2004–06 interview had a 75% retention rate).5,6 At each wave, Add Health analysed whether patterns of attrition pose any bias to estimates of survey outcomes.7–10 In general, non-response analyses compare respondents and non-respondents on a range of demographic, health, behavioural and attitudinal indicators measured at baseline, and estimate the extent to which differences between respondents and non-respondents introduce bias in study results. Results indicated that total and relative biases, remaining after study estimates were adjusted with final sampling weights, were minimal and that the sample at each wave adequately represented the same population as the Wave I sample. Analysis of bias due to attrition at Wave IV indicated low rates of bias that rarely exceeded 1%, which is small relative to the 20% to 80% prevalence rates for most of the baseline indicators. Despite common patterns of attrition over time, the design strategy to re-interview the original Wave I cohort at each follow-up wave minimizes non-response bias and continues to adequately represent the original cohort of 7-12th graders in US schools in 1995. Add Health contains unprecedented environmental, behavioural, psychosocial, biological and genetic data from early adolescence into adulthood on a large, nationally representative sample with extensive racial, ethnic, socioeconomic and geographical diversity.4 Longitudinal survey data on respondents’ social, economic, psychological and physical well-being is combined with contextual data on family, neighbourhood, community, school, friendships, peer groups and romantic relationships, providing unique opportunities to study how psychological characteristics, social environments and behaviours beginning in early adolescence are linked to health and well-being in adulthood. Extensive longitudinal life histories of health-related behaviour are available, including physical activity, risk behaviour, substance use, sexual behaviour, civic engagement, education and multiple longitudinal indicators of health status, such as general health, chronic illness, overweight status and obesity, mental health, disability, health promotion and sleep. Objective measures of health were collected across all waves, including anthropometrics, sexually transmitted infection (STI) test results [including human immunodeficiency virus (HIV)], DNA and an expanded set of biomarkers in adulthood (Waves IV and V) (including blood pressure and pulse, measures of glucose homeostasis, lipid metabolism, inflammation, immune and renal function and a medications inventory). Below we describe the innovative multilevel data that have provided unprecedented research opportunities for a multidisciplinary scientific community. The clustered design of Add Health makes possible unique contextual levels of measurement, shown in Table 2. School-context data come from school administrator reports on school policies, health services and other school characteristics and from the in-school interviews of students whose aggregated responses represent school census measures. From respondent reports of colleges attended, college context data have been linked to individual records. Family-context data come from parent questionnaires, adolescent in-school and in-home questionnaires and interviews with siblings and additional adolescents living in the same household. Contextual levels of measurement in Add Health W1 = adolescent in- school and in-home, parent and school administrator surveys, geocodes. W2 = adolescent in-home, school administrator and geocodes. W3 = young adult in-home and partner sample surveys, geocodes, biomarkers. W4 = young adult in-home, biomarkers, geocodes. W5 = adult survey, biomarkers, geocodes. Additional variables from administrative datasets (e.g. US Census, Centers for Disease Control and Prevention, National Center for Health Statistics, Federal Bureau of Investigation, National Council of Churches, Common Core of Data, Private School Survey). , variable available; o, planned variable construction. Contextual levels of measurement in Add Health W1 = adolescent in- school and in-home, parent and school administrator surveys, geocodes. W2 = adolescent in-home, school administrator and geocodes. W3 = young adult in-home and partner sample surveys, geocodes, biomarkers. W4 = young adult in-home, biomarkers, geocodes. W5 = adult survey, biomarkers, geocodes. Additional variables from administrative datasets (e.g. US Census, Centers for Disease Control and Prevention, National Center for Health Statistics, Federal Bureau of Investigation, National Council of Churches, Common Core of Data, Private School Survey). , variable available; o, planned variable construction. Adolescents were asked to nominate friends and sexual and romantic partners from the school rosters in the in-school and in-home surveys at Waves I and II. Peer networks characteristics can be constructed by linking friends’ data and constructing variables based on friends’ responses, and similar measures can be constructed for linked romantic and sexual partners. These peer- and dyad-context measures constitute the social network data, including information on friendship networks, sexual networks and friendship and relationship dyads. Respondents’ home residences have been geocoded at each interview wave, and contextual data on the neighbourhood, community and state have been merged to all individual records. Nearly 12 000 environmental data elements at multiple geographical levels are available across waves. This includes such information as race, ethnic, foreign-born and religious denomination composition, poverty rates, crime statistics, STI prevalence, divorce and child support laws, welfare policies, cigarette taxes, the proximity and number of parks, sidewalks, recreation centres, fast food restaurants, alcohol outlets and other physical and social characteristics of the environments in which young people live. Table 3 shows the array of survey and biological data in Add Health. The top panel lists the domains covered by the survey instruments at each wave, including individual-level data on household and family structure, personality, religiosity and spirituality, relationships, sexual behaviour, contraception, pregnancy, children and parenting, sleep patterns, physical activity, diet, substance use/abuse, violence, delinquency, involvement with the criminal justice system, education history, work experiences, military service, chronic and disabling conditions, injury, mental health, suicide and health service access and use. Even though respondents were first interviewed in early adolescence, there are data on infancy (birthweight) and childhood (e.g. maltreatment, chronic conditions, attention deficit hyperactivity disorder) and complete data on fertility outcomes (there were more than 14 500 births to Add Health respondents by Wave IV). Survey and biomarker domains across Waves I-V in Add Health Survey and biomarker domains across Waves I-V in Add Health The bottom panel of Table 3 shows the biological measures available across waves. The original study design included important features for understanding biological processes in health and developmental trajectories across the life course, including an embedded genetic sample with more than 3000 pairs of adolescents with varying biological resemblance (see Figure 1) and measurement of height and weight to track the obesity epidemic. At Wave III, urine and saliva samples were collected to test for STI and HIV,11,12 and buccal cell saliva was collected from twins and full siblings in the genetic subsample for DNA extraction.13 An expanded set of biological measures were collected at Wave IV, including biomarkers of cardiovascular health (blood pressure, pulse), metabolic processes (waist circumference, glycosylated haemoglobin, blood glucose, lipids), immune function (Epstein-Barr virus), inflammation (C-reactive protein) and a medications inventory. Repeat biomarker measures were collected at Wave V, including new markers of renal disease. Saliva DNA was collected from the full sample at Wave IV. Candidate loci in the dopamine and serotonin pathways have been genotyped and disseminated to the scientific community.14 Genome-wide genotyping was completed on 10 974 Wave IV respondents who consented to archive their specimens for further testing, and genome-wide association study (GWAS) data are available from the database of Genotypes and Phenotypes (dbGaP). Add Health maintains a biospecimen archive available for ancillary studies. Add Health has a large and multidisciplinary user base of more than 50 000 researchers around the world, who have published over 3500 peer-reviewed articles in more than 750 different disciplinary journals, and has been the data source for more than 800 master’s theses and dissertations. Publications are listed at [https://www.cpc.unc.edu/projects/addhealth/publications]. Early publications focused on the role of social context in the development of adolescent health, behaviour, expectations and attainment, finding important influences of family and school connectedness,15 peer influence,16–18 romantic relationships,19 and neighbourhoods.20–22 For example, adolescents with a greater number and higher quality of connections to their school and family had better physical and mental health and higher attainment than youth with Adolescents whose friendship networks included friends with highly parents were than those whose friends had parents to studies that romantic in adolescence can adolescent and is with higher rates of obesity and weight in publications an of chronic young including a prevalence of and prevalence of the longitudinal data, researchers have the developmental and health pathways to young adult Add Health data support longitudinal studies of partner substance and health during the early life course from adolescence into young Add Health has the obesity and outcomes for adolescents. In adolescence of the sample were in 2001–02 when the cohort was aged the to in of the cohort at 24–32 was on these longitudinal data, The and the of obesity early in that adolescents were more to obesity in young adulthood with overweight by a risk of to individual obesity trajectories from adolescence at Wave II to young adulthood at Wave III into not who were who during the transition to young adulthood, and who were adolescence and young adulthood, As shown in Figure greater to obesity during adolescence and young adulthood is with a higher of high and sleep in adulthood. from adolescence to young adulthood with multiple health outcomes in adulthood (n The unique design and of the sample possible health research on special including the adopted youth living with parents sexual and adopted adolescents are more to suicide than their adolescents are at higher health risk on a range of indicators with adolescents who only one and more and than There is a large and of research that the genetic data with the longitudinal environmental data to the of and in health and behavioural of genetic research articles have these on a range of including risk substance sexual and friendship and Genome-wide association study (GWAS) data were for the pairs and Wave IV archive the of a large number of These the new differences in the education and of school environments in the education association with and family and education role in social and cohort differences in the genetic relationship between education and In innovative new research is providing human of genetic in which the of individual behaviour, for and Figure for social genetic of and friends on attainment, and The the of school and of for attainment in the top in the second panel and height in the The is the baseline of on outcomes in a with other and the represent the adjusted for individual-level The results that the of an and friends the attainment, an height is with the height of Add Health has in for new including attainment, height and alcohol genetic Add Health research uses biomarker data to social and behavioural with measures of research has the between a childhood and STI social status and and and life course of social and life for The role of social and social context in pathways was for the first young the for in the early in life and biological are to family and urban young from social is with mental health but physical health for young with The of Add Health from contextual and national design. The adolescent social context and peer network data, in are unique because they not on to an of an national of people who live in all 50 and come from race, ethnic, geographical and socioeconomic and ethnic with sufficient numbers to of Puerto and and and vulnerable including with children and adopted and sexual genetic sample of over 3000 pairs of with varying biological and longitudinal data from respondents and their longitudinal social, behavioural and biological data beginning in early adolescence and into extensive longitudinal multilevel data beginning in early adolescence on life and social and physical including family, school, neighbourhood, community and social measures of health including blood pressure, glucose, virus circumference, and and DNA on 000 and genome-wide genotyping on the full sample at Wave and collection of DNA on twins and full data be available in the including and data (see Table a of the of survey data measurement of specific and a for survey and biomarker measures. are available to researchers in representing a subset of and high which are only to which can only be used in a data to Add Health data to other and high school data, which are available in data access the and of respondents data access to a range of including data access study and can be at data can be Add Health is an longitudinal study of a nationally representative US cohort of 20 745 adolescents in grades (aged in includes four in-home interviews in 1996, 2016–18. attrition has been with response rates from to across follow-up waves, and attrition bias has been The study unprecedented environmental, behavioural, psychosocial, biological and genetic data from early adolescence into adulthood with extensive racial, ethnic, socioeconomic and geographical Add Health has a large, multidisciplinary user base of over 50 000 researchers around the world, who have published over 3500 research the Add Health cohort at the of the obesity with for health and social genetic of and on health and Add Health datasets are to a data to the of information and in of the see Add Health is by the National of Health and with from other and The full list of can be at This research uses data from Add a project by Kathleen Mullan Harris and designed by J Richard and Kathleen Mullan at the University of North Carolina at and by from the National of Health and with from other and is due to and for in the original design. also to data from National of Health and to Kathleen Mullan Harris and to Kathleen Mullan and of

International Journal of Epidemiology · 531 citationsread the source →

A peer intervention reduces loneliness and improves social well-being in low-income older adults: A mixed-methods study.

Background: Evidence-based interventions addressing loneliness and social isolation are needed, including among low-income, community-dwelling older adults of diverse racial and ethnic backgrounds. Our objective was to assess the effect of a peer intervention in addressing loneliness, isolation, and behavioral health needs in this population. Methods: We conducted a mixed-method, two-year longitudinal study of a peer-outreach intervention in 74 low-income older adults recruited via an urban senior center in San Francisco. Structured participant surveys were conducted at baseline and every 6 months for up to 2 years. Outcomes included loneliness (3-item UCLA loneliness scale), social interaction (10-item Duke index), self-perceived socializing barriers (range: 0-10), and depression (PHQ-2 screen). Data were analyzed using mixed-effects linear and logistic regression adjusted for age and gender. Qualitative, semi-structured interviews with participants (N = 15) and peers (N = 6) were conducted in English and Spanish and analyzed thematically. Results: Participants were on average 71 years old (range: 59-96 years), with 58% male, 15% LGBT, 18% African American, 19% Latinx, 8% Asian, 86% living alone, and 36% with an ADL impairment. On average, 43 contact visits (IQR: 31-97 visits) between participants and peers occurred over the first year. Loneliness scores decreased by, on average, 0.8 points over 24 months (p = 0.015). Participants reported reduced depression (38%-16%, p < 0.001) and fewer barriers to socializing (1.5 fewer, p < 0.001). Because of the longitudinal relationship and matching of characteristics of peers to participants, participants reported strong feelings of kinship, motivations to reach out in other areas of life, and improved mood. Conclusion: Diverse older adults in an urban setting participating in a longitudinal peer program experienced reduced loneliness, depression, and barriers to socializing. Matching by shared backgrounds facilitated rapport and bonding between participants and peers.

Journal of the American Geriatrics Society · 34 citationsread the source →

Mentalization based treatment for borderline personality disorder

Borderline personality disorder (BPD) is a complex and serious mental disorder characterized by a pervasive pattern of difficulties with emotion regulation and impulse control, and instability both in relationships and in selfimage 1. It represents a serious public health problem, because it is associated with suicide attempts and self harm, both of which are consistent targets of mental health services. Recurrent suicidal behaviour is reported in 69–80% of patients with BPD, and suicide rates are estimated to be up to 10% 2. BPD is a common condition that is thought to occur globally with a prevalence of 0.2–1.8% in the general population 3. Higher prevalence rates are found in clinical populations. Moran et al 4 found a prevalence rate of 4–6% among primary care attenders, suggesting that people with BPD are more likely to visit their general practitioner. Chanen et al 5 reported a prevalence rate of 11% in adolescent outpatients and 49% in adolescent inpatients. The highest prevalence has been found in people requiring the most intensive level of care, with a rate of 60–80% among patients in forensic services 6–7. The high prevalence and increased suicide rate in patients with BPD make an unassailable argument that effective treatment needs to be developed and that treatment has to be widely available. Whilst a number of treatments for BPD have been shown to be moderately effective in randomized controlled trials, it remains of considerable concern that most of them require extensive training, making them unavailable to most patients. Mentalization based treatment (MBT) was developed with this in mind. It requires relatively little additional training on top of general mental health training, and has been implemented in research studies by community mental health professionals, primarily nurses, with limited training given modest levels of supervision. The term mentalization grew out of the Ecole Psychosomatique de Paris and to some extent was operationalized by developmental researchers investigating theory of mind 8. It was first used by Fonagy in 1989 9 in a broader way and has since been developed in relation to understanding a number of mental disorders. Mentalization, or better mentalizing, is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization. In fact, we can conceive of most mental disorder as the mind misinterpreting its own experience of itself, thus ultimately a disorder of mentalization. However, the key issue is whether the dysfunction is core to the disorder and/or a focus on mentalization is heuristically valid, i.e. provides an appropriate domain for therapeutic intervention. While mentalizing theory is being applied to a number of disorders (e.g., posttraumatic stress disorder 10, eating disorders 11 and depression 12), in a number of contexts (e.g., inpatient, partial hospital, and outpatient facilities), and in different groups of patients (e.g., adolescents, families, substance abusers), the treatment method is most clearly organized as a therapy for BPD 13. It is only in this condition that clear empirical support with randomized controlled trials 14–15 is available. In BPD, a fragile mentalizing capacity vulnerable to social and interpersonal interaction is considered a core feature of the disorder. If a treatment is to be successful, it must either have mentalization as its focus or at the very least stimulate development of mentalizing as an epiphenomenon. The failure of adult mental processing in borderline states had been apparent to most clinicians, but none had identified the primary difficulty as a loss of mentalizing arising from early development. The simple basic suggestion we made was that representing self and others as thinking, believing, wishing or desiring did not arrive at age 4 as a consequence of maturation, but rather was a developmental achievement that was profoundly rooted in the quality of early object relations. Its predictable vulnerability to disappearance under stress in borderline conditions was seen as an appropriate focus for psychodynamically oriented psychological intervention, even though concerns had been expressed over many decades about the use of psychodynamic therapy in the treatment of BPD. These began as long ago as 1938, when an American psychoanalyst, Adolph Stern, identified a group of patients, now considered to have had BPD, who did not respond to classical psychoanalytic treatment 16. He later described modifications of psychotherapy for his borderline group that remain relevant today 17. Mentalizing theory is rooted in Bowlby's attachment theory and its elaboration by contemporary developmental psychologists, whilst paying attention to constitutional vulnerabilities. There is suggestive evidence that borderline patients have a history of disorganized attachment, which leads to problems in affect regulation, attention and self control 18–19. It is our suggestion that these problems are mediated through a failure to develop a robust mentalizing capacity. Our understanding of others critically depends on whether as infants our own mental states were adequately understood by caring, attentive, non-threatening adults. The most important cause of disruption in mentalizing is psychological trauma early or late in childhood, which undermines the capacity to think about mental states or the ability to give narrative accounts of one's past relationships. Building on the accumulating evidence from developmental psychopathology, the mentalization theory of BPD first suggests that individuals are constitutionally vulnerable and/or exposed to psychological trauma; second, that both these factors can undermine the development of social/cognitive capacities necessary for mentalization via neglect in early relationships 20, especially where the contingency between their emotional experience and the caregiver's mirroring is non-congruent 21; third, that this results in an hypersensitive attachment system within interpersonal contexts; and fourth, that this leads to the development of an enfeebled ability to represent affect and effortfully control attentional capacity 22. Given the known continuity of attachment styles over time, residues of attachment problems of childhood might be expected to be apparent in adulthood. The adult attachment literature in relation to BPD has been reviewed by Levy 23. While the relationship between BPD diagnosis and a specific attachment category is not obvious, there is little doubt that BPD is strongly associated with insecure attachment (only 6–8% of BPD patients are coded as secure). It appears that early attachment insecurity is a relatively stable characteristic of BPD patients, particularly in conjunction with subsequent negative life events 24. The focus in treatment of BPD needs to be on stabilizing the sense of self and helping the patient maintain an optimal level of arousal in the context of a well-managed, i.e. not too intense and yet not too detached, attachment relationship between patient and therapist. The patient with BPD is exquisitely sensitive to all interpersonal interactions. So, the therapist needs to be aware that therapy, an interpersonal interaction, inevitably will provoke anxiety related to loss of a sense of self and that the ensuing emotional experiences will rapidly threaten to overwhelm the patient's mental capacities, leading to escalating emotions and inability to accurately understand others’ motives. Psychiatrists and other mental health professionals also need to be aware of this sensitivity if they are to avoid iatrogenic interactions with patients with BPD. Inpatient hospital admission, for example, is an intense emotional experience for all patients and, unless carefully managed, will make patients with BPD worse by overstimulating their attachment processes. This overstimulation in treatment may account for the poor long-term outcomes of patients with BPD when unmodified intensive treatments were offered (25). Patients with BPD have a vulnerability in regulating emotional responses and generating effective strategies for controlling their thoughts and feelings, which challenges their capacity for thinking about their own actions in terms of subtle understandings of their thoughts and feelings. They slip into what superficially could be described as a kind of mindless state, both in relation to others and to themselves. Of course, the story turns out to be more complicated than this, because these incapacities, palpable at certain times, are not always evident. But, at moments of emotional distress, particularly distress triggered by actual or threatened loss, the capacity for mentalization is most likely to apparently evaporate. The question is how this understanding and the clinical observations can usefully be translated into a therapeutic approach that could be helpful given the prevalence and severity of this clinical problem within a public healthcare system. To this end, we defined some core underpinning techniques to be used in the context of group and individual therapy and labeled them MBT 13–26. Only three important aspects of treatment will be considered here, namely the aim of interventions, the therapeutic stance, and mentalizing the transference. The initial task in MBT is to stabilize emotional expression, because without improved control of affect there can be no serious consideration of internal representations. Although the converse is also true, identification and expression of affect are targeted first because they represent an immediate threat to continuity of therapy as well as potentially to the patient's life. Uncontrolled affect leads to impulsivity, and only once this affect is under control is it possible to focus on internal representations and to strengthen the patient's sense of self. The aim and the actual outcome of an intervention are more important in MBT than the type of intervention itself. The primary aim of any intervention has to be to reinstate mentalizing when it is lost or to help to maintain it in circumstances when it might be lost or is being lost. Any intervention that succeeds in these aims may be used in MBT. As a result of this, MBT takes a more permissive approach to interventions than most other therapies, giving it a plurality in terms of technique which might account for its popularity and appeal to practitioners from different schools as well as the limited amount of training required before practitioners begin using it in their everyday practice. We do not ask that practitioners learn a new model of therapy from the beginning, but that they modify their current practice focussing on mentalizing rather than behaviours, cognitions, or insight. We do, however, ask that they undertake to develop a particular therapeutic stance and implement a series of steps to try to engage the patient in a process of mentalizing, firstly using some generic psychotherapy techniques such as empathy, support and clarification, and then moving on to other interventions specifically designed to “stress” the attachment relationship within controlled conditions, which includes a focus on the patienttherapist relationship through “mentalizing the transference”. The therapist's mentalizing therapeutic stance should include: a) humility deriving from a sense of “notknowing”; b) patience in taking time to identify differences in perspectives; c) legitimizing and accepting different perspectives; d) actively questioning the patient about his/her experience — asking for detailed descriptions of experience (“what questions”) rather than explanations (“why questions”); e) careful eschewing of the need to understand what makes no sense (i.e., saying explicitly that something is unclear). An important component of this stance is monitoring one's own mentalizing failures as a therapist. In this context, it is important to be aware that the therapist is constantly at risk of losing his/her capacity to mentalize in the face of a nonmentalizing patient. Consequently, we consider therapists’ occasional enactments as an acceptable concomitant of the therapeutic alliance, something that simply has to be owned up to. As with other instances of breaks in mentalizing, such incidents require that the process is “rewound and the incident explored”. Hence, in this collaborative patient-therapist relationship, the two partners involved have a joint responsibility to understand mental processes underpinning events both within and without therapy. We caution about the use of transference interpretation in the treatment of BPD because it assumes a level of mentalizing capacity of the patient that he/she often does not possess. This may have led to the suggestion that we “specifically eschew transference interpretation” (27). We do not. In fact we specifically employ transference interpretation, give indicators about when it can be used and carefully define six essential components. But equally we caution practitioners firstly about the commonly stated aim of transference interpretation, namely to provide insight, and secondly about genetic aspects, such as linking current experience to the past, because of their potential iatrogenic effects. Our first step is the validation of the transference feeling, that is establishing the patient's perspective. Of course this is not the same as agreeing with the patient, but it must be evident to the patient that the therapist has at least understood his/her point of view. The danger of the genetic approach to the transference is that it might implicitly invalidate the patient's experience. The second step is exploration. The events which generated the transference feelings must be identified. The behaviours that the thoughts or feelings are tied to need to be made explicit, sometimes in painful detail. The third step is accepting enactment on the part of the therapist. Most experiences of the patient in the transference are likely to be based on reality, even if on a very partial connection to it. Mostly this means that the therapist has been drawn into the transference and acted in some way consistent with the patient's perception of him/her. It may be easy to attribute this to the patient, but this would be completely unhelpful. On the contrary, the therapist should initially explicitly acknowledge even partial enactments of the transference as inexplicable voluntary actions that he/she accepts agency for, rather than identifying them as a distortion of the patient. Drawing attention to such therapist components may be particularly significant in modeling to the patient that one can accept agency for involuntary acts and that such acts do not invalidate the general attitude which the therapist tries to convey. Only then can distortions be explored. Step four is collaboration in arriving at an interpretation. Transference interpretations must be arrived at in the same spirit of collaboration as any other form of interpretive mentalizing. The metaphor we use in training is that the therapist must imagine sitting side-by-side with the patient, not opposite. They sit side-by-side looking at the patient's thoughts and feelings, where possible both adopting the inquisitive stance. The fifth step is for the therapist to present an alternative perspective and the final step is to monitor carefully the patient's reaction as well as one's own. We suggest these steps are taken in sequence and we talk about mentalizing the transference to distinguish the process from transference interpretation, which is commonly viewed as a technique to provide insight. Mentalizing the transference is a shorthand term for encouraging patients to think about the relationship they are in at the current moment (the therapist relationship) with the aim to focus their attention on another mind, the mind of a therapist, and to assist them in the task of contrasting their own perception of themselves with how they are perceived by another, by the therapist or indeed by members of a therapeutic group. Whilst we might point to similarities in patterns of relationships in the therapy and in childhood or currently outside of the therapy, the aim of this is not to provide the patients with an explanation (insight) that they might be able to use to control their behaviour pattern, but far more simply to highlight one other puzzling phenomenon that requires thought and contemplation, part of our general therapeutic stance aimed to facilitate the recovery of mentalization which we see as the overall aim of treatment. Our initial study of MBT 14 compared its effectiveness in the context of a partial hospital program with routine general psychiatric care for patients with BPD. Treatment took place within a routine clinical service and was implemented by mental health professionals without full psychotherapy training who were offered expert supervision. Results showed that patients in the partial hospital program showed a statistically significant decrease on all measures, in contrast with the control group, which showed limited change or deterioration over the same period. Improvement in depressive symptoms, decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began after 6 months and continued to the end of treatment at 18 months. The 44 patients who participated in the original study were assessed at 3 month intervals after of the using the same of outcome Results that patients who had partial hospital treatment not only their but also showed a statistically significant continued on most measures, in contrast with the control group of patients who showed only limited change the same period. of continued in social and interpersonal these suggest that were an was made to health care associated with partial hospital treatment compared with treatment within general psychiatric services care of all patients who participated in the was assessed using from and service were compared 6 months to 18 months of and at differences were found between the groups or treatment. the treatment the of partial hospital treatment were by psychiatric inpatient care and reduced treatment. The for to decrease in the group was not in the control group, suggesting that partial hospital treatment for BPD is no more than general psychiatric care and leads to considerable after the of treatment. patients who participated in the partial hospital treatment have now been up after initial The primary outcome for this study was number of suicide However, in the of the limited related to social in we were to whether the social and interpersonal found at the end of months had been and whether additional in the of achievement had been made in either group. Patients in the MBT program better than those treatment as their initial at the end of their general social function many more were in or full time than the group, and only for BPD compared to of the patients in the group who were for randomized controlled of MBT in an outpatient has been patients were to or clinical representing current practice. were in both conditions all outcome Patients randomized to showed a of both and significant suicide attempts and research studies are randomized controlled trials on patients with substance use disorders and patients with eating disorders. partial study of the original partial hospital has also been by an group in the that results are within mental health services from the of the treatment. MBT may not be different from other of intervention widely by and other mental health professionals in the contexts in which individuals with BPD are being We no for the intervention. MBT represents the relatively of a of developmental processes identified in all our a) the of an intense relationship based on attempts to engage the patients in a process of understanding their mental and b) the of their feelings and that patients are able to identify themselves as thinking and in the context of and high levels of emotional In the recovery of mentalization patients their thoughts and feelings, which then makes relationships and a Although we would to have identified a particular method that makes the of this therapeutic process we make no of can likely about and personality change by this and our of The of research is to identify effective and for generating change in this group.

World Psychiatry · editorial or comment · 663 citationsread the source →

Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms. Objective: To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic. Design, setting, and participants: This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020. Exposures: The COVID-19 pandemic and outcomes associated with the measures to mitigate it. Main outcomes and measures: Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20). Results: A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]). Conclusions and relevance: These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.

JAMA network open · 1509 citationsread the source →

Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden.

Background: Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS. Methods: The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13-16 years with a BMI of at least 35 kg/m2, who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259. Findings: 500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m2 (SD 5·2). After 2 years, BMI change was -12·6 kg/m2 (-35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and -0·2 kg/m2 (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference -12·4 kg/m2 [95% CI -15·5 to -9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference -0·9 [95% CI -1·2 to -0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up. Interpretation: MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity. Funding: Sweden's Innovation Agency, Swedish Research Council Health.

The Lancet. Child & adolescent health · randomised controlled trial · 45 citationsread the source →

Living with type 1 diabetes mellitus in emerging adulthood: A qualitative study.

Objective: Few studies have investigated the impact of diabetes considering its effects on developmental tasks that are typical of emerging adulthood. The present study aimed to investigate how emerging adults with a chronic condition such as type 1 diabetes mellitus manage with this developmental phase. Methods: 30 emerging adults diagnosed with diabetes (18-34 years, females = 19) took part in an autobiographical interview investigating their experience of dealing with type 1 diabetes. Narratives were analysed by means of a qualitative thematic analysis of an inductive type. Results: Thematic analysis pointed out five thematic areas strictly related to the tasks of emerging adulthood: the development of intimate relationships, university life, work and plans for the future, the achievement of individual autonomy, the construction of an adult identity and family planning. Every thematic area reported a number of subthemes related to specific difficulties experienced by participants in reaching their developmental tasks due to chronic disease. Emerged themes considered both negative and positive outcomes of living with type 1 diabetes mellitus in emerging adulthood, such as a personal growth related to identity development. Conclusion: The authors discussed results considering complexities and resources associated with diabetes in the light of developmental tasks of emerging adulthood.

British journal of health psychology · 13 citationsread the source →

Psychological interventions to foster resilience in healthcare professionals.

Background: Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work-related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience-promoting training programmes. Objectives: To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists). Search methods: We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results. Selection criteria: Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, wait-list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well-being or quality of life. Secondary outcomes were resilience factors. Data collection and analysis: Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only). Main results: We included 44 RCTs (high-income countries: 36). Thirty-nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face-to-face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive-behavioural therapy) versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD -0.29, 95% CI -0.50 to -0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD -0.61, 95% CI -1.07 to -0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD -0.06, 95% CI -0.35 to 0.23; 5 studies, 231 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.14, 95% CI -0.01 to 0.30; 13 studies, 1494 participants; very-low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very-low certainty evidence). Authors' conclusions: For healthcare professionals, there is very-low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post-intervention. The paucity of medium- or long-term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high-quality replications and improved study designs.

The Cochrane database of systematic reviews · meta-analysis · 227 citationsread the source →

Mindfulness-based stress reduction for healthy individuals: A meta-analysis.

Background: An increasing number of mindfulness-based stress reduction (MBSR) studies are being conducted with nonclinical populations, but very little is known about their effectiveness. Objective: To evaluate the efficacy, mechanisms of actions, and moderators of MBSR for nonclinical populations. Data sources: A systematic review of studies published in English journals in Medline, CINAHL or Alt HealthWatch from the first available date until September 19, 2014. Study selection: Any quantitative study that used MBSR as an intervention, that was conducted with healthy adults, and that investigated stress or anxiety. Results: A total of 29 studies (n=2668) were included. Effect-size estimates suggested that MBSR is moderately effective in pre-post analyses (n=26; Hedge's g=.55; 95% CI [.44, .66], p<.00001) and in between group analyses (n=18; Hedge's g=.53; 95% CI [.41, .64], p<.00001). The obtained results were maintained at an average of 19 weeks of follow-up. Results suggested large effects on stress, moderate effects on anxiety, depression, distress, and quality of life, and small effects on burnout. When combined, changes in mindfulness and compassion measures correlated with changes in clinical measures at post-treatment and at follow-up. However, heterogeneity was high, probably due to differences in the study design, the implemented protocol, and the assessed outcomes. Conclusions: MBSR is moderately effective in reducing stress, depression, anxiety and distress and in ameliorating the quality of life of healthy individuals; however, more research is warranted to identify the most effective elements of MBSR.

Journal of psychosomatic research · meta-analysis · 738 citationsread the source →

Yoga and Emotion Regulation in High School Students: A Randomized Controlled Trial.

Middle adolescents (15-17 years old) are prone to increased risk taking and emotional instability. Emotion dysregulation contributes to a variety of psychosocial difficulties in this population. A discipline such as yoga offered during school may increase emotion regulation, but research in this area is lacking. This study was designed to evaluate the impact of a yoga intervention on the emotion regulation of high school students as compared to physical education (PE). In addition, the potential mediating effects of mindful attention, self-compassion, and body awareness on the relationship between yoga and emotion regulation were examined. High school students were randomized to participate in a 16-week yoga intervention (n = 19) or regular PE (n = 18). Pre-post data analyses revealed that emotion regulation increased significantly in the yoga group as compared to the PE group (F (1,32) = 7.50, p = .01, and eta(2) = .19). No significant relationship was discovered between the changes in emotion regulation and the proposed mediating variables. Preliminary results suggest that yoga increases emotion regulation capacities of middle adolescents and provides benefits beyond that of PE alone.

Evidence-based complementary and alternative medicine : eCAM · 33 citationsread the source →

The association of gait speed and self-reported difficulty walking with social isolation: A nationally-representative study.

Background: Mobility assessments are commonly used among older adults as risk stratification for falls, preoperative function, frailty, and mortality. We determined if gait speed and self-reported difficulty walking are similarly associated with social isolation and loneliness, which are key markers of social well-being and linked to health outcomes. Methods: We used 2015-2016 data from the National Social life Health and Aging Project (NSHAP), an in-person nationally-representative survey of 2640 community-dwelling adults ≥65 years old. We measured gait speed (timed 3-m walk: unable to walk, ≥5.7 s, and <5.7 s), and self-reported difficulty walking one block or across the room (unable, "much," "some," or "no" difficulty). Social measures included loneliness (3-item UCLA scale), social isolation (12-item scale), and individual social activities (frequency socializing, religious participation, community participation, and volunteering). We used logistic regression to determine the adjusted probability of each social measure by gait speed and difficulty walking, adjusting for sociodemographic and health characteristics, and tested for interaction terms with age. Results: Participants were on average 75 years old (SD = 7.1), 54% female, 9% Black/African American, and 6% Hispanic. Difficulty walking one block was associated with (p < 0.05): social isolation (much difficulty: 26% vs no difficulty: 18%), low socializing (33% vs 19%), low volunteering (67% vs 53%), low community participation (54% vs 43%), low religious participation (51% vs 46%), and loneliness (25% vs 14%). Difficulty walking across the room was similarly strongly associated with social isolation and individual activities. The association between self-reported difficulty walking and social isolation was stronger at older ages (p-value of interaction <0.001). Conclusions: Self-reported mobility difficulty is a widely used clinical assessment that is strongly associated with loneliness and social isolation, particularly at older ages. Among persons with limited mobility, clinicians should consider a careful social history to identify social needs and interventions addressing mobility to enhance social connections.

Journal of the American Geriatrics Society · 17 citationsread the source →

Enacted Stigma, Mental Health, and Protective Factors Among Transgender Youth in Canada.

Purpose: We aimed to assess the Minority Stress Model which proposes that the stress of experiencing stigma leads to adverse mental health outcomes, but social supports (e.g., school and family connectedness) will reduce this negative effect. Methods: We measured stigma-related experiences, social supports, and mental health (self-injury, suicide, depression, and anxiety) among a sample of 923 Canadian transgender 14- to 25-year-old adolescents and young adults using a bilingual online survey. Logistic regression models were conducted to analyze the relationship between these risk and protective factors and dichotomous mental health outcomes among two separate age groups, 14- to 18-year-old and 19- to 25-year-old participants. Results: Experiences of discrimination, harassment, and violence (enacted stigma) were positively related to mental health problems and social support was negatively associated with mental health problems in all models among both age groups. Among 14-18 year olds, we examined school connectedness, family connectedness, and perception of friends caring separately, and family connectedness was always the strongest protective predictor in multivariate models. In all the mental health outcomes we examined, transgender youth reporting low levels of enacted stigma experiences and high levels of protective factors tended to report favorable mental health outcomes. Conversely, the majority of participants reporting high levels of enacted stigma and low levels of protective factors reported adverse mental health outcomes. Conclusion: While these findings are limited by nonprobability sampling procedures and potential additional unmeasured risk and protective factors, the results provide positive evidence for the Minority Stress Model in this population and affirm the need for policies and programs to support schools and families to support transgender youth.

Transgender health · 115 citationsread the source →

Comparison of Racial, Ethnic, and Geographic Location Diversity of Participants Enrolled in Clinic-Based vs 2 Remote COVID-19 Clinical Trials.

Importance: Racial and ethnic diversity among study participants is associated with improved generalizability of clinical trial results and may address inequities in evidence that informs public health strategies. Novel strategies are needed for equitable access and recruitment of diverse clinical trial populations. Objective: To investigate demographic and geographical location data for participants in 2 remote COVID-19 clinical trials with online recruitment and compare with those of a contemporaneous clinic-based COVID-19 study. Design, setting, and participants: This cohort study was conducted using data from 3 completed, prospective randomized clinical trials conducted at the same time: 2 remotely conducted studies (the Early Treatment Study and Hydroxychloroquine COVID-19 Postexposure Prophylaxis [PEP] Study) and 1 clinic-based study of convalescent plasma (the Expanded Access to Convalescent Plasma for the Treatment of Patients With COVID-19 study). Data were collected from March to August 2020 with 1 to 28 days of participant follow-up. All studies had clinical sites in Seattle, Washington; the 2 remote trials also had collaborating sites in New York, New York; Syracuse, New York; Baltimore, Maryland; Boston, Massachusetts; Chicago, Illinois; New Orleans, Louisiana; and Los Angeles, California. Two remote trials with inclusive social media strategies enrolled 929 participants with recent SARS-CoV-2 exposure (Hydroxychloroquine COVID-19 PEP Trial) and 231 participants with COVID-19 infection (Early Treatment Study); the clinic-based Expanded Access to Convalescent Plasma for the Treatment of Patients With COVID-19 study enrolled 250 participants with recent COVID-19 infection. Data were analyzed from April to August 2021. Interventions: Remote trials used inclusive social media strategies and clinician referral for recruitment and telehealth, courier deliveries, and self-collected nasal swabs for remotely conducted study visits. For the clinic-based study, participants were recruited via clinician referral and attended in-person visits. Main outcomes and measures: Google Analytics data were used to measure online participant engagement and recruitment. Participant demographics and geographical location data from remote trials were pooled and compared with those of the clinic-based study. Statistical comparison of demographic data was limited to participants with COVID infections (ie, those in the remotely conducted Early Treatment Study vs those in the clinic-based study) to improve accuracy of comparison given that the Hydroxychloroquine COVID-19 PEP Trial enrolled participants with COVID-19 exposures and thus had different enrollment criteria. Results: A total of 1410 participants were included. Among 1160 participants in remote trials and 250 participants in the clinic-based trial, the mean (range) age of participants was 39 (18-80) years vs 50 (19-79) years and 676 individuals (58.3%) vs 131 individuals (52.4%) reported female sex. The Early Treatment Study with inclusive social media strategies enrolled 231 participants in 41 US states with increased rates of racial, ethnic, and geographic diversity compared with participants in the clinic-based study. Among 228 participants in the remotely conducted Early Treatment Study with race data vs participants in the clinic-based study, 39 individuals (17.1%) vs 1 individual (0.4%) identified as Alaska Native or American Indian, 11 individuals (4.8%) vs 22 individuals (8.8%) identified as Asian, 26 individuals (11.4%) vs 4 individuals (1.6%) identified as Black, 3 individuals (1.3%) vs 1 individual identified as Native Hawaiian or Pacific Islander, 117 individuals (51.3%) vs 214 individuals (85.6%) identified as White, and 32 individuals (14.0%) vs 8 individuals (3.2%) identified as other race (P < .001). Among 230 individuals in the Early Treatment Study vs 236 individuals in the clinic-based trial with ethnicity data, 71 individuals (30.9%) vs 11 individuals (4.7%) identified as Hispanic or Latinx (P<.001). There were 29 individuals in the Early Treatment Study with nonurban residences (ie, rural, small town, or peri-urban; 12.6%) vs 6 of 248 individuals in the clinic-based trial with residence data (2.4%) (P < .001). In remote trial online recruitment, the highest engagement was with advertisements on social media platforms; among 125 147 unique users with age demographics who clicked on online recruitment advertisements, 84 188 individuals (67.3%) engaged via Facebook. Conclusions and relevance: These findings suggest that remote clinical trials with online advertising may be considered as a strategy to improve diversity among clinical trial participants.

JAMA network open · 48 citationsread the source →

Trust Matters: A Qualitative Study on Healthcare Access and Utilization Among African Immigrants in the United States.

Trust in healthcare is declining in the U.S. and is associated with decreased engagement in preventive care, low adherence to treatments, lack of motivation to seek care and poor health outcomes. Using the Health Belief Model (HBM), this study examined the impacts of trust on the healthcare access and utilization among African immigrants in Florida, United States. In-depth interviews were conducted with purposively selected African immigrants (N = 19) over the age of 18, lived in Florida for five or more years, and had recent experience with the U.S. healthcare system. Interviews were audio-recorded, transcribed verbatim, and analyzed using NVivo14. Perceived barriers to trust led to discontinuation and delays of care. Uncertainties on insurance coverage, ambiguous medical bills, and broken patient-provider communication constitute perceived barriers. Perceived benefit determined trust and medical adherence among participants. Findings revealed that being Black immigrant and legal requirements such as proof of legal status fueled perceived susceptibility. To counter their susceptibility and earn trust from providers, participants were pressured to present themselves in an 'acceptable' manner in healthcare settings. Self-efficacy was demonstrated through self-research on their cases and self-advocacy. Cues to action included seeking second opinions and changing providers depending on availability. Healthcare systems should prioritize billing transparency, effective communication, equitable practices, and legal protections for immigrants. Providers need continuous training in cultural humility and trauma-informed care, centered on immigrant experiences. Co-developing multilingual health information and engaging trusted messengers such as community and faith leaders will enhance the credibility of health promotion efforts.

Journal of community health · 2 citationsread the source →

Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis.

Importance: There are conflicting accounts about the risk for attention-deficit/hyperactivity disorder (ADHD) following traumatic brain injury (TBI), possibly owing to variations between studies in acute TBI severity or when ADHD was assessed postinjury. Analysis of these variations may aid in identifying the risk. Objective: To conduct a meta-analysis of studies assessing ADHD diagnoses in children between ages 4 and 18 years following concussions and mild, moderate, or severe TBI. Data sources: PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials (1981-December 19, 2019) were searched including the terms traumatic brain injury, brain injuries, closed head injury, blunt head trauma, concussion, attention deficit disorders, ADHD, and ADD in combination with childhood, adolescence, pediatric, infant, child, young adult, or teen. Study selection: Limited to English-language publications in peer-reviewed journals and patient age (4-18 years). Differences about inclusion were resolved through consensus of 3 authors. Data extraction and synthesis: MOOSE guidelines for abstracting and assessing data quality and validity were used. Odds ratios with 95% credible intervals (CrIs) are reported. Main outcomes and measures: The planned study outcome was rate of ADHD diagnoses. Results: A total of 12 374 unique patients with TBI of all severity levels and 43 491 unique controls were included in the 24 studies in this review (predominantly male: TBI, 61.8%; noninjury control, 60.9%; other injury control, 66.1%). The rate of pre-TBI ADHD diagnoses was 16.0% (95% CrI, 11.3%-21.7%), which was significantly greater than the 10.8% (95% CrI, 10.2%-11.4%) incidence of ADHD in the general pediatric population. Compared with children without injuries, the odds for ADHD were not significantly increased following concussion (≤1 year: OR, 0.32; 95% CrI, 0.05-1.13), mild TBI (≤1 year: OR, 0.56; 0.16-1.43; >1 year: OR, 1.07; 95% CrI, 0.35-2.48), and moderate TBI (≤1 year: OR, 1.28; 95% CrI, 0.35-3.34; >1 year: OR, 3.67; 95% CrI, 0.83-10.56). The odds for ADHD also were not significantly increased compared with children with other injuries following mild TBI (≤1 year: OR, 1.07; 95% CrI, 0.33-2.47; >1 year: OR, 1.18; 95% CrI, 0.32-3.12) and moderate TBI (≤1 year: OR, 2.34; 95% CrI, 0.78-5.47; >1 year: OR, 3.78; 95% CrI, 0.93-10.33). In contrast, the odds for ADHD following severe TBI were increased at both time points following TBI compared with children with other injuries (≤1 year: OR, 4.81; 95% CrI, 1.66-11.03; >1 year: OR, 6.70; 95% CrI, 2.02-16.82) and noninjured controls (≤1 year: OR, 2.62; 95% CrI, 0.76-6.64; >1 year: OR, 6.25; 95% CrI, 2.06-15.06), as well as those with mild TBI (≤1 year OR, 5.69; 1.46-15.67: >1 year OR, 6.65; 2.14-16.44). Of 5920 children with severe TBI, 35.5% (95% CrI, 20.6%-53.2%) had ADHD more than 1 year postinjury. Conclusions and relevance: This study noted a significant association between TBI severity and ADHD diagnosis. In children with severe but not mild and moderate TBI, there was an association with an increase in risk for ADHD. The high rate of preinjury ADHD in children with TBI suggests that clinicians should carefully review functioning before a TBI before initiating treatment.

JAMA pediatrics · meta-analysis · 30 citationsread the source →

A Meta-Analysis of the Effects of Acute Sleep Deprivation on the Cortical Transcriptome in Rodent Models.

Sleep deprivation (SD) causes large disturbances in mood and cognition. The molecular basis for these effects can be explored using transcriptional profiling to quantify brain gene expression. In this report, we used a meta-analysis of public transcriptional profiling data to discover SD effects on gene expression that are consistent across studies and paradigms. To conduct the meta-analysis, we used pre-specified search terms related to rodent SD paradigms to identify relevant studies within Gemma, a database containing > 19,000 re-analysed microarray and RNA-Seq datasets. Eight studies met our systematic inclusion/exclusion criteria. These studies characterised the effect of 18 SD interventions on gene expression in the mouse cerebral cortex (collective n = 293). For each gene with sufficient data (n = 16,290), we fit a random effects meta-analysis model to the SD effect sizes (log(2) fold changes). Our meta-analysis revealed 182 differentially expressed genes in response to SD (false discovery rate: FDR < 0.05), most of which (115/182) showed similar effects (FDR < 0.05) in an independent large dataset (GSE114845: n = 86 RNA-Seq samples from n = 222 mice). Gene-set enrichment analysis revealed down-regulation in pathways related to stress response (e.g., glucocorticoid receptor Nr3c1), vasculature, growth and development, and upregulation related to stress, inflammation, and neuropeptide signalling. Exploratory analyses suggested that recovery sleep (included in six contrasts: range: 1-18 h) could reverse the impact of SD on gene expression. Our meta-analysis provides a useful reference database illustrating the diverse molecular impact of SD on the rodent cerebral cortex.

Journal of sleep research · meta-analysis · 7 citationsread the source →

Aerobic exercise for adult patients with major depressive disorder in mental health services: A systematic review and meta-analysis.

Although exercise is associated with depression relief, the effects of aerobic exercise (AE) interventions on clinically depressed adult patients have not been clearly supported. The purpose of this meta-analysis was to examine the antidepressant effects of AE versus nonexercise comparators exclusively for depressed adults (18-65 years) recruited through mental health services with a referral or clinical diagnosis of major depression. Eleven e-databases and bibliographies of 19 systematic reviews were searched for relevant randomized controlled clinical trials. A random effects meta-analysis (Hedges' g criterion) was employed for pooling postintervention scores of depression. Heterogeneity and publication bias were examined. Studies were coded considering characteristics of participants and interventions, outcomes and comparisons made, and study design; accordingly, sensitivity and subgroup analyses were calculated. Across 11 eligible trials (13 comparisons) involving 455 patients, AE was delivered on average for 45 min, at moderate intensity, three times/week, for 9.2 weeks and showed a significantly large overall antidepressant effect (g = -0.79, 95% confidence interval = -1.01, -0.57, P < 0.00) with low and nonstatistically significant heterogeneity (I2 = 21%). No publication bias was found. Sensitivity analyses revealed large or moderate to large antidepressant effects for AE (I2 ≤ 30%) among trials with lower risk of bias, trials with short-term interventions (up to 4 weeks), and trials involving individual preferences for exercise. Subgroup analyses revealed comparable effects for AE across various settings and delivery formats, and in both outpatients and inpatients regardless symptom severity. Notwithstanding the small number of trials reviewed, AE emerged as an effective antidepressant intervention.

Depression and anxiety · meta-analysis · 224 citationsread the source →

Psychological interventions for antisocial personality disorder.

Background: Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review). Objectives: To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD. Search methods: We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies. Selection criteria: Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Main results: This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence). Authors' conclusions: There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

The Cochrane database of systematic reviews · meta-analysis · 32 citationsread the source →

Does pulmonary rehabilitation address treatable traits? A systematic review.

Background: There is growing interest in a "treatable traits" approach to pulmonary rehabilitation in chronic airways disease. The frequency with which pulmonary rehabilitation programmes address treatable traits is unknown. Methods: Randomised controlled trials of pulmonary rehabilitation compared to usual care in patients with stable chronic airways disease were included. The components of pulmonary rehabilitation delivered were extracted and mapped to treatable traits in pulmonary, extrapulmonary and behavioural/lifestyle domains. Meta-analysis was used to evaluate the impact of addressing >1 treatable trait on exercise capacity and health-related quality of life (HRQoL). Results: 116 trials were included (6893 participants). Almost all pulmonary rehabilitation programmes addressed deconditioning (97% of trials). The most commonly addressed extrapulmonary traits were nutritional status (obesity and cachexia, 18% each) and mood disturbance (anxiety and depression, 10% each). Behavioural/lifestyle traits most frequently addressed were nonadherence (46%), poor inhalation technique (24%) and poor family/social support (19%). Exercise capacity and HRQoL outcomes did not differ between studies that addressed deconditioning alone and those that targeted additional traits, but heterogeneity was high. Conclusion: Aside from deconditioning, treatable traits are infrequently addressed in existing trials of pulmonary rehabilitation. The potential of the treatable traits approach to improve pulmonary rehabilitation outcomes remains to be explored.

European respiratory review : an official journal of the European Respiratory Society · meta-analysis · 12 citationsread the source →

Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis.

Background: The best treatment options for binge-eating disorder are unclear. Purpose: To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder. Data sources: English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016. Study selection: 9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias. Data extraction: 2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence. Data synthesis: Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite. Limitations: Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment. Conclusion: Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder. Primary funding source: Agency for Healthcare Research and Quality.

Annals of internal medicine · meta-analysis · 159 citationsread the source →

How can interventions increase motivation for physical activity? A systematic review and meta-analysis.

Motivation is a proximal determinant of behaviour, and increasing motivation is central to most health behaviour change interventions. This systematic review and meta-analysis sought to identify features of physical activity interventions associated with favourable changes in three prominent motivational constructs: intention, stage of change and autonomous motivation. A systematic literature search identified 89 intervention studies (k = 200; N = 19,212) which assessed changes in these motivational constructs for physical activity. Intervention descriptions were coded for potential moderators, including behaviour change techniques (BCTs), modes of delivery and theory use. Random effects comparative subgroup analyses identified 18 BCTs and 10 modes of delivery independently associated with changes in at least one motivational outcome (effect sizes ranged from d = 0.12 to d = 0.74). Interventions delivered face-to-face or in gym settings, or which included the BCTs 'behavioural goal setting', 'self-monitoring (behaviour)' or 'behavioural practice/rehearsal', or which combined self-monitoring (behaviour) with any other BCT derived from control theory, were all associated with beneficial changes in multiple motivational constructs (effect sizes ranged from d = 0.12 to d = 0.46). Meta-regression analyses indicated that increases in intention and stage of change, but not autonomous motivation, were significantly related to increases in physical activity. The intervention characteristics associated with changes in motivation seemed to form clusters related to behavioural experience and self-regulation, which have previously been linked to changes in physical activity behaviour. These BCTs and modes of delivery merit further systematic study, and can be used as a foundation for improving interventions targeting increases in motivation for physical activity.

Health psychology review · meta-analysis · 156 citationsread the source →

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis.

Background: There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants. Methods: In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291. Findings: 18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I2 98·8%; τ2 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I2 96·8%; τ2 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I2 97·4%; τ2 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I2 96·6%; τ2 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner. Interpretation: One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants. Funding: UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

The Lancet. Public health · meta-analysis · 63 citationsread the source →

Mindfulness-based interventions for binge eating: a systematic review and meta-analysis.

Mindfulness-based interventions are increasingly used to treat binge eating. The effects of these interventions have not been reviewed comprehensively. This systematic review and meta-analysis sought to summarize the literature on mindfulness-based interventions and determine their impact on binge eating behavior. PubMED, Web of Science, and PsycINFO were searched using keywords binge eating, overeating, objective bulimic episodes, acceptance and commitment therapy, dialectical behavior therapy, mindfulness, meditation, mindful eating. Of 151 records screened, 19 studies met inclusion criteria. Most studies showed effects of large magnitude. Results of random effects meta-analyses supported large or medium-large effects of these interventions on binge eating (within-group random effects mean Hedge's g = -1.12, 95 % CI -1.67, -0.80, k = 18; between-group mean Hedge's g = -0.70, 95 % CI -1.16, -0.24, k = 7). However, there was high statistical heterogeneity among the studies (within-group I(2) = 93 %; between-group I(2) = 90 %). Limitations and future research directions are discussed.

Journal of behavioral medicine · meta-analysis · 119 citationsread the source →