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Tinnitus groups: A model of social support and social connectedness from peer interaction.

Tinnitus is a chronic condition for which there is no medical treatment. Tinnitus groups are a widely available resource for people with tinnitus. Objectives: Our objectives were to explore the active ingredients of tinnitus support groups in terms of their mechanisms for providing support, the contextual factors that elicit such mechanisms, and the outcomes in terms of coping enhancement. Design: We adopted a pluralist and iterative approach informed by the realist evaluation method. Methods: We conducted ethnographic data generation at tinnitus support groups involving observations (n = 160), focus groups (n = 130), and individual interviews (n = 20). Inductive analyses were conducted following the constant comparison method of grounded theory. We then interrogated the inductive themes to identify evidence of Contexts, Mechanisms, and Outcomes. We then produced a model which was tested in a survey of tinnitus group members (n = 65) in effect providing large-scale respondent validation of the data-driven model created through our inductive analysis. Results: We identified that tinnitus groups can facilitate social connectedness between group members. This experience appeared to build resilience among those experiencing tinnitus-related distress. Groups also played a role in building a sense of control related to knowledge and information sharing. Additionally, we identified risks associated with not accessing social support in a group environment. Conclusions: Our findings contribute to the growing understanding of the power of social connectedness as building shared social identity when living with tinnitus. Statement of contribution What is already known on this subject? Tinnitus is a prevalent condition with approximately 10-15% of the population experiencing a spontaneous sound without obvious source. Tinnitus is an invisible health and chronic condition. People with tinnitus experience high levels of distress, anxiety, and depression. Group support is beneficial to people with many health problems. What does this study add? This study describes the mechanisms by which tinnitus support groups can support coping in tinnitus. This is the first study to comprehensively explore the views of those who attend tinnitus groups. The study identifies the key features of support groups that facilitate social connectedness among group members. The most valued features of groups are the knowledge and information provided, the sense of belonging communicated to group members, and the creation and maintenance of a sense of hope towards the tinnitus. This study contributes new insights to both the tinnitus field and adds to the literature on support groups in health.

British journal of health psychology · 24 citationsread the source →

Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa.

Objective: There is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment. Method: This 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination. Results: Participants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6). Conclusion: In this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments. Clinical trial registration information: Study of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.

Journal of the American Academy of Child and Adolescent Psychiatry · randomised controlled trial · 113 citationsread the source →

Underlying mechanisms and efficacy of a suicide-focused psychological intervention for psychosis, the Cognitive Approaches to Combatting Suicidality (CARMS): a multicentre, assessor-masked, randomised controlled trial in the UK.

Background: There is a need for theoretically grounded and testable suicide-focused psychological therapies, especially in people with severe mental health problems, specifically non-affective psychosis. We aimed to test both the underlying mechanisms and efficacy of a suicide-focused therapy, cognitive behavioural suicide prevention for psychosis (CBSPp). Methods: We did a multicentre, assessor-masked, randomised controlled trial conducted at four UK National Health Service (NHS) sites. Participants were eligible for enrolment if they were 18 years or older; met ICD-10 criteria for non-affective psychosis (F20-F29); had self-reported suicidal experiences in the 3 months before recruitment; were under the care of an NHS mental health services team; were not receiving a psychological therapy as part of a similar trial; had sufficient competency in the English language not to need an interpreter to participate; and were able to give informed consent. After screening for eligibility and completion of baseline assessments, participants were randomly allocated in a 1:1 ratio to either the treatment as usual group (control) or CBSPp therapy plus standard treatment group (treatment), with stratification by use of antidepressant medication and NHS site. Randomisation took place using an online Sealed Envelope randomisation procedure conducted and overseen by the Manchester Academic Health Sciences Centre Clinical Trials Unit (MCTU). This system was accessed only by specially allocated staff (eg, the CARMS Trial Manager or the MCTU Trial manager). When the system randomly allocated a participant, an unmasked email confirmation was sent to the unmasked coprincipal investigator and the CARMS Trial Manager (also unmasked). Assessors, the trial statistician, and one coprincipal investigator were masked to allocation group. Participants were informed of their randomised allocation group by an unmasked CARMS staff member. Experts-by-experience were involved in all stages of the research. For those in the treatment group, approximately 24 one-to-one therapy sessions were offered, usually weekly, for around 50 min per session. Assessments were conducted at baseline, month 6, and month 12. The primary outcome was suicide ideation severity measured by the 25-item Adult Suicide Ideation Questionnaire (ASIQ), assessed at month 6 relative to baseline. Outcome analyses used mixed models in the intention-to-treat population. Planned mediation indirect linear regression models examined appraisals of poor social support, emotional difficulties, interpersonal problem-solving difficulties, defeat, entrapment, and hopelessness as mediators at 6 months with allocation condition (treatment vs control) as the predictor variable and suicidal ideation severity (ASIQ) at 6 months as the outcome variable, whilst controlling for baseline levels of the mediator and outcome variables. The trial was registered before recruitment at ClinicalTrials.gov (NCT03114917) and ISRCTN (ISRCTN17776666) and is complete. Findings: We recruited participants from four NHS sites from June 21, 2017, to Nov 25, 2020, with the final 12-month assessment completed on Jan 10, 2022. 479 participants were screened for eligibility, and of these 329 (69%) provided consent and were enrolled. After 69 participants were lost to follow-up, 292 participants were randomly allocated to the treatment and control groups (149 [51%] and 143 [49%], respectively). At baseline, 161 (55%) participants were male and 130 (45%) were female; one participant (<1%) in the treatment group was missing gender data. Mean age was 35·1 years (SD 13·2; range 18-69), and 247 (85%) were White or Caucasian. Severity of suicidal ideation was not statistically different between the treatment (n=136) and the control groups (n=116) at 6 months (p=0·07; Cohen's d -0·20 [95% CI -0·42 to 0·02]). A significant indirect mediation effect (-2·85, -7·00 to -0·23) showed that therapy strengthened social support appraisals which, in turn, reduced suicidal ideation severity at 6 months more in the treatment group than in the control group. Suicide attempts were the most frequent severe adverse event (132 attempts in 26 participants in the treatment group vs 91 attempts in 30 participants in the control group). There were four deaths in the CARMS study, none of which were by suicide or considered related to treatment. Interpretation: CBSPp had no effect on suicidal ideation at 6 months, but it did have a significant indirect effect via improving appraisals of social support. It is important to explore how suicide-focused therapies can be developed and implemented in mental health services so that they maximally enhance appraisals of social support and social connection in ways that endure. Funding: Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership (reference number: 13/161/25).

The lancet. Psychiatry · randomised controlled trial · 4 citationsread the source →

Fear of cancer recurrence in adult cancer survivors: a systematic review of quantitative studies.

Purpose: Fear of cancer recurrence (FCR) is among the most commonly reported problems and one of the most prevalent areas of unmet needs for cancer survivors and their carers. This review aims to provide a comprehensive overview of current scientific knowledge on FCR and to formulate recommendations for future research. Methods: A systematic review was undertaken to identify quantitative studies associated with FCR. Relevant studies were identified via Medline, CINAHL, PsycINFO and AMED databases from 1996 through December 2011. Data from 130 eligible papers were extracted and summarized following a systematic scheme. Results: Multiple FCR assessment methods were identified. Survivors reported low to moderate level of FCR but considered it as one of the top greatest concerns and the most frequently endorsed unmet need. FCR remains stable over the survivorship trajectory. Younger age, presence and severity of physical symptoms, psychological distress and lower quality of life were associated with higher FCR. Health behaviours, psychological reactions and functional impairments were identified as FCR consequences. Carers reported higher FCR than the patients. Limited data on interventions were available. Conclusions: FCR research has expanded somewhat haphazardly over the last 20 years. Adopted consensual definition and used well-validated measures will be necessary. Longitudinal research examining the longer-term development and impact of FCR is clearly needed. The proposal and evaluation of theoretical models of FCR is a priority. Implications for cancer survivors: Identifying the key features of FCR will stimulate the research and the development of targeted interventions for cancer survivors and their carers.

Journal of cancer survivorship : research and practice · systematic review · 808 citationsread the source →

Trauma web-based psychoeducational programme: systematic cultural adaptation and protocol for a feasibility-acceptability study.

Background: Trauma exposure in Indonesia is high despite the fact that there is limited accessibility to mental healthcare. Pulihkan Luka (PL) is a web-based trauma psychoeducation intervention that aims to provide a practical solution to overcome barriers to accessing mental healthcare. Objectives: This article aimed to (1) describe the cultural adaptation process of PL for Indonesian students and (2) describe the design of the pilot randomised controlled trial (RCT) that examines the feasibility and acceptability of PL.Methods: First, we describe the cultural adaptation process of PL following the 5-phase Formative Method for Adapting Psychotherapy (FMAP) approach: (1) knowledge generation, (2) information integration, (3) review and revision, (4) mini-testing, and (5) finalisation. Focus Group Discussion (FGD) was conducted to gather the views of 15 stakeholders on psychoeducation material and trauma-related mental health problems. Based on the outcomes, we decided to utilise the informal Indonesian language, incorporate practical worksheets and infographics, which include illustrations that reflect Indonesia's cultural diversity, and provide guidance on seeking help that aligns with the mental health system in Indonesia. Second, we describe the design of a pilot RCT. Undergraduate students (N = 130) will be randomised to (1) four to seven sessions of PL + Enhanced Usual Care (PL + EUC; n = 65) or (2) Enhanced Usual Care only (EUC only; n = 65). Assessments will be conducted at baseline, post-intervention, and three and six-month follow-up. Additionally, 20 participants will be invited for an FGD to explore their experiences with the intervention. Quantitative data will be analysed using linear mixed-effect models, and qualitative data will be analysed using thematic analysis. Discussion: Cultural adaptation is crucial for optimally developing and assessing the feasibility and acceptability of a web-based trauma psychoeducation intervention in Indonesia. The outcomes of the RCT will inform the feasibility and acceptability of web-based trauma psychoeducation in the Indonesian undergraduate student population.

European journal of psychotraumatology · clinical trial · 2 citationsread the source →

Effectiveness of a Novel Integrative Online Treatment for Depression (Deprexis): Randomized Controlled Trial

BACKGROUND: Depression is associated with immense suffering and costs, and many patients receive inadequate care, often because of the limited availability of treatment. Web-based treatments may play an increasingly important role in closing this gap between demand and supply. We developed the integrative, Web-based program Deprexis, which covers therapeutic approaches such as behavioral activation, cognitive restructuring, mindfulness/acceptance exercises, and social skills training. OBJECTIVE: To evaluate the effectiveness of the Web-based intervention in a randomized controlled trial. METHODS: There were 396 adults recruited via Internet depression forums in Germany, and they were randomly assigned in an 80:20 weighted randomization sequence to either 9 weeks of immediate-program-access as an add-on to treatment-as-usual (N = 320), or to a 9-week delayed-access plus treatment-as-usual condition (N = 76). At pre- and post-treatment and 6-month follow-up, we measured depression (Beck Depression Inventory) as the primary outcome measure and social functioning (Work and Social Adjustment Scale) as the secondary outcome measure. Complete analyses and intention-to-treat analyses were performed. RESULTS: Of 396 participants, 216 (55%) completed the post-measurement 9 weeks later. Available case analyses revealed a significant reduction in depression severity (BDI), Cohen's d = .64 (CI 95% = 0.33 - 0.94), and significant improvement in social functioning (WSA), Cohen's d = .64, 95% (CI 95% = 0.33 - 0.95). These improvements were maintained at 6-month follow-up. Intention-to-treat analyses confirmed significant effects on depression and social functioning improvements (BDI: Cohen's d = .30, CI 95% = 0.05 - 0.55; WSA: Cohen's d = .36, CI 95% = 0.10 - 0.61). Moreover, a much higher percentage of patients in the intervention group experienced a significant reduction of depression symptoms (BDI: odds ratio [OR] = 6.8, CI 95% = 2.90 - 18.19) and recovered more often (OR = 17.3, 95% CI 2.3 - 130). More than 80% of the users felt subjectively that the program had been helpful. CONCLUSIONS: This integrative, Web-based intervention was effective in reducing symptoms of depression and in improving social functioning. Findings suggest that the program could serve as an adjunctive or stand-alone treatment tool for patients suffering from symptoms of depression.

Journal of Medical Internet Research · randomised controlled trial · 388 citationsread the source →

The language of demand/withdraw: verbal and vocal expression in dyadic interactions.

Associations between vocally expressed emotional arousal, influence tactics, and demand/withdraw behavior were examined in a treatment-seeking sample of 130 seriously and stably distressed, married, heterosexual couples and in a community sample (N = 38) of 18 married heterosexual and 20 dating heterosexual couples. Fundamental frequency was used to measure emotional arousal, and computational linguistics were used to measure influence tactics. Higher levels of demand/withdraw behavior were associated with greater use of manipulative and controlling influence tactics, higher levels of emotional arousal, and less frequent use of cooperative and compromising influence tactics. Overall, demanders tended to express more arousal and to use more influence tactics than withdrawers. Both influence tactics and emotional arousal were uniquely associated with demand/withdraw behavior. Implications of results are discussed for refining theories of demand/withdraw interaction.

Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43) · cohort or longitudinal · 20 citationsread the source →

The relations among maternal depressive disorder, maternal expressed emotion, and toddler behavior problems and attachment.

Direct and indirect relations among maternal depression, maternal Expressed Emotion (EE: Self- and Child-Criticism), child internalizing and externalizing symptoms, and child attachment were examined. Participants were mothers with depression (n = 130) and comparison mothers (n = 68) and their toddlers (M age = 20 mo.; 53% male). Assessments included the Diagnostic Interview Schedule (maternal depression); the Five Minute Speech Sample (EE); the Child Behavior Checklist (toddler behavior problems); the Strange Situation (child attachment). Direct relations were significant linking: 1) maternal depression with both EE and child functioning; 2) Child-Criticism with child internalizing and externalizing symptoms; 3) Self-Criticism with child attachment. Significant indirect relations were found linking maternal depression with: 1) child externalizing behaviors via Child-Criticism; 2) child internalizing behaviors via Self- and Child-Criticism; and 3) child attachment via Self-Criticism. Findings are consistent with a conceptual model in which maternal EE mediates relations between maternal depression and toddler socio-emotional functioning.

Journal of abnormal child psychology · 43 citationsread the source →

A patient with a resistant major depression disorder treated with deep brain stimulation in the inferior thalamic peduncle.

Objective and importance: The present report explored the effect of electrical stimulation on the inferior thalamic peduncle in a patient with resistant major depression disorder (MDD). Clinical presentation: This report refers to a 49-year-old woman with a history of recurrent episodes of major depression for 20 years (12 episodes and 2 hospitalizations), fulfilling Diagnostic and Statistical Manual of Mental Disorders, 4th edition, revised, criteria for MDD; in addition, the patient met criteria for borderline personality disorder and bulimia. Her longest episode of depression with suicidal ideation began 5 years before surgery. The patient's symptom array responded poorly to different combinations of antidepressants, cognitive therapy, and electroconvulsive therapy, which induced improvement only for short periods of time. Immediately before surgery, her Global Assessment of Functioning score was 20 and her Hamilton Depression Scale score ranged from 33 to 42. The patient was proposed for surgery for MDD. Intervention: The patient had bilateral eight-contact electrodes stereotactically implanted for stimulation of areas at and around the inferior thalamic peduncle. Electrode position was corroborated by unilateral electrical stimulation searching for recruiting responses and regional direct current shifts in the electroencephalogram. Recording electrodes were replaced by tetrapolar electrodes for deep brain stimulation and connected to an internalized stimulation system for continuous bipolar stimulation at 130 Hz, 0.45 milliseconds, 2.5 V. Bimonthly follow-up included psychiatric and neuropsychological evaluations performed over the course of 24 months. After 8 months of ON stimulation, the patient entered a double-blind protocol with stimulators turned OFF. Improvement of depression measured by the Hamilton Depression Scale score was evident after initial placement of electrodes without electrical stimulation. Depression relapsed partially at the end of the first week. Electrical stimulation further improved depression, normalizing depression scores and neuropsychological performance. Patient depression scores ranked between 2 and 8 during 8 months of ON stimulation without antidepressant medication. After stimulation was turned OFF, spontaneous fluctuations in patient symptoms reflected by Hamilton Depression Scale and Global Assessment of Functioning scores were documented; these fluctuations disappeared after stimulation was turned on by Month 20. Conclusion: Complicated patients with comorbid conditions are common referrals to psychosurgery services. In this report, we present promising results of electrical stimulation of the inferior thalamic peduncle to treat recurrent unipolar depression in a patient with MDD and borderline personality disorder who responded poorly to treatment.

Neurosurgery · case report · 180 citationsread the source →

Suicide in children and young people in England: a consecutive case series.

Background: There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies. Methods: This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death. Findings: 145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18-19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 [27%] individuals), bullying (28 [22%]), bereavement (36 [28%]), suicide in family or friends (17 [13%]), physical health conditions (47 [36%]), family problems (44 [34%]), social isolation or withdrawal (33 [25%]), child abuse or neglect (20 [15%]), excessive drinking (34 [26%]), and illicit drug use (38 [29%]). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies. Interpretation: Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system. Funding: The Healthcare Quality Improvement Partnership.

The lancet. Psychiatry · 71 citationsread the source →

Provider Burnout and Fatigue During the COVID-19 Pandemic: Lessons Learned From a High-Volume Intensive Care Unit

The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in an overall surge in new cases of depression and anxiety and an exacerbation of existing mental health issues, with a particular emotional and physical toll on health care workers.1 Limited resources, longer shifts, disruptions to sleep and to work-life balance, and occupational hazards associated with exposure to COVID-19 have contributed to physical and mental fatigue, stress and anxiety, and burnout.2 Similar to most hospitals in the COVID-19–affected areas, the Houston Methodist Hospital (HMH) system has experienced an overwhelming impact of this pandemic on personnel. For example, we have observed an unprecedented number of staff requesting Americans with Disabilities Act exemptions. Physicians and nurses are worried about their families, and some hesitate to go home in fear of exposing family members to infection. It is common to see emotional exhaustion in the intensive care unit (ICU). We have observed front-line health care providers emotionally breaking down, mainly due to the added pressure to choose between family responsibilities and their inner sense of duty toward patients. At the same time, we have seen an overwhelming influx of support from medical leadership, public and private acknowledgments, community support (eg, food sent to care units), as well as additional services offered to staff, such as music therapy, counseling services, chaplain services, and accommodations in work schedules. Other organizational adaptations include allocation of more resources (eg, float nurses, physicians, patient care assistants, and new equipment). Moving forward, our institution has plans for marshaling resources from surgeons, anesthesiologists, other medical specialists across all disciplines, and, in extreme circumstances, anyone with medical training and background. In this article, we share the lessons learned collectively by an interdisciplinary team of ICU leadership and collaborating scientists at the Center for Outcomes Research at HMH about the experience of occupational fatigue and burnout of intensive care personnel as a result of responding to the COVID-19 pandemic. We propose specific policy recommendations and guidelines for organizational readiness, resilience, and disaster mitigation. BACKGROUND Houston Methodist Hospital HMH is the flagship hospital of an 8-hospital nonprofit health care system spanning the Greater Houston metropolitan area, including a wide range of urban, suburban, and rural settings. For more than 100 years, HMH has served the Houston and global community with the highest quality patient care in a spiritual environment―indeed ironically, beginning its existence amidst the 1918 influenza pandemic. HMH has 952 operating beds (2393 systemwide) and 8294 employees (25,543 systemwide). Each year, it has 45,511 emergency room visits, 381,585 outpatient visits, and 41,976 admissions (more than 1.3 million outpatient visits and more than 126,000 admissions systemwide).3US News & World Report has named HMH the no. 1 hospital in Texas for 8 consecutive years, with placement among its top 20 “Best Hospitals Honor Roll” 3 times. In addition, HMH is nationally ranked in 9 specialties,4 and has been named the no. 1 employer in Texas by Forbes.5 Of particular note regarding its critical care capacities during this pandemic, HMH has 5 ICU units (cardiovascular, medical, coronary, surgical, and neonatal—with a total of 130 ICU beds), with 311 ICU beds systemwide across the community hospitals. At the time of this writing, HMH is caring for about 120 patients who have tested positive for COVID-19. COVID-19 Pandemic The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is in the same family as the causative agent for previous Middle East Respiratory Syndrome (MERS) and severe acute respiratory syndrome (SARS) outbreaks. COVID-19 arose most likely from animal-to-human transfer in Wuhan, China. Unlike previous coronavirus outbreaks, the current COVID-19 emergence was marked by high rates of person-to-person transmission, including from asymptomatic carriers, combined with high severity of illness in vulnerable populations, including those with very common preexisting chronic conditions like diabetes, heart disease, and lung disease.6 The dilemma posed to health care workers is 2-fold: first, the anticipated, and now experienced, overload on the health care system capacity to respond to this pandemic with a suitable flow of equipment; and second, the high risk posed to health care workers on the front lines and their family members as a result of constant exposure. The public has been repeatedly called on to “flatten the curve,” in reference to the social and behavioral changes that we as a society can undertake to slow the spread of disease. This strategy has been prominent in US Centers for Disease Control and Prevention (CDC) reports since 2007, with maintenance of the guidelines as recent as 2017.7,8 This strategy was even deftly memed by medical experts on social media.9 However, across several states, implementation of these preventive measures has fallen short of desired goals.1,2,10–14 LESSONS LEARNED Several factors may have exacerbated occupational fatigue and burnout in ICUs. Given our overarching roles across various facets of the health care system and our first-hand experiences with the response, the “lessons learned” documented here provide a holistic overview of major system-level problems exposed by the pandemic. In what follows, 4 major contributors to COVID-19–related occupational fatigue and burnout are discussed: (1) occupational hazards; (2) national versus locally scaled response; (3) process inefficiencies; and (4) financial instability. Occupational Hazards Given the highly contagious nature of SARS-CoV-2, the US CDC has published strict infection control and prevention guidelines for front-line health care workers, including limited administrative access, strict workplace hygiene requirements, and usage of personal protective equipment (PPE).15 The rapid spread of the COVID-19 pandemic revealed an overall lack of preparedness and insufficient training as well as limited supplies of PPE for ICU staff, including anesthesiologists, intensivists, pulmonologists, nurses, respiratory therapists, and other front-line providers in most affected areas. From the onset of the COVID-19 outbreak, it was apparent that testing for the virus, detecting its distribution through widespread surveillance, and subsequent contact tracing were major public health gaps. Most hospitals, including HMH, lacked the capacity to test significant portions of our patient population for novel infectious threats. This removed a highly effective infection control tool from our arsenal. Unfortunately, such unpreparedness, potentially resulting in poor patient outcomes, had a significant psychological burden on personnel. National Versus Locally Scaled Response The COVID-19 outbreak also exposed the inadequacy of the US Strategic National Stockpile (SNS) of PPE and ventilators during a pandemic affecting many states. In fact, to our knowledge, only 10%–25% of states’ requested PPE is being delivered, about 1 month into the pandemic. In addition, there are many uncertainties about when and how more PPE—and most important, ventilators—will become available. The process to access the US SNS should be as lean as possible, but it has proven slow and logistically cumbersome. While federal authorities are assembling practical guidelines to extend the life and use of PPE, such plans may void the warranty on PPE.16 Critical care personnel are well aware that the effectiveness of PPE deteriorates outside of recommended usage, and such awareness only worsens the psychological pressure on these personnel. Process Inefficiencies The COVID-19 pandemic has revealed several issues related to current processes and established practices. Most importantly, the lack of established policies for pandemic triage, equipment ordering, and emergency management has led to systemwide inefficiencies and has increased the burden on health care workers. While new protocols were put in place in response to the pandemic, these protocols were perceived as complex and, in some cases, premature. For example, anecdotal evidence suggests that most health care workers’ vulnerabilities and contamination were related to improper PPE doffing. While training videos on donning and doffing were shared with staff, such videos were not updated to reflect specific PPE used in our system, and instructions were not intuitive for less experienced personnel. Another important issue was related to policy overload coupled with mismatching policy from different levels or sources. For example, each subspecialty (eg, anesthesiology, critical care medicine, respiratory therapy, nursing, and others) follow guidelines provided by their respective professional societies for various procedures, in addition to new policies developed by the hospital. However, holistic efforts to align such guidelines were largely absent at the system level, resulting in teamwork issues, confusion, and frustration. At HMH, our physician executive and chief medical officer has addressed this issue via regular and timely update communications. Financial Instability At the time of this writing, COVID-19 has pushed the global economy to the brink of, or already into, a major recession. Modifications of population dispersion (social distancing) and quarantine protocols, and a complete halt to large portions of the US economy, have resulted in unprecedented overall societal stress and anxiety. Unfortunately, a disproportionate share of the sacrifice is borne by the portions of our population who are at greatest socioeconomic risk. While business is booming in health care, all indicators point to a likely sustained overall economic downturn. This undoubtedly contributes to health care workers’ stress and anxiety. In addition, anecdotal and news report evidence suggests that some private anesthesia groups in the country have experienced financial distress, resulting in furloughs and layoffs because they depend heavily on providing services for routine, elective surgeries, which have been canceled or delayed in a number of states.17 It is well documented that such uncertainty about future occupational stability (job security) is associated with a deterioration in mental well-being.18 ORGANIZATIONAL ADAPTATION AND OPPORTUNITIES Several traits of resilient performance and improvisation have been observed at HMH. The incident command team was rapidly assembled; leadership–employee communication was constant and responsive; and human resources (HR) adapted policies to employee needs. To long-standing employees, these adaptations were not surprising, because our leadership and teams have literally weathered storms before, including in recent history, Hurricane Ike and Hurricane Harvey. Hurricanes are not pandemics, but their local effects are similar in terms of financial and emotional strains on employees, as well as sudden geographical isolation of both employees and patients. In particular, the seamless way in which HMH executive leadership and HR adapted policies―including alternate paid time off options, advanced check dispersal with waived fees, telecommute policies, and waived copays for mental health services―was consistent with how the health system has previously assessed emerging disaster situations and responded with astute budget analyses to bolster employee bank accounts without breaking the hospital budget. Likewise, procedures for maintaining sensitive research areas such as our animal laboratories, clinical trials, and expedited institutional review board (IRB) approval mechanisms for disaster-critical research, much of which is now being implemented nationwide, are reminiscent of ride-out and recovery procedures already commonplace in a Texas Gulf Coast medical center. These proactive, positive responses corroborate that the best way to weather a storm is to look where storms have repeatedly been weathered. In a more direct way, we have seen this for the COVID pandemic in portions of Asia like Singapore and Hong Kong, which were previously affected most by SARS and novel influenza A (H1N1pdm09) virus of 2009 (H1N1) avian influenza and have likewise adapted comparatively faster to COVID-19.19 Digital communication tools have also shown promise in enabling remote work as well as intrainstitutional collaborative efforts. COVID-19 has brought health care professionals together across cities, states, and countries. For example, in the Greater Houston area alone, there have been more than 200 intensivists, extracorporeal membrane oxygenation (ECMO) specialists, and other specialized providers communicating through popular social media platforms (eg, WhatsApp) and learning from one another. In addition, this pandemic has opened the opportunity for innovations and adoption of alternative care delivery methods like telemedicine and virtual ICUs. HMH has been able to utilize these technologies for ECMO-treated COVID-19 patients and thus decreased traffic in and out of our ICU patient rooms. Resilience was also evident in the formation of interdisciplinary teams to design novel devices to help protect anesthesiologists in intubating COVID-19–positive patients or persons under investigation. DISCUSSION The COVID-19 pandemic exposed several gaps in our health care system, including the need for proactive investment to increase large-scale epidemic and pandemic preparedness. The following recommendations are made to prevent burnout and mitigate occupational stress, especially among intensive care providers during a pandemic. RECOMMENDATIONS AND POLICY IMPLICATIONS The national and regional disaster mitigation plans for future epidemics have to incorporate mechanisms to allow rapid and agile transformation of relevant industry to support massively increased demand for disinfectants, cleaning supplies, PPE, and other medical equipment for health care and community use. Although certain industries and corporations have exhibited a heightened sense of responsibility during the current COVID-19 pandemic, such efforts need to be preemptively planned, and specific industries should be earmarked, trained, and equipped for a rapid transformation. Industries willing to step up in times of crises and invest in disaster readiness may be incentivized by tax breaks or other mechanisms. Access to updated information about the availability of COVID-19 testing kits and PPE for health care workers may reduce the anxiety associated with uncertainty and reduce unproductive information seeking20 and emotional distress.21 Daily rounds and huddles, along with communication technologies, such as huddle boards, can be used to serve as reliable information sources. Structured training on large-scale disaster management and response must be provided. The Society of Critical Care Management offers a Fundamentals of Disaster Management course, which can build crucial mental models and support development of organization-specific structures for response management.22 In addition, the Federal Emergency Management Agency (FEMA) offers a variety of free courses and resources. Disasters necessitate innovation. With the rise of COVID-19, several innovative designs were proposed to protect the health care workers on the front lines from the rapidly and widely spreading virus.23 However, there is a dearth of manufacturing capacity and materials to produce many of these solutions. Systems of innovation that were developed and honed during other national emergencies when most resources were constrained (eg, the Functional Analysis Systems Technique [FAST] developed during the Manhattan Project)24 are being revisited to tackle the problem nationally and globally. We need these solutions to buy time for effective antiviral medications and a vaccine for COVID-19. Meanwhile, there is a need to provide technical oversight to ensure that new designs meet minimum safety requirements. For example, during this pandemic, an abundance of homemade masks and gowns were designed and adopted without proper attention to fit and leak protection, potentially leading to a false perception of protection among health care workers. The United States has a well-trained yet largely untapped resource of medical professionals in the form of internationally trained physicians, nurses, medical technicians, and other health care providers. Due to strict state licensing regulations, such individuals are barred from routine direct patient care. Though we do not propose a blanket relaxation in medical licensure requirements, we feel it is imperative that willing and able individuals be periodically trained to maintain a medical reserve corps at the regional, state, and national level. We opine that the notion of wartime-like preparedness has to be a serious and deliberate consideration, and maintaining a readily deployable human capital reserve is part and parcel of such preparedness. While studies emerged to investigate pandemic-related mental health issues,1 there is a need for feasible and practical methods to assess health care workers’ fatigue and burnout.25,26 Wearable sensors have shown promise27 by providing an opportunity to monitor fatigue, stress, and sleep biomarkers noninvasively and then communicating this information to clinical unit managers for timely intervention. In addition, mobile health (mHealth) tools have shown promise to facilitate mental health self-management. Simple methods such as breathing exercises, biofeedback, and mindfulness can be utilized to mitigate acute episodes of stress and anxiety, while telehealth services can be used to enable peer-support and occupational counseling. However, the integration of new technologies with current workflows may present additional burden and needs to be further examined. The lessons learned and documented here demonstrate that when confronted with seemingly inadequate federal-level logistics and response, it is perhaps time to recall the social virtues of local-level resilience and self-reliance. It is beyond the logistical capabilities of any government to provide what is needed to every citizen when the scope and of the disaster are beyond a (eg, large-scale and national capacity for It was local in many cases by private that all as one (eg, the during and response during We can the and efforts and resources to mitigate such and These efforts with and leadership that a sense of community and duty to the into the of our of this every 100 years, with more or less severe cases in the We have learned from each of but we have to of our public resources into providing supplies and to these This is to and it is our to The Center for Outcomes Houston Methodist review and of the for flow and This complete the and led the of the This and the This and the This and the This and the This was

Anesthesia & Analgesia · 388 citationsread the source →

Higher Grit Scores Are Associated With Earlier Increases in Knee Flexion Following Anterior Cruciate Ligament Reconstruction With Meniscus Repair in Pediatric Patients.

Background: The Grit Scale is used to measure grit, defined by Duckworth and colleagues as the disposition to show perseverance and passion for long-term goals. It has been shown that psychological factors like motivation, coachability, and coping with adversity are correlated with faster readiness for return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigates the association between pediatric patients' baseline grit scores and; preoperative Patient-reported Outcomes Measurement Information System (PROMIS) Pain scores and the recovery of range of motion (ROM) after ACLR. The investigators hypothesized that higher preoperative grit scores would predict lower preoperative pain scores and earlier return of knee ROM in patients undergoing ACLR. Methods: This is a retrospective cohort study. Pediatric patients who underwent primary ACLR were assigned the pediatric Grit Scale. Patients were subdivided by meniscal procedures due to differences in postoperative protocols. ACLR alone or with meniscectomy (ACLR ± meniscectomy) were grouped together and ACLR with meniscal repair (ACLR + meniscus repair) represented the other cohort. Patients above the 50th grit percentile were considered "high grit". Patients below the 50th percentile were considered "low grit". Baseline PROMIS pain intensity and interference were collected. ROM was compared by grit cohort using the Mann-Whitney U test with a significance threshold of P ≤ 0.05. Results: A total of 58 patients undergoing ACLR were analyzed: 20 ACLR ± meniscectomy and 38 ACLR + meniscus repair. The mean age was 15.0 ± 2.1 years with 41.4% of participants identifying as females. No significant difference was noted between baseline PROMIS pain intensity and interference and grit score ( P = 0.82, P = 0.91, respectively). Three months postoperatively, for those in the ACLR + meniscus repair cohort, low grit ROM was 130 degrees (interquartile range = 10 degrees), whereas high grit ROM was 135 degrees (interquartile range = 8 degrees) ( P = 0.006). Conclusions: This study found no differences in pain scores at presentation between grit cohorts but found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Quicker ROM recovery in patients with high grit may be a leading indicator of these patients' likelihood to achieve other postoperative milestones and meet criteria for RTS more quickly; the relationship between grit and readiness for RTS should be further investigated. Level of evidence: Level IV; retrospective cohort study.

Journal of pediatric orthopedics · 3 citationsread the source →

Sexual victimisation, peer victimisation, and mental health outcomes among adolescents in Burkina Faso: a prospective cohort study.

Background: Sexual victimisation and peer victimisation are pervasive and increase risk for mental illness. Longitudinal studies that compare their unique and cumulative effects are scarce and have been done predominantly in high-income countries. The aims of this study were to examine the prevalence, prospective associations, and gender differences in sexual and peer victimisation and mental health in a low-income, African setting. Methods: In this prospective cohort study, data were obtained from the 2017 ARISE Adolescent Health Study, a population-representative, two-wave, prospective study of adolescents (aged 12-20 years) from Burkina Faso. A random sample of adolescents was drawn from ten villages, selected to capture the five main ethnic groups, and from one of the seven sectors of Nouna town, Burkina Faso, at two timepoints: Nov 12 to Dec 27, 2017, and Nov 15 to Dec 20, 2018. Standardised interviews were conducted in French or a local language by trained researchers. We measured victimisation exposure as sexual victimisation, peer victimisation, and polyvictimisation, using lifetime frequency of exposure, and we measured mental health symptoms and disorders using the Kutcher Adolescent Depression Scale, the Primary Care Post-Traumatic Stress Disorder screen IV and 5, and a question on lifetime self-harm and number of incidents in the past year. We calculated prevalence of victimisation and mental health symptoms and disorders at the two timepoints, and we used lifetime victimisation at the first timepoint to predict mental health at the second timepoint using logistic and negative binomial regressions. Gender differences were examined using interaction terms. Findings: Of 2544 eligible adolescents, 1644 participated at time 1 and 1291 participated at time 2. The final sample with data at both timepoints included 1160 adolescents aged 12-20 years (mean 15·1, SE 0·2), of whom 469 (40·4%) were girls and 691 (59·6%) were boys. The majority ethnic group was Dafin (626 [39·1%]), followed by Bwaba (327 [20·5%]), Mossi (289 [16·0%]), Samo (206 [13·0%]), Peulh (166 [9·7%]), and other (30 [1·6%]). After survey weight adjustment, sexual victimisation (weighted percentages, time 1, 256 [13·8%] of 1620; time 2, 93 [7·2%] of 1264) and peer victimisation (weighted percentages, time 1, 453 [29·9%] of 1620; time 2, 272 [21·9%] of 1264) were common, whereas polyvictimisation was more rare (weighted percentages, time 1, 116 [6·6%] of 1620; time 2, 76 [5·7%] of 1264). Longitudinally, sexual victimisation was associated with probable clinical disorder (adjusted odds ratio 2·59, 95% CI 1·15-5·84), depressive symptoms (adjusted incidence rate ratio [aIRR] 1·39, 95% CI 1·12-1·72), and symptoms of post-traumatic stress disorder (aIRR 2·34, 1·31-4·16). Peer victimisation was associated with symptoms of post-traumatic stress disorder (aIRR 1·89, 1·13-3·17) and polyvictimisation was associated with depressive symptoms (aIRR 1·34, 1·01-1·77). Girls reported more sexual victimisation (weighted percentages, 130 [17·3%] of 681 vs 126 [11·4%] of 939), boys reported more peer victimisation (weighted percentages, 290 [33·1%] of 939 vs 163 [25·2%] of 681), and there was a significant interaction between lifetime victimisation and gender for probable clinical disorder (F [degrees of freedom 7, sample 376] 2·16; p=0·030). Interpretation: Sexual and peer victimisation were common in the study setting and increased risk for mental health problems. Adolescent girls who have been sexually victimised are especially at risk of mental health problems. Interventions targeting sexual and peer violence in low-income settings are needed. Funding: Alexander von Humboldt Foundation, the Wellcome Trust, Fondation Botnar, and Harvard TH Chan School of Public Health.

The lancet. Psychiatry · 9 citationsread the source →

Atypical Antipsychotics: CATIE Study, Drug-Induced Movement Disorder and Resulting Iatrogenic Psychiatric-Like Symptoms, Supersensitivity Rebound Psychosis and Withdrawal Discontinuation Syndromes

Chronic illness can result in chronicity of clinical practice. As we have moved away from prescribing classical antipsychotics and tricyclic antidepressants, issues remain with the use of atypical antipsychotics and second-generation antidepressants that need to be addressed, namely, iatrogenic discontinuation syndromes and supersensitivity psychiatric symptoms. An optimal maintenance drug treatment consists of regular attempts to reduce the dose by finding a minimal therapeutic dose, regularly asking the question of when to reduce or withdraw treatment and for which patients, and moreover, why it is difficult to decrease a given drug treatment. Recently, Falloon [1] proposed that maintenance pharmacotherapy in schizophrenia will depend on finally finding minimally effective doses through ‘extensive training in stress management’. In the long-term treatment of major depression, Fava [2] has hypothesized that antidepressants can aggravate the course of depressive illness. Lambert [3] recently suggested that ‘antipsychotic-switching syndromes’, which include discontinuation syndromes, are a ‘major barrier’ to adjusting antipsychotic treatment. In this paper, we propose that to achieve optimal maintenance treatment with antipsychotics, and to reduce or withdraw antipsychotics effectively, we must distinguish syndromes associated with discontinuing antipsychotics, such as supersensitivity psychosis, from true relapse. While the prevalence and incidence of drug-induced movement disorder(s) (DIMD) has continuously decreased with atypical antipsychotics, DIMD persist as do psychiatric and psychiatric-like symptoms associated with DIMD, and these must also be identified and evaluated. Persistent DIMD have been found to be a predictor of the later emergence of tardive dyskinesia (TD) and supersensitivity psychosis [4]. At present, we need to determine the relative risk of iatrogenic discontinuation syndromes, DIMD and DIMD psychiatric symptoms resulting from atypical antipsychotics. Although atypical antipsychotics are now most commonly prescribed, a debate has emerged on the differences between classical and atypical antipsychotics following the results of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study [5]. The question that comes to the forefront is why recent studies are no longer finding well-established differences between these two generations in terms of efficacy and DIMD. Reasons to explain why recent schizophrenia studies have found reduced drug and placebo differences were examined at the International Society for CNS Clinical Trials and Methodology Annual Mid-Year Conference [6]. While the fact must be considered that patients included in recent studies have less severe illness with symptoms that are better controlled than in past studies (likely due to earlier treatment), the issue that psychiatric symptoms specific to schizophrenia are not being adequately measured nor differentiated from psychiatric and psychiatric-like symptoms associated with DIMD is crucial to answering this question. For example, it is hard to believe that in a recent review of psychomotor slowing in schizophrenia, the authors, when evaluating its effect on measurement and treatment research to improve cognition in schizophrenia (MATRICS), nearly completely ignored the influence of akinesia and DIMD on neuropsychological tests in schizophrenia and the importance of accurate DIMD measurements [7]. As we pursue this ongoing discussion, we recommend the discontinuation of all classical antipsychotics due to their neurotoxic association with a high prevalence of DIMD and increases in basal ganglia volumes [8], and now address how to prescribe atypical antipsychotics most effectively, by taking into account DIMD-associated psychiatric symptoms and iatrogenic discontinuation syndromes. The first widely prescribed atypical antipsychotic, risperidone, was first approved in Canada in 1993 following the publication of the Canadian Multicenter Risperidone Study, which reported clear advantages of risperidone over haloperidol and the placebo, and significantly less appearance of DIMD with risperidone than haloperidol [9]. DIMD includes the 4 types of movement disorders induced by antipsychotics: parkinsonism, dystonia, dyskinesia and akathisia [10]. These findings were confirmed by the American Risperidone Study [11] and several other studies reporting greater efficacy of risperidone over classical antipsychotics in terms of cost-efficiency [12] and the clinical management of patients with schizophrenia [13,14,15,16,17]. However, the CATIE study [5] challenged these results. The CATIE study found that of the 4 atypical antipsychotics studied, olanzapine was the only atypical to be more efficacious than the classical antipsychotic perphenazine, and to be highly superior to risperidone for discontinuation of treatment, due to lack of efficacy [5]. Olanzapine is known to produce less DIMD compared to risperidone, therefore one would expect psychiatric symptoms caused by DIMD to be less frequent with olanzapine than risperidone. The expected higher rate of DIMD-induced emergent psychiatric symptoms associated with risperidone would explain the CATIE results, showing risperidone to be significantly less efficacious than olanzapine [5], despite risperidone being known to be at least as efficacious as olanzapine for true schizophrenic symptoms. Furthermore, the rating scales used to measure DIMD did not find the well-established differences between the 5 antipsychotics for DIMD rates [5]. Thus, we propose that DIMD and DIMD-induced psychiatric symptoms were confounded with true schizophrenic symptoms in the CATIE study. DIMD-associated psychiatric symptoms could be classified into 3 types: (1) emergent psychiatric symptoms caused by DIMD, such as akinesia inducing depression, akathisia inducing anxiety; (2) iatrogenic psychiatric-like symptoms resulting from confounding DIMD with psychiatric symptoms, such as akinesia confounded with psychomotor retardation, akathisia with agitation; (3) supersensitivity psychosis symptoms associated with DIMD. In the CATIE study, quetiapine (mean dose = 543.4 mg/day), which shares a low rate of DIMD with olanzapine, was also found to be significantly less efficacious compared to olanzapine, but in contrast to risperidone, this lack of efficacy could be due to psychiatric symptoms related to supersensitivity psychosis explained by quetiapine’s loose binding properties at the D2 receptor [18]. Patients taking quetiapine had a completion rate of 18% out of 329 patients, whereas in our 3-year prospective study of quetiapine monotherapy with a lower mean dose of 487 mg/day (thus less likely to develop therapeutic tolerance), the completion rate was 21.7% out of 23 patients; 6 of 7 patients who relapsed, after a minimum 3 months of stabilized quetiapine treatment, met the criteria for supersensitivity psychosis [19]. Without distinguishing these DIMD-associated psychiatric symptoms from symptoms due to the original illness, the major impact of atypical antipsychotics is on the reduction of DIMD and TD [10, 20,] and their beneficial effects on psychosis are masked by DIMD emergent psychiatric symptoms, including supersensitivity psychosis. We will review 4 multicenter trials, which include a total of 14,497 patients, to illustrate how psychiatric and schizophrenic symptoms are confounded with DIMD-associated psychiatric symptoms.TD epidemiology has changed significantly since the introduction of atypical antipsychotics, with a constant decline in its prevalence [10]. TD, classified as a DIMD, is a hyperkinetic, involuntary and purposeless movement disorder [10, 20]. Considered as the most significant side effect of classical antipsychotics, TD has been associated with antipsychotics and gastrointestinal neuroleptics, and usually occurs after several years of treatment. Persistent TD can also occur after short-term exposure to classical antipsychotics and gastrointestinal neuroleptics even at low doses and for as few as 2 months [8,21,22,23], while reversible and withdrawal dyskinesias share properties with levodopa-induced dyskinesia [24]. We conducted several epidemiological studies of TD [4,25,26,27] and in 1975, using the National Institute of Mental Health (NIMH) psychopharmacology criteria, we found a 31% prevalence of TD in 261 outpatients with schizophrenia [25]. We also evaluated these patients according to the Schooler and Kane research diagnostic criteria and found a 22% prevalence of TD. This variability of findings related to defining criteria complicates comparisons across studies [10]. In a 5-year follow-up study of 169 of the same patients [4, 25], 45% met the research diagnostic criteria for TD. In 1975, 131 of the 261 patients did not meet the research diagnostic for TD, and in 1980 treatment-emergent TD was found in 46 of the patients who did not have it in 1975, for a 5-year cumulative incidence rate of 35% and a mean annual incidence rate of 8.4%. When corrected for remissions, the mean annual incidence rate decreased to 2.9%. This incidence rate, which includes both patients who developed and remitted from TD over time, is similar to results found by other studies during the same time period [28, 29]. The cumulative incidence of treatment-emergent TD in the study by Kane et al. [29] was 12% after 4 years and 40% after 8 years of neuroleptic exposure, which is similar to our finding of an annual incidence rate (corrected for remissions) of 3% for classical antipsychotics. In a study carried out in 130 lithium-treated affective disorder patients previously, but less, exposed to antipsychotics, we found a TD prevalence of 9.2% [26], which was a quarter of the incidence reported in our previous studies on patients with schizophrenia who had greater exposure to antipsychotics. In this time period of classical antipsychotics, 2 meta-analyses (including mostly patients with schizophrenia) reported mean TD prevalences of 23% [30] and 20% [31]. In view of the fact that 58% of patients treated with classical antipsychotics will develop treatment-emergent TD after 10–15 years of treatment [4], and the known beneficial neuroprotective effects of atypical antipsychotics on TD [32] and on increased basal ganglia volumes induced by classical antipsychotics [8], we recommend the discontinuation of all classical antipsychotics due to their neurotoxic effects. In the time period of both classical and atypical antipsychotics, the following multicenter studies (n = 3,753) evaluated the incidence and prevalence of TD, using the same definitions, Extrapyramidal Symptom Rating Scale [20] and training videotapes as in the previous time period. In the first study, an annual TD incidence of 0.68% was reported prospectively in 725 patients with schizophrenia, treated with the long-acting injectable atypical antipsychotic risperidone [27, 33]. Treatment-emergent TD was found in 12 of 587 patients without dyskinesia at the baseline [33]; however, expert case assessment determined 7 cases (1.19%) of withdrawal dyskinesia (3 cases resolved, 4 cases unchanged), 1 case (0.17%) of reversible dyskinesia and 4 cases (0.68%) of persistent treatment-emergent TD. Of the patients with baseline dyskinesia, 28.4% improved, no longer met TD criteria and maintained this response [33]. This annual treatment-emergent TD incidence of 0.68% with atypical antipsychotics is only 22% of the annual incidence of 3% reported with classical antipsychotics [4]. In the second study, the Schizophrenia International Suicide Prevention Trial (67 centers in 11 countries) [34], 980 patients with schizophrenia, or schizoaffective disorders, taking an atypical alone (25.6%), a classical alone (31.5%) or both a classical and an atypical antipsychotic (42.9%) were included from March 19, 1998, to February 14, 1999, and TD was found at the baseline in 115 (12%) patients [27, 35]. Thus, after 10 years in the time period of both classical and atypical antipsychotics, the overall prevalence of TD decreased by at least twofold compared to our previous 1979–1988 studies with classical antipsychotics [4, 25], using the same definitions, Extrapyramidal Symptom Rating Scale and training videotapes. In the third study (baseline data from three Ris-Consta multicenter studies) [27, 36] carried out 1 year later, 2,048 patients were included from March 21, 1999, to December 15, 2000, and TD was found at the baseline in 209 patients (10.2%), using the same methodology. This study showed a further decrease in the prevalence of TD after an additional year of atypical use. This changing epidemiology of TD with atypical antipsychotics is confirmed by Correll et al. [37] in a systematic review of 1-year prospective studies with atypical antipsychotics, and by Jeste et al. [38] in a 1-year study of elderly patients treated with risperidone. In conclusion, following the introduction of atypical antipsychotics, the prevalence and incidence of TD have significantly decreased. However, the risk for TD still exists with both atypical and classical antipsychotics, and there is a need for continued surveillance of emerging cases of TD in patients taking antipsychotics [39], especially as the current debate continues on the differences in efficacy between these two generations of antipsychotics following results from studies such as the CATIE [5, 39]. Furthermore, Kane [39] has pointed out that newly trained clinicians using mostly atypical antipsychotics may not have had the same exposure to TD as previously trained clinicians.A high prevalence of all 4 types of DIMD (parkinsonism, dystonia, dyskinesia and akathisia) remains. In the Schizophrenia International Suicide Prevention Trial (n = 980), a prevalence of 57.5% of DIMD (n = 551 patients) was found [27, 35]. In the Ris-Consta studies (n = 2,048) [27, 36], 970 patients (47.4%) had DIMD at the baseline, which consisted of 778 patients with parkinsonism (38.0%), 285 patients with akathisia (14%) and 209 patients with TD (10.2%). Thus, nearly 1 patient out of 2 had a definite DIMD in this time period of classical and atypical antipsychotics. In addition, DIMD have been consistently associated with significant psychiatric symptoms as measured by the positive and negative syndrome scale (PANSS) [40, 41]. In the InterSept study (n = 980), which included patients with schizophrenia and schizoaffective disorder who were at risk of suicide, suicidality was associated at baseline with DIMD, parkinsonism, TD and akathisia, and depression was associated with TD and akathisia [27, 35]. Based on these results, we recommend routinely assessing DIMD in patients with schizophrenia with suicidal and depressive symptoms. In the Ris-Consta studies (n = 2,048), baseline DIMD were also significantly associated with the PANSS total score, positive, negative and anxiety/depression symptoms [27, 36]. Greater anxiety and depression were seen in patients with severer DIMD, akathisia and parkinsonism. Higher PANSS negative symptom rating was associated with parkinsonism and higher PANSS total scores were associated with akathisia. In this time period, these last two studies (n = 3,028) show that DIMD persists with atypical antipsychotics, and that patients with DIMD have significantly higher PANSS scores compared to patients without DIMD.These results are in agreement with findings from 2 other multicenter studies: the American CATIE study [5] and the European Schizophrenia Outpatient Health Outcomes (SOHO) study [42]. In the CATIE baseline data, patients with TD (n = 212) were found to have significantly more psychopathology than patients without TD (n = 1,098) as measured by the PANSS total score and PANSS general psychopathology subscale [43]. In the 3-year prospective SOHO study, emergent cases of TD were associated with greater overall psychopathology. An increase in clinical global impression overall symptom severity was longitudinally associated with cases of TD in patients without TD at the baseline (n = The SOHO and the CATIE studies have also examined other for TD. the CATIE and SOHO studies found that other DIMD were associated with TD the CATIE study showed that patients with TD had more parkinsonism akathisia while the SOHO study found that baseline symptoms TD our findings in a prospective study of TD [4]. In to reporting that the incidence of TD was lower in patients taking atypical compared to classical antipsychotics after 6 months the SOHO study showed that the incidence of TD was associated with the incidence of of drug-induced in is crucial to that there is a of DIMD with atypical antipsychotics, which are not and confounded with psychiatric symptoms rating scales used routinely in clinical to DIMD do not DIMD from psychiatric symptoms from the 4 multicenter (n = 14,497 patients) into this the CATIE the [27, the Ris-Consta [27, 36] and the SOHO studies have all confirmed the association of DIMD with psychiatric symptoms. most of the studies included in this measure psychiatric symptoms according to the we propose the following of PANSS psychiatric symptoms associated with emergent psychiatric symptoms caused by DIMD, such as depression and suicidality example, akinesia is known to produce depression, psychomotor and suicidal while akathisia psychomotor and suicidal and TD is also associated with suicidal iatrogenic psychiatric-like symptoms resulting from confounding and DIMD with psychiatric symptoms, such as confounding and with and retardation, akathisia with anxiety and and and dyskinesias with and schizophrenic psychiatric schizophrenic symptoms associated with DIMD caused by supersensitivity psychosis, which we are now to first reported drug-induced associated with TD a in and increased receptor after long-term treatment with classical antipsychotics, and we this supersensitivity psychosis. We that TD and supersensitivity psychosis with the decrease or withdrawal of an antipsychotic, given risk not and at the same The debate continues on how to most withdraw antipsychotic [1] and and psychiatric syndromes associated with types of syndromes have been with the discontinuation of (1) withdrawal syndromes and major (2) syndromes anxiety and which have been reported with and (3) supersensitivity syndromes such as TD and supersensitivity psychosis These discontinuation syndromes all produce psychiatric symptoms that can be confounded with true of the original illness. In a recent review of the on psychosis the importance of between antipsychotic withdrawal effects related to the course of the original illness and drug-induced effects such as supersensitivity psychosis. due to the discontinuation of a drug can be differentiated from the course of original illness and more long-term maintenance treatment could be reduced and in patients The long-term maintenance with second-generation antidepressants and of a major depressive disorder is of the in and during long-term maintenance treatment. The has also recently been to produce a persistent disorder following withdrawal to be related to supersensitivity When discontinuing antipsychotics and antidepressants, the of supersensitivity syndromes and other iatrogenic discontinuation syndromes must be to high doses or of outpatients and with schizophrenia treated with a classical antipsychotic treatment also included 1 but no antidepressants, no and no showed a prevalence of 22% for supersensitivity psychosis The prevalence of TD using Schooler and Kane criteria, was that found for supersensitivity psychosis. cases of supersensitivity psychosis increased the prevalence of supersensitivity psychosis to psychosis was associated with a higher maintenance dose of classical antipsychotics, high and schizophrenia with a The higher antipsychotic dose and higher associated with supersensitivity psychosis to the of supersensitivity and these results that lower doses of antipsychotics could the appearance of supersensitivity psychosis. In this study, there was no found between TD and supersensitivity psychosis, due to TD being associated with schizophrenia and supersensitivity psychosis with higher antipsychotic dose was not to be a risk for TD, whereas increased was associated with TD but not associated with supersensitivity psychosis. is that most patients in this study were treated with which has a high for the D2 which could to both a high incidence of supersensitivity psychosis and DIMD as the drug is known to produce a high incidence of symptoms psychosis, in its masked and withdrawal is known to occur 6 following the decrease or withdrawal of an antipsychotic or 3 months for a long-acting injectable We have proposed that TD and supersensitivity psychosis can result from the of in the caused by following in D2 with high for The of supersensitivity psychosis and TD share can both occur after long-term use of antipsychotics and can and difficult to with of the antipsychotic stress both TD and supersensitivity psychosis and both can be by and by and TD was to be the predictor of supersensitivity psychosis in our and follow-up study of supersensitivity psychosis [4, TD and supersensitivity psychosis may or may not occur in the same time but TD is associated with supersensitivity psychosis when it occurs during withdrawal of antipsychotics These two supersensitivity syndromes have been difficult to study due to the fact that antipsychotics can their appearance further with supersensitivity psychosis is that symptoms the original illness and true however, supersensitivity psychosis can be as it more after of the antipsychotic than true occurs with high doses of antipsychotics and not with antipsychotic treatment and therapeutic to antipsychotic treatment after drug response time, as therapeutic there is further of supersensitivity and further syndromes, TD, can (1) or (2) persistent or (3) reversible or symptoms can persist for several months or years and can still be reversible or When persistent and supersensitivity symptoms symptoms, being severer than the original symptoms, but these supersensitivity symptoms persist in contrast to symptoms and may include symptoms atypical antipsychotics, it has been proposed that supersensitivity psychosis occurs more with antipsychotics with from the D2 receptor The 2 atypical antipsychotics most associated with supersensitivity psychosis are quetiapine and which both have loose binding properties at the D2 receptor An additional which and severe in the withdrawal of is its effect as an receptor Thus, for the withdrawal would be by the receptor following of at this drug in the of the a and psychosis results cases of supersensitivity psychosis have also been reported with olanzapine psychosis was found to be associated with quetiapine in our 3-year study of quetiapine in 23 outpatients with schizophrenia and schizoaffective disorder who had previously been treated with classical antipsychotics risperidone, and had symptoms and of side effects [19]. As in our of the CATIE study, 7 patients after a minimum of 3 months of stabilized treatment and 6 of these patients met the criteria for supersensitivity psychosis [19]. the 11 of patients with baseline TD relapsed, the that TD to supersensitivity psychosis and have been to be efficacious in of patients with supersensitivity psychosis We also recommend the use of in supersensitivity and anxiety disorder induced by the discontinuation of the An can be used in with an antipsychotic or an in to more decrease or withdraw these and find the minimal therapeutic dose for patients who still need long-term treatment. a minimal therapeutic dose with an has an additional for a drug olanzapine, as the dose will significant side In in the of Mental Health psychiatric 35% of patients with a of schizophrenia and For severe cases of schizophrenia, the use of or is in to drug to antipsychotic While is less than or it is superior to for anxiety and the of optimal minimal maintenance drug treatment. proposed the beneficial results of treatment in schizophrenia is their effect We have also related their beneficial effects to an of a We recommend treatment as a first for from treatment, can also be prescribed as with as it has a In a and that and had than other in addition, emerging that may improve DIMD has also been to be effective as an to antipsychotic monotherapy in patients with schizophrenia who treatment We that of cases of schizophrenia can be related to supersensitivity psychosis. In patients for maintenance treatment is a minimal therapeutic dose can be with the use of an that will patients from antipsychotic or conclusion, DIMD-induced psychiatric symptoms and supersensitivity syndromes will to to results such as found in the CATIE study which show that olanzapine is the only atypical antipsychotic more efficacious than a classical The proposed for psychiatric and psychiatric-like symptoms associated with DIMD may to the of all classical antipsychotics and the use of higher doses and longer than of atypical antipsychotics. research is in to develop to distinguish between true and iatrogenic discontinuation syndromes and to to more withdraw antipsychotics and antidepressants by and supersensitivity syndromes, for the antipsychotics and quetiapine and for the may to further of DIMD, TD and supersensitivity psychosis as we to more differences in the of As most of antipsychotics and second-generation antidepressants are not routinely or for more differences in drug will also to prescribe minimal therapeutic doses of antipsychotics and antidepressants for greater efficacy and better in the maintenance has and the last 3 years from and

Psychotherapy and Psychosomatics · editorial or comment · 168 citationsread the source →

Seroprevalence of cytomegalovirus infection in the United States, 1988-1994.

Background: Cytomegalovirus (CMV) is a leading cause of congenital illness and disability, including hearing loss and mental retardation. However, there are no nationwide estimates of CMV seroprevalence among pregnant women or the overall population of the United States. Methods: To determine CMV prevalence in a representative sample of the US population, we tested serum samples for CMV-specific immunoglobulin G from participants aged > or =6 years (n=21,639) in the third National Health and Nutrition Examination Survey (1988-1994). Results: The prevalence of CMV infection was 58.9% in individuals > or =6 years old. CMV seroprevalence increased gradually with age, from 36.3% in 6-11-year-olds to 90.8% in those aged > or =80 years. CMV seroprevalence differed by race and/or ethnicity as follows: 51.2% in non-Hispanic white persons, 75.8% in non-Hispanic black persons, and 81.7% in Mexican Americans. Racial and/or ethnic differences in CMV seroprevalence persisted when controlling for household income level, education, marital status, area of residence, census region, family size, country of birth, and type of medical insurance. Among women, racial and/or ethnic differences were especially significant; between ages 10-14 years and 20-24 years, seroprevalence increased 38% for non-Hispanic black persons, 7% for non-Hispanic white persons, and <1% for Mexican Americans. Conclusions: On the basis of these results, we estimate that each year in the United States approximately 340,000 non-Hispanic white persons, 130,000 non-Hispanic black persons, and 50,000 Mexican American women of childbearing age experience a primary CMV infection. Given the number of women at risk and the significance of congenital disease, development of programs for the prevention of CMV infection, such as vaccination or education, is of considerable public health importance.

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America · 658 citationsread the source →

Cardiovascular disease risk factor patterns and their implications for intervention strategies in Vietnam.

Background. Data on cardiovascular disease risk factors (CVDRFs) in Vietnam are limited. This study explores the prevalence of each CVDRF and how they cluster to evaluate CVDRF burdens and potential prevention strategies. Methods. A cross-sectional survey in 2009 (2,130 adults) was done to collect data on behavioural CVDRF, anthropometry and blood pressure, lipidaemia profiles, and oral glucose tolerance tests. Four metabolic CVDRFs (hypertension, dyslipidaemia, diabetes, and obesity) and five behavioural CVDRFs (smoking, excessive alcohol intake, unhealthy diet, physical inactivity, and stress) were analysed to identify their prevalence, cluster patterns, and social predictors. Framingham scores were applied to estimate the global 10-year CVD risks and potential benefits of CVD prevention strategies. Results. The age-standardised prevalence of having at least 2/4 metabolic, 2/5 behavioural, or 4/9 major CVDRF was 28%, 27%, 13% in women and 32%, 62%, 34% in men. Within-individual clustering of metabolic factors was more common among older women and in urban areas. High overall CVD risk (≥20% over 10 years) identified 20% of men and 5% of women-especially at higher ages-who had coexisting CVDRF. Conclusion. Multiple CVDRFs were common in Vietnamese adults with different clustering patterns across sex/age groups. Tackling any single risk factor would not be efficient.

International journal of hypertension · 26 citationsread the source →

Positive mental health: is there a cross‐cultural definition?

The great epidemiological studies of the past half century have focused upon who was mentally ill and not who was well. Mental illness, after all, is a condition that can be defined reliably, and its limits are relatively clear. Until recently, only the Sterling County Studies by A. Leighton 1 came close to defining positive mental health operationally. In addition, it has been argued that achieving above average mental or physical health is not the province of medicine, but of education. Early in the past century, internists began studying physiology at high altitude and devise measures of positive physical health for athletes, pilots, and finally astronauts. In 1929–30, at the University of California at Berkeley, the Institute of Human Development was founded by H. Jones, N. Bayley and J. McFarlane 2,3. Originally created to study healthy child development, the Institute was to provide a seminal influence on E. Erikson's model of healthy adult development. In the late 1930s, A. Bock, an internist trained in high altitude physiology and interested in positive physical health, began the Study of Adult Development at the Harvard University 4,5. This was designed as an interdisciplinary study of both mental and physical health. Like physical fitness, positive mental health is too important to be ignored, but its definition is not easy. Several precautions are necessary. First, in defining mental health, cross-cultural differences must be kept in mind. My own efforts to define mental health may appear parochial to those from other countries. Thus, the commentaries on this paper will be particularly important. The second precaution is to keep in mind that “average” is not healthy. Community surveys always mix in the healthy with the prevalent amount of psychopathology. In the case of red blood count, or thyroid function, the middle of the bell curve is healthy. In the case of eyesight, only the upper end of the bell curve is healthy; and in the case of cholesterol and bilirubin only the low end of the curve is healthy. A third precaution is to make clear whether one is discussing trait or state. Longitudinal study is particularly important. A world-class soccer player temporarily sidelined with a sprained ankle (state) is probably healthier than a type 1 diabetic (trait) with a temporarily normal blood sugar. Finally, mental health needs to be seen in context. Sickle cell trait is unhealthy in Paris, but not in central Africa where malaria is endemic. In the 1940s, paranoid personalities made very poor submariners but excellent airplane spotters. Punctuality and competitiveness are seen as healthy in some communities, but not in others. Moreover, if mental health is “good”, what is it good for? The self or the society? For “fitting in” or for creativity? In defining mental health, biology usually trumps anthropology. Cultural anthropology teaches us that almost every form of behavior is considered healthy in some cultures, but that does not mean that the tolerated behavior is mentally healthy. Until recently, Portugal did not recognize alcoholism as an illness, but that did not reduce the contribution of alcoholism to mortality in Lisbon. The best way to enrich our understanding of what constitutes mental health is to study a variety of healthy populations from different perspectives, in different cultures and for a long period of time. This paper will contrast seven different empirical models of mental health. First, mental health can be conceptualized as above normal, as epitomized by a DSM-IV's Global Assessment of Functioning (GAF, 6) score of over 80. Second, it can be regarded as the presence of multiple human strengths rather than the absence of weaknesses. Third, it can be conceptualized as maturity. Fourth, it can be seen as the dominance of positive emotions. Fifth, it can be conceptualized as high socio-emotional intelligence. Sixth, it can be viewed as subjective well-being. Seventh, it can be conceptualized as resilience. To avoid quibbling over which traits characterize mental health, it is helpful to adopt the analogy of a decathlon champion. What constitutes a “track star”? A decathlon star must possess muscle strength, speed, endurance, grace and competitive grit, although the combinations may vary. Amongst decathlon champions, the general definition will not differ from nation to nation, or century to century. The salience of a given facet of a decathlon champion, or of mental health, may vary from culture to culture, but all facets are important. After World War II, influential works on mental health began to be published 7,8,9. Although all studies concentrated on normal populations, they still put their emphasis on not pathological rather than on above average mental health. Besides, many post-war psychiatrists continued to agree with S. Freud who had dismissed mental health as “an ideal fiction”. Then, in 1958, M. Jahoda's report to the American Joint Commission on Mental Illness and Health 10 led to a psychiatric sea change regarding the existence of mental health. She suggested that mental health includes autonomy (being in touch with one's own identity and feelings); investment in life (self-actualization and orientation toward the future); efficient problem solving (accurate perception of reality, resistance to stress, environmental mastery); and ability to love, work and play. However, at the time she published her criteria, there was still no evidence to prove that her plausible definitions were more than mere platitudes. Next, came R. Grinker's 1962 studies of “homoclites”, the first empirical study of positive mental health 11. Grinker's homoclites were physical education majors selected for normality but studied only briefly. A second more longitudinal study was the elimination process, by which out of 130 healthy jet pilots, already selected for mental health, the seven original American astronauts were selected 12. These astronauts not only enjoyed exemplary work records, but also were competent at loving. Although venturesome test pilots, they all had had very few accidents during their years of flying. They could tolerate both close interdependent association and extreme isolation. Although each of the astronauts was very different, they all would have starred in a mental health “decathlon”. An even more influential study of mental health was the Menninger Psychotherapy Project led by the psychologist L. Luborsky. He devised the Health-Sickness Rating Scale, with a scale from 0 to 100 13, based on behavior rather than pencil and paper tests. A score of 80 or above reflected positive mental health; a score of 95–100 reflected “an ideal state of complete integration, of resiliency in the face of stress, of happiness and social effectiveness”. Luborsky's scale was modified by two of the architects of DSM-III into what is now Axis V 14. In cross-cultural comparisons, investigators have confirmed the usefulness of Luborsky's measure as an international thermometer of mental health 15. The fact that psychologists have approached mental health somewhat differently from psychiatry has led to this second model, which has provided the basis for the positive psychology movement 16. Psychologists, like physiologists, look at continua (traits) rather than categories, while in medicine you either have an illness or you do not. In psychology, interventions to improve adequate intelligence or social skills are common, while in medicine to meddle with adequate thyroid function, or a healthy hematocrit or a normal mood, is only to cause trouble. In the healthy rested individual, virtually all psychopharmacological interventions will, over time, make the brain function worse. Thus, the medical goal of using medication to remove pathology is different from the psychologists’ goal of fostering positive mental health in an educative model. As early as in 1925, the psychiatrist A. Meyer was already warning of the need to stop “moralizing” about utopian mental health. Mental health, he suggested, should be studied through “conscientious and impartial study” and “constructive experimentation” 17. Subsequently, the psychologist M. Seligman stated that positive psychology will use evidence-based experimentation to study positive mental health and incorporate recent empirical advances in cognitive psychology 18. Since the late 19th century, many social scientists had mistrusted optimistic cognition, especially religious optimism, as a maladaptive “American” illusion interfering with accurate perception of reality. Nietzsche, Freud, Marx and Darwin all perceived optimism as evidence of an ingenuous cultural adolescence, not of mature mental health. However, cognitive therapists have then demonstrated that optimistic cognition can not only change behavior, but even alter brain function 19. If pessimism is the dominant cognition of the depressed, optimism appears the dominant cognition of the mentally healthy. In part, the importance of optimism to positive mental health depends upon an attributional cognitive style which asserts that the good things happening to me are my “fault”, will last forever and are pervasive, while the bad things are limited, not my fault, and unlikely to happen again 20. The psychologists C. Peterson and M. Seligman identified four components in positive mental health: talents, enablers, strengths, and outcomes. Talents are inborn, genetic and are not much affected by intervention (e.g., high IQ) 21. Enablers reflect benign social conditions, interventions, and environmental good luck (e.g., a strong family, a good school system, living in a democratic merito- cracy). Strengths are character traits (such as kindness, forgiveness, curiosity, honesty) which reflect facets of mental health that are amenable to change. Outcomes reflect dependent variables (e.g., improved social relationships and subjective well-being) which can be used to provide evidence that efforts by clinicians to enhance strengths are effective. Which strengths are most associated with mental health is open to debate. Wisdom, kindness and the capacity to love and be loved are strengths upon which few would argue. But should courage be included as a strength? And why were intelligence, perfect musical pitch and punctuality excluded? In addition, there is considerable debate within the mental health professions about whether positive mental health is a process that any insurance program should be expected to cover. Over time society will have to decide who should pay for positive mental health: the individual, the educational system, third party payers, religious organizations, or a combination of all four? Unlike other organs of the body that have evolved to stay the same or deteriorate after puberty, the human brain continues to evolve in adulthood. A ten-year-old's lungs and kidneys are more likely to reflect optimal function than are those of a sixty-year-old, but that is not true of their central nervous systems. To some extent, then, adult mental health reflects a continuing process of maturational unfolding and progressive brain myelinization into the sixth decade 22,23. Prospective studies reveal that individuals are less depressed and show greater emotional modulation at age 70 than they did at age 30 5,24. In some respects E. Erikson in 1950 anticipated Jahoda and Grinker when he provided the first model of adult lifespan development 25. All previous models had depicted deterioration after 45–50. In contrast, Erikson viewed each of his eight stages of human development as a fresh “criterion of mental health”. Subsequently, J. Loevinger provided a model of adult ego development 26 and L. Kohlberg built up a model of adult moral development 27. Implicit in all these models is the assumption that greater maturity reflects greater mental health. Arguably, the best definition of mental health that we have is W. Menninger's definition of maturity 28 as capacity for love, absence of stereotyped patterns of problem solving, realistic acceptance of the destiny imposed by one's time and place in the world, appropriate expectations and goals for oneself, and capacity for hope. In this model, maturity is not only the opposite of narcissism, but it is quite congruent with other models of mental health. To support the maturational model of mental health, the assessment of the behavior and feeling states of persons studied over a lifetime becomes necessary. Although such longitudinal studies have come to fruition only recently, all illustrate the positive association of maturity with increasing mental health 5,24,29,30,31. In order to illustrate the association between mental health and brain maturity, individuals with brain trauma, major depression, arteriosclerosis, Alzheimer's disease, alcoholism, and schizophrenia must all be excluded. Erikson conceptualized that maturity, through the evolution of adult development via life experience, produces a “widening social radius”. In Erikson's model, adult maturity is achieved over time through the mastery of the four sequential tasks of “identity”, “intimacy”, “generativity”, and “integrity”. On the basis of empirical data from Study of Adult has two more to and of the to the mastery of such tasks appears relatively of social and probably The age at which any is but the maturity of life is with mental health. is not a of of from or of to out of a is a of between the of from and the of where one's end and one's own as much from the and of important and as it does from For our relatively by age and reflect those of our rather than the of our Next, should which to and not with a with one other in an and may to a the capacity for may as and as a the is with a of the same it is and as in religious the is with a is a that is usually with or that the mastery of of this to a as as they play. are four that a into a to not a and to is almost of of the the of a clear capacity to for and the that between age and our need for and our need for and on the that the society can mean as a or to in the is achieved by a more than half the and is a of positive mental health in other The life is to a of the This of on the of the past to the The of a of the is on and of the of and its of one rather than In contrast, of the and its of and are less for not The last life is the of achieving some of and with to both one's own life and the world, and the acceptance of one's life as that had to be and by of no In our healthy adult development the same for and as for However, cross-cultural is In the 19th century, psychiatrists of like and and mental health was to and religious the century, the of cultural and in general led psychiatrists to there was any between as by and health. However, recent advances in the understanding of positive have psychiatry In the last positive to and have been years medical were about like and are also in and like and love were to be in the and in the of of education not of Then, in the H. and J. to love as rather than love as the basis for to provide to the of and even of with his of and The out that the our not only to but also to to out at and to of our own for of these a and she do but a competent her system, and she can still do but not her The of positive clear. the last have studies the of positive emotions. studies have human and in especially in the and These are and to us to and to recognize all that the of love and human In the last years like J. and have identified the and that human in the and and appear to the of the of The of in the and is most in individuals with the of social and confirmed by pencil and paper positive forgiveness, and the important positive and included in this model. great the eight selected positive all human is all about they are all and they all appear to be a of the major from the are other positive and a of for we can these while on a importance to are all about both the of and but the mental health of these two are very are for in time by like J. and psychologists like and S. while and the for the positive especially make patterns more and on time positive our for our moral and enhance our The of positive on the nervous has much in with the and via our nervous system, and via our nervous system, reduce blood and muscle studies of that of the and the which in to and the of socio-emotional intelligence reflects above average mental health in the same way that a high reflects above average emotional intelligence at the of positive mental health. In the defined socio-emotional intelligence as can that is easy. But to be with the to the at the time, for the and in the way that is not as as years a on intelligence dismissed the of such social intelligence as only in the did the modulation of more important to psychiatry than the modulation of and emotional intelligence can be defined by the accurate perception and of one's own of our that their is accurate of and to in in close relationships with capacity for toward a Over the last have been to our understanding of the of socio-emotional intelligence to positive mental health. The first is that both and experimentation have led to advances in our understanding of the of with the The second has been our but in the and even the of Over the last measures of emotional intelligence have been are now many in relationships that and more at and In the past there has also been an increasing to emotional and social for mental health, they considered for happiness and the However, if through the have regarded happiness as the psychologists and psychiatrists have to that from or love or from and or from and but reflects health. that from and or from mature or from of on and the is a to depends upon achieving positive and positive relationships 18. On the other subjective happiness can have maladaptive as as The for happiness can appear and can come and be happiness is seen in the character associated with and and with of by much American of maladaptive can to any but need like and is of such of in this the will be for The of the has always been of American with in the last have investigators like M. Seligman and E. out that a function of subjective is that it an to for and disease, high in subjective efforts to measure subjective have been quite and a investigators measure subjective as life other investigators more like work or However, the do you about life as a on a scale from to works well. environmental variables can have a is that are the most way to subjective well-being. such are by at during the for or and at each are to their subjective in order to from subjective experience, measures of measures of and by have also are of that use to The first two are social support and cognitive that we to The third of is by which our perception of and in order to reduce subjective and These mental are by the of as They can (e.g., by or (e.g., by or the need for other (e.g., by or (e.g., by They can our of the (e.g., by or the of a (e.g., by the or the (e.g., by or the associated with an (e.g., of The most pathological of includes and of reality. to life are the and maladaptive in and in with out and The third of associated with and with the of and at a more The of characterize mental health still and alter relationships and reality, but they these and as one would be by a upper in the ability not to one's self too and into are the very from which positive mental health is But these be achieved by a of Thus, the such as as the may the of and the of out as like other facets of mental health, the of healthy but longitudinal Studies from both Institute of Human Development and Study of Adult Development have the importance of the mature to mental health. as psychiatry needs to on Axis a score of psychiatry needs to best to the of less mature into more mature is in using studies to these are by the brain and to use empirical to change in the of during This paper has suggested seven models of positive mental health. As in the Study of Adult Development at Harvard an empirical of the of of these different models in a study of only was each of models by with the other but each model mental health years of the models was by social or even by a The of mental health the of interventions to What facets of mental health are and which are to As can mental illness, but do not improve healthy brain can enhance mental health only through and education. Finally, the study of positive mental health First, mental health must be defined in that are and Second, the for mental health must be and Finally, although mental health is one of important it should not be regarded as an good in must in our efforts to positive mental health while for This work was by from the Institute of Mental

World Psychiatry · 199 citationsread the source →

Cohort Profile: The biopsychosocial religion and health study (BRHS)

In The Secrets of Long Life in the National Geographic1 Buettner explored longevity among three communities in Sardinia Italy, Okinawa Japan, and Loma Linda California. Loma Linda is largely a community of 7th-day Adventists. In 1969 initial research2 found that among individuals surviving past age 35 Adventist women in California lived 3.7 years longer than their counterparts and Adventist men 6.2 years longer. In a later, larger California sample3 the differences were even stronger—4.4 years for women and 7.3 years for men. Exercise, vegetarian diet, not smoking, eating nuts and social support have been found to predict longevity in Adventists.4 Yet even when these and several psychological variables are controlled church attendance still predicts greater longevity.5 Interest has been increasing regarding the association of both mental and physical health with religion or spirituality.6 There have been a number of literature reviews that have concluded that the associations of religion and health are largely positive.7–9 In fact, Hall10 concluded religious attendance was more cost-effective in increasing longevity than statin-type medications. While some have questioned the quality of these research conclusions11 and others have pointed out that the benefits or costs of religion may vary depending on the indicator of religious involvement,12,13 there is general agreement regarding the need for more and better research on the subject. Nonetheless, Hummer and his colleagues14 concluded there was consistent evidence that religious attendance was associated with lower mortality risk in cross-sectional and prospective studies. They also concluded there was a need for more diverse measures of religious involvement, comparison among specific subpopulations, and a better understanding of the pathways by which religion might influence health (p. 1226). It was with this goal in mind that this Biopsychosocial Religion and Health Study was developed. The coverage of the study is best understood in the framework of our conceptual model. Two central concepts in this model are allostatic load and cumulative risk exposure. Allostasis is the process of achieving biologic stability through change—specifically, dynamic adjustments in multiple physiological systems to maintain equilibrium and set points (homeostasis) when responding to environmental demands.15 Healthy functioning requires allostasis, which is adaptive and protective over the short term. However, allostasis ‘has a potential cost to the body when allostasis is either called upon too often or is inefficiently managed, and that cost is referred to as “allostatic load” ’ (p. 174).16 Allostatic load can occur when chronic stressors place a burden on the organism but can also result from a lifetime of exposure to events demanding allostatic adjustment. We refer to this lifetime exposure as cumulative risk exposure. Allostatic load, over the life course, ultimately results in increased morbidity and mortality.17,18 In our model cumulative risk exposure aggregates an individual's risk level across physical risks such as poverty, poor housing quality, and violence exposure (which often co-occur), as well as psychosocial risks such as poor parental or marital bond, or poor job satisfaction.19 Cumulative risk exposure influences allostasis to affect allostatic load. Allostatic load, in turn, produces changes in morbidity, mortality and quality of life. However, the effects of cumulative risk exposure are both mediated and moderated by positive and negative aspects of religion. These positive and negative aspects have at least part of their influence by causing changes in lifestyle, psychological and social factors. We use the term manifestations to refer to beliefs and behaviors as they show themselves in psychosocial and biological responses. Our primary aims were to examine: (i) how religious experience moderates the impact of cumulative risk exposure on quality of life, health, and mortality; (ii) the mechanisms by which these manifestations of religion might operate; (iii) how manifestations of religious experience relate to biologic indicators of allostatic load within the context of cumulative risk exposure, and (iv) whether these manifestations operate differently in non-Blacks and Blacks—Blacks being a group for whom religion may be more central in life and, perhaps, in health.13,20,21 We could answer aims i, ii and iv with new questionnaire data and with the mortality and hospitalization data being collected by AHS-2.22 However, obtaining biologic samples as required by aim iii is much more difficult and expensive. Hence, we divided our study into two sub-studies: the Psychosocial Manifestations of Religion Sub-study (PsyMRS) and the Biological Manifestations of Religion Sub-study (BioMRS). PsyMRS is a large prospective study of approximately 11 000 individuals from the AHS-2 population who completed the supplemental PsyMRS questionnaire. Figure 1 shows our sampling plan. The sample will be surveyed at 3-year intervals while the study continues. AHS-2 will provide data on mortality and hospitalizations as described later. BioMRS is an approximately 530-person sub-study embedded within the larger PsyMRS. All members of BioMRS complete the PsyMRS questionnaire and, in addition, attend a clinic where biologic indicators are assessed. All individuals in both PsyMRS and BioMRS were selected from those participating in AHS-2. The AHS-2 recruitment methods and sampling strategy are described elsewhere.22 Sampling plan. AHS-2 is the Adventist Health Study 2. PsyMRS is the Psychosocial Manifestations of Religion Sub-study involving collection of questionnaire data. BioMRS is the Biological Manifestations of Religion Sub-study that includes assessment of biometrics, blood/saliva/urine markers, and memory/learning ability. Numbers are targets. For example, while our year one target for PsyMRS was 10 000, as August 2007, 11 004 were in the dataset We randomly sampled 20 000 AHS-2 participants and sent each the 20-page religion and health questionnaire with up to three reminder cards. Based on pilot studies we expected response rates of 55% from Caucasian and 26% from African American participants. Our goal was to enroll 3400 Blacks and 6600 Caucasians. Data collection started in September 2006 and was largely completed by August 2007. Our return rate was higher than expected with 60% from Caucasians and 31% from Blacks. Recruitment for BioMRS was through an initial letter followed by phone calls. Our goal was to obtain 300 non-Black and 200 Black participants; this moderately overweighs Black participants when compared with the overall AHS-2 sample and the PsyMRS study. Only individuals living within driving distance of our clinic sites in Loma Linda, Riverside, and Los Angeles were contacted. There were 536 participants (296 Whites, 239 Blacks, and 1 Hispanic). In the 3rd year after the initial sample we aim for a minimum of 3000 PsyMRS participants and 400 BioMRS participants. If further funding is obtained, both PsyMRS and BioMRS data will be collected at additional time points to allow latent growth curve modelling of the relations among study variables.23 Our conceptual framework suggested four categories of variables relevant to the PsyMRS questionnaire: cumulative risk exposure, religion, mediating and outcome variables. Allostatic load cannot be directly assessed from the questionnaire. In almost all cases we have used scales which have been validated in other studies or, where they are not available, validated our own. Cumulative risk exposure variables are included to assess a broad spectrum of cumulative and acute stressors that have been associated with health or quality of life.19,24 Most available single measures do not assess risk exposure at more than one point in the person's life so we broadly sampled cumulative risk across the life course. The measures include physical and socioeconomic stress: housing quality, family size, and poverty; and psychosocial stress: perceived stress, job stress/control/satisfaction, unfair treatment and discrimination, parent bonding, marital satisfaction, and trauma exposure. Religion variables were selected to include four aspects of religion: (i) affective—gratitude, forgiveness, loving vs controlling God, positive and negative eschatological attitudes; (ii) cognitive—intrinsic religiosity, some forms of religious coping, spiritual meaning; (iii) behavioural—church attendance, Sabbath keeping, prayer types, church organizational activity; and (iv) social—congregational sense of community, religious support. Mediating variables were selected based on Ellison and Levin's typology of six mechanisms for the religion/health connection25—(i) health behaviors and personal lifestyle variables (from AHS-2), (ii) social integration and social support, (iii) self-esteem and personal efficacy, (iv) positive vs negative emotions, (v) healthy beliefs (e.g. optimism) and (vi) coping resources and behaviors. Additionally we included measures of neuroticism, impression management and self-deception to serve as control variables. Outcome variables included health related quality of life (the SF-12)26 and life satisfaction as well as various medical history, symptom frequency, medication use and sleep disturbance questions and an adaptation of the Charlson comorbidity index.27 Finally, total and coronary disease mortality will be available on followup. All BioMRS participants completed a PsyMRS questionnaire, provided a waking saliva sample and a 12-h, overnight urine sample. At the clinic, fasting blood and adipose samples were taken; biometrics and percentage body fat (bioimpedence) were also assessed. Participants then provided physical and cognitive function data—Independent Activities of Daily Living; physical performance, based on five separate tests of physical ability—balance, gait, chair stands, manual ability, and grip strength; and the California Verbal Learning Test.28 Our measure of allostatic load (Table 1) is designed to summarize levels of physiological activity across a wide range of regulatory systems pertinent to disease risk, as previously described.29–31 Biological parameters used to determine the allostatic load index Biological parameters used to determine the allostatic load index The AHS-2 questionnaire was completed by BRHS participants 1–3 years before the PsyMRS questionnaire. The AHS-2 data set includes 130 food frequency items, daily physical activity, detailed ethnicity and other demographics, country of birth, religion of mother and father who raised participant, religion at age 15–25, age at baptism, medical history, women's health conditions and history, alcohol and tobacco use, and medications used at baseline. AHS-2 will provide hospitalization history information based on a biennial survey and causes of mortality by matching the sample with the National Death Index.22 Based on previous studies of Adventists in California32 we expect good retention in our sample. With the planned cohort maintenance and retention activities of AHS-222 we hope to trace a high percentage of the participants over at least a 3-year period. The demographics of the PsyMRS sample are shown in Table 2 along with comparisons with the 2006 General Social Survey, a survey based on national probability sample.33 Ages below 35 are omitted as the inclusion criteria for AHS-2 in the first several years was age 35+ for non-Blacks and age 30+ for Blacks. Comparison of demographics in the biopsychosocial religion and health study (BRHS) and the general social survey (GSS) by ethnicity and gender Notes: Only individuals older than 35 were included from both samples since that was an initial inclusion criteria for BRHS. All GSS vs BRHS comparisons on education, marital status, and age within genders are statistically significant. Comparison of demographics in the biopsychosocial religion and health study (BRHS) and the general social survey (GSS) by ethnicity and gender Notes: Only individuals older than 35 were included from both samples since that was an initial inclusion criteria for BRHS. All GSS vs BRHS comparisons on education, marital status, and age within genders are statistically significant. One concern is the relatively small number of Black male Adventist participants. However, there are sufficient numbers for data analysis in the middle ranges of age, education and income. There are no large education differences between male and female or Black and White Adventists. While not shown in Table 2 there are no large percentage differences in income though females and Black Adventists have slightly lower income than males and White Adventists respectively. One interesting figure is the relatively low number of Black Adventist women who are married and a correspondingly high number who are divorced or never married relative to both Black male Adventists and to both male and female White Adventists. Comparing the PsyMRS sample and the GSS sample, the BRHS sample has more females, more college educated individuals especially among the Blacks, more married individuals and more individuals above age 65 in all genders and ethnicities. The educational difference may be the result of the literacy level implied by being able to fill out the 50 page AHS-2 questionnaire and possibly the emphasis on education among 7th-day Adventists—e.g. though in the 2000 Census only the 18th largest denominational group,34 Adventists have the 5th largest number of denominational schools35 and the 9th largest number of students enrolled in such schools.36 The difference between Adventists and the GSS sample is consistently larger for Black males than other groups. Adventists are more likely to be married and less likely to be divorced than the GSS sample. Black Adventist women are also less likely to be widowed (P = 0.022 by Fisher's exact Test) and never married (P < 0.0005) than Black women in the GSS sample. Table 3 compares the BRHS and GSS data for two religious questions. BRHS participants were much more likely to report attending church. On the other hand, while prayer was more frequent for Adventists than for those in the GSS participants, the frequency of daily prayer for Black Adventist females was similar to that found in GSS Black females. Comparison of religion variables in the biopsychosocial religion and health study and the general social survey by ethnicity and gender Notes: All GSS versus BRHS comparisons on church attendance and prayer frequency within genders are statistically significant except for prayer in Black females. Comparison of religion variables in the biopsychosocial religion and health study and the general social survey by ethnicity and gender Notes: All GSS versus BRHS comparisons on church attendance and prayer frequency within genders are statistically significant except for prayer in Black females. Previous research with earlier Adventist cohorts has shown that 7th-day Adventists have lower mortality rates than the general population.4 However, until now we have had no data on quality of life. Figure 2 shows physical and mental quality of life on the SF-12v2 for Black and White Adventists compared with the national norms taken from the 2002 SF-12v2 manual based on data collected in 1999 and 2000.37 Unfortunately, national norms for the SF-12v2 are not available by ethnicity but the comparisons are nonetheless interesting. It appears that both Black and White Adventists in our sample report better physical and mental health than the national norms but the patterns differ by age group. For physical health Adventist females tend to be higher than national norms in the 45–54 age group and the differences tend to get smaller as the age of the groups increase. For males the differences tend to be there at all ages but are more pronounced in the 55- to 74-year old age range. Adventists and non-Adventists have similar levels of mental health in the 35- to 44-year old age group but the mental health of both Black and White Adventists is better in the older age groups. Interestingly, Black Adventists at some ages seem to report better mental health than even White Adventists. Physical and Mental Health based on SF-12 composite scores for 7th-day Adventist Blacks and Whites and for SF-12 national norms.38 Numbers are scale scores (mean 50, SD 10) for individuals over 35 years of age The overall better level of physical and mental health for Adventists could be a volunteer effect since our respondents had to fill out long questionnaires. On the other hand, the national norms were also based on volunteers though the questionnaires involved were not as extensive. Still, the fact that the gaps were bigger for mental health and that that gap is greater at older ages is interesting and harder to explain as a volunteer bias alone. These patterns will warrant further examination as our study progresses. The better physical health of Black Adventists than the national norms also warrants attention given the data on health disparities suggests Blacks score lower on physical health measures.38 One potential weakness of this study is that the data are collected exclusively on 7th-day Adventists. While this means that cross-denominational differences cannot be explored this is no different from other studies which have focused on single denominations such as Baptists,39,40 Catholics,41 Mormons,38–40 and Presbyterians.43 Additionally, our preliminary examination of the data shows a wide range of responses on most religion variables. While other approaches are useful,43–45 examination of the religion-health association within a single denomination has several strengths: (i) single denomination studies eliminate the need to control for denominational differences; (ii) because members of a single denomination have a shared religious tradition they will have less variation in how they interpret more nuanced religious questions, even as they differ in their responses to such questions; (iii) in addition, the examination of Blacks is easier because confounding by socio-economic status is less pronounced and thus easier to control than in the U.S. population due to the Adventist education emphasis;46 (iv) finally, just as one cannot learn about economic mobility and success solely by studying the urban underclass and focusing on barriers to achievement, one cannot learn about health and longevity by focusing exclusively on causes of death and studying persons who die prematurely. It behoves us to examine groups that defy the odds and enjoy better-than-average health and longevity; there is no better source of good biopsychosocial, quality of life and religious data on one of these strategically important groups, the 7th-day Adventists, than the data from this study. This study has a number of strengths. First, it includes a much wider range of religious variables than previous epidemiological studies.14,43–45 Second, we used a systematic theoretical scheme for inclusion of possible mediators of the religion and health relationship and, hence, the study includes a wide range of potential psychosocial- and lifestyle-mediating variables. Third, it includes a variety of biologic and functional assessments of allostatic load that have not been incorporated in previous studies of the religion and health connection. Fourth, the quality of life measures, assessed for the first time on an Adventist population, will allow us to determine whether the longer lives of Adventists are accompanied by a longer span of high quality life or whether these longer lives just stretch out the period of poor quality life. The Biopsychosocial Religion and Health Study has potential to greatly increase our understanding of the religion-health relationship and its implications for public health. We are still in the process of cleaning data and prospective data collection has yet to begin. Thus, the data are not freely available. However, BRHS researchers would welcome contacts from other investigators interested in collaboration on projects relating to specific aspects of the data we are can be through the of this or through the Adventist Health Study at Loma Linda National on for their support of this National for their support of the Adventist Health Study 2 which is the parent study for the Biopsychosocial Religion and Health and have been as on this and to the that the we have in and assessment are good we a We would to a to and for the on the BioMRS biological and to for all aspects of the BioMRS We would also to the students who have in our and on the participants. of

International Journal of Epidemiology · 63 citationsread the source →

Emotional intelligence, emotional labor, and job satisfaction among physicians in Greece.

Background: There is increasing evidence that psychological constructs, such as emotional intelligence and emotional labor, play an important role in various organizational outcomes in service sector. Recently, in the "emotionally charged" healthcare field, emotional intelligence and emotional labor have both emerged as research tools, rather than just as theoretical concepts, influencing various organizational parameters including job satisfaction. The present study aimed at investigating the relationships, direct and/or indirect, between emotional intelligence, the surface acting component of emotional labor, and job satisfaction in medical staff working in tertiary healthcare. Methods: Data were collected from 130 physicians in Greece, who completed a series of self-report questionnaires including: a) the Wong Law Emotional Intelligence Scale, which assessed the four dimensions of emotional intelligence, i.e. Self-Emotion Appraisal, Others' Emotion Appraisal, Use of Emotion, and Regulation of Emotion, b) the General Index of Job Satisfaction, and c) the Dutch Questionnaire on Emotional Labor (surface acting component). Results: Emotional intelligence (Use of Emotion dimension) was significantly and positively correlated with job satisfaction (r=.42, p<.001), whereas a significant negative correlation between surface acting and job satisfaction was observed (r=-.39, p<.001). Furthermore, Self-Emotion Appraisal was negatively correlated with surface acting (r=-.20, p<.01). Self-Emotion Appraisal was found to influence job satisfaction both directly and indirectly through surface acting, while this indirect effect was moderated by gender. Apart from its mediating role, surface acting was also a moderator of the emotional intelligence-job satisfaction relationship. Hierarchical multiple regression analysis revealed that surface acting could predict job satisfaction over and above emotional intelligence dimensions. Conclusions: The results of the present study may contribute to the better understanding of emotion-related parameters that affect the work process with a view to increasing the quality of service in the health sector.

BMC health services research · 29 citationsread the source →