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Parental education and inequalities in child mortality: a global systematic review and meta-analysis.

Background: The educational attainment of parents, particularly mothers, has been associated with lower levels of child mortality, yet there is no consensus on the magnitude of this relationship globally. We aimed to estimate the total reductions in under-5 mortality that are associated with increased maternal and paternal education, during distinct age intervals. Methods: This study is a comprehensive global systematic review and meta-analysis of all existing studies of the effects of parental education on neonatal, infant, and under-5 child mortality, combined with primary analyses of Demographic and Health Survey (DHS) data. The literature search of seven databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Web of Science) was done between Jan 23 and Feb 8, 2019, and updated on Jan 7, 2021, with no language or publication date restrictions. Teams of independent reviewers assessed each record for its inclusion of individual-level data on parental education and child mortality and excluded articles on the basis of study design and availability of relevant statistics. Full-text screening was done in 15 languages. Data extracted from these studies were combined with primary microdata from the DHS for meta-analyses relating maternal or paternal education with mortality at six age intervals: 0-27 days, 1-11 months, 1-4 years, 0-4 years, 0-11 months, and 1 month to 4 years. Novel mixed-effects meta-regression models were implemented to address heterogeneity in referent and exposure measures among the studies and to adjust for study-level covariates (wealth or income, partner's years of schooling, and sex of the child). This study was registered with PROSPERO (CRD42020141731). Findings: The systematic review returned 5339 unique records, yielding 186 included studies after exclusions. DHS data were compiled from 114 unique surveys, capturing 3 112 474 livebirths. Data extracted from the systematic review were synthesized together with primary DHS data, for meta-analysis on a total of 300 studies from 92 countries. Both increased maternal and paternal education showed a dose-response relationship linked to reduced under-5 mortality, with maternal education emerging as a stronger predictor. We observed a reduction in under-5 mortality of 31·0% (95% CI 29·0-32·6) for children born to mothers with 12 years of education (ie, completed secondary education) and 17·3% (15·0-18·8) for children born to fathers with 12 years of education, compared with those born to a parent with no education. We also showed that a single additional year of schooling was, on average, associated with a reduction in under-5 mortality of 3·04% (2·82-3·23) for maternal education and 1·57% (1·35-1·72) for paternal education. The association between higher parental education and lower child mortality was significant for both parents at all ages studied and was largest after the first month of life. The meta-analysis framework incorporated uncertainty associated with each individual effect size into the model fitting process, in an effort to decrease the risk of bias introduced by study design and quality. Interpretation: To our knowledge, this study is the first effort to systematically quantify the transgenerational importance of education for child survival at the global level. The results showed that lower maternal and paternal education are both risk factors for child mortality, even after controlling for other markers of family socioeconomic status. This study provides robust evidence for universal quality education as a mechanism to achieve the Sustainable Development Goal target 3.2 of reducing neonatal and child mortality. Funding: Research Council of Norway, Bill & Melinda Gates Foundation, and Rockefeller Foundation-Boston University Commission on Social Determinants, Data, and Decision Making (3-D Commission).

Lancet (London, England) · meta-analysis · 132 citationsread the source →

Assessing child development scores among minority and Indigenous language versus dominant language speakers: a cross-sectional analysis of national Multiple Indicator Cluster Surveys.

Background: Multiple studies have highlighted the inequities minority and Indigenous children face when accessing health care. Health and wellbeing are positively impacted when Indigenous children are educated and receive care in their maternal language. However, less is known about the association between minority or Indigenous language use and child development risks and outcomes. In this study, we provide global estimates of development risks and assess the associations between minority or Indigenous language status and early child development using the ten-item Early Child Development Index (ECDI), a tool widely used for global population assessments in children aged 3-4 years. Methods: We did a secondary analysis of cross-sectional data from 65 UNICEF Multiple Indicator Cluster Surveys (MICS) containing the ECDI from 2009-19 (waves 4-6). We included individual-level data for children aged 2-4 years (23-60 months) from datasets with ECDI modules, for surveys that captured the language of the respondent, interview, or head of household. The Expanded Graded Intergenerational Disruption Scale was used to classify household languages as dominant versus minority or Indigenous at the country level. Our primary outcome was on-track overall development, defined per UNICEF's guidelines as development being on track for at least three of the four ECDI domains (literacy-numeracy, learning, physical, and socioemotional). We performed logistic regression of pooled, weighted ECDI scores, aggregated by language status and adjusting for the covariables of child sex, child nutritional status (stunting), household wealth, maternal education, developmental support by an adult caregiver, and country-level early child education proportion. Regression analyses were done for all children aged 3-4 years with ECDI results, and separately for children with functional disabilities and ECDI results. Findings: 65 MICS datasets were included. 186 393 children aged 3-4 years had ECDI and language data, corresponding to an estimated represented population of 34 714 992 individuals. Estimated prevalence of on-track overall development as measured by ECDI scores was 65·7% (95% CI 64·2-67·2) for children from a minority or Indigenous language-speaking household, and 76·6% (75·7-77·4) for those from a dominant language-speaking household. After adjustment, dominant language status was associated with increased odds of on-track overall development (adjusted OR 1·54, 95% CI 1·40-1·71), which appeared to be largely driven by significantly increased odds of on-track development in the literacy-numeracy and socioemotional domains. For the represented population aged 2-4 years (n=11 465 601), the estimated prevalence of family-reported functional disability was 3·6% (95% CI 3·0-4·4). For the represented population aged 3-4 years with a functional disability (n=292 691), language status was not associated with on-track overall development (adjusted OR 1·02, 95% CI 0·43-2·45). Interpretation: In a global dataset, children speaking a minority or Indigenous language were less likely to have on-track ECDI scores than those speaking a dominant language. Given the strong positive benefits of speaking an Indigenous language on the health and development of Indigenous children, this disparity is likely to reflect the sociolinguistic marginalisation faced by speakers of minority or Indigenous languages as well as differences in the performance of ECDI in these languages. Global efforts should consider performance of measures and monitor developmental data disaggregated by language status to stimulate efforts to address this disparity. Funding: None. Translations: For the Spanish, Kaqchikel and K'iche' translations of the abstract see Supplementary Materials section.

The Lancet. Global health · 2 citationsread the source →

Psychosocial rehabilitation after war trauma with adaptive disclosure: Design and rationale of a comparative efficacy trial.

Background: Posttraumatic stress disorder (PTSD) from warzone exposure is associated with chronic and disabling social and occupational problems. However, functional impairment is rarely assessed or targeted directly in PTSD treatments, which instead focus on symptom reduction. Trauma-related contributors to diminished functioning, including guilt, shame, and anger resulting from morally compromising or loss-based war experiences, are also underemphasized. The goal of this clinical trial is to fill a substantial gap in the treatment of military-related PTSD by testing a modified Adaptive Disclosure (AD) therapy for war-related PTSD stemming from moral injury and traumatic loss focused on improving psychosocial functioning AD. Method and design: This paper describes the rationale and design of a multi-site randomized controlled trial comparing AD to Present-Centered Therapy (PCT). We will recruit 186 veterans with PTSD, who will be assessed at baseline, post-treatment, and 3- and 6-months post-treatment. Primary outcomes are functional changes (i.e., functioning/disability and quality of life). Secondary outcomes are mental health variables (i.e., PTSD, depression, guilt, shame). We hypothesize that veterans treated with AD will experience greater improvements in all outcomes compared to those treated with PCT. Discussion: This trial will advance knowledge in rehabilitation research by testing the first therapy specifically designed to address psychosocial functioning among veterans with war-related PTSD. The results may improve the quality of mental health care for veterans by offering an ecologically sound treatment for experiences that are uniquely impactful for war veterans.

Contemporary clinical trials · randomised controlled trial · 14 citationsread the source →

Death Anxiety in the Elderly: The Role of Spiritual Health and Perceived Social Support

Aging as one of the most important periods of life is associated with many challenges including death anxiety. Therefore, the aim of the current study was to investigate the role of spiritual health and perceived social support in predicting death anxiety in the elderly. The present study was a descriptive-correlational one. The study population consisted of the elderly living in Shahrekord in 2020, among whom 385 were selected using convenience sampling method and were assessed by the scales of Templer Death Anxiety, Zemen Perceived Social Support and Paloutzian & Ellison spiritual health. Data were analyzed using correlation coefficient and linear regression analysis in SPSS software version 22. The results indicated that there is a significant relationship between spiritual health (r=-0.51), perceived social support by family (r=-0.37), friends (r=-0.30) and significant other (r=-0.16) with death anxiety in the elderly. The results of linear regression analysis releaved that spiritual health (P=0.001, β=-0.46) and perceived social support by the family (P=0.001, β=-0.29) can predict negatively the death anxiety in the elderly and explain 26.7% of the variance of death anxiety in the elderly. Consequently, counselors and psychologists in the field of aging are suggested to reduce death anxiety in the elderly, using strategies to promote spiritual health and social support. ReferencesAbdel-Khalek, A. M. (2001). Death, anxiety, and depression in Kuwaiti undergraduates. OMEGA-Journal of Death and Dying, 42(4), 309-320.Abdel-Khalek, A. M. (2005). Death anxiety in clinical and non-clinical groups. Death Studies, 29(3), 251-259.Alipour, A., Aliakbari Dehkord, D. M., Amini, F., & Hashemi Jashni, J. A. (2016). Relationship between perceived social support and adherence of treatment in Diabetes Mellitus type 2: mediating role of resiliency and rope. Journal of Research in Psychological Health, 10(2), 53-67. 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[Persian].Basharpoor, S., Rahimi, S., Sedaghat, M. (2019). The Role of psychological flexibility and emotional processing styles in predicting death anxiety in the elderly. Aging Psychology, 5(2), 131-141. [Persian].Becker, E. (1973). The denial of death. Free Press. Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social science & medicine, 51(6), 843-857.Bufford, R. K., Paloutzian, R. F., & Ellison, C. W. (1991). Norms for the spiritual weil-being scale. Journal of psychology and theology, 19(1), 56-70.Chukwuorji, J. C., Uzuegbu, C. N., Chukwu, C. V., Ifeagwazi, C. M., & Ugwu, C. (2020). Social support serves emotion regulation function in death anxiety among people living with HIV/AIDS. South African Journal of Psychology, 50(3), 395-410.Cochran, W. G. (1940). Note on an approximate formula for the significance levels of z. The Annals of Mathematical Statistics, 11(1), 93-95.Dos Santos, S. B., Rocha, G. P., Fernandez, L. L., de Padua, A. C., & Reppold, C. T. (2018). Association of lower spiritual well-being, social support, self-esteem, subjective well-being, optimism and hope scores with mild cognitive impairment and mild dementia. Frontiers in psychology, 9, 1-10.Ebrahimi, B., Hosseini, M., & Rashedi, V. (2018). The Relationship between social support and death anxiety among the elderly. Elderly Health Journal, 4(2), 37-42.Emamirad, A., Amiri, H. (2018). The Relationship between spiritual health and meaning of life with death anxiety in elders. Aging Psychology, 4(3), 251-261. [Persian]Esmaeilishad, B. (2020). The Effectiveness of self-care training on quality of life, self-care behaviors and blood sugar in elderly lacking self-Care behaviors. Aging Psychology, 6(1), 1-11. [Persian].Fortner, V., Robert A. Neimeyer, B. (1999). Death anxiety in older adults: A quantitative review. Death studies, 23(5), 387-411.Ghasempour, A., Sooreh, J., & Seid Tazeh Kand., M.T (2017). Predicting death anxiety on the basis of emotion cognitive regulation strategies. Knowledge & Research in Applied Psychology, 13(48), 63-70. [Persian].Han, A. R., Park, S. A., & Ahn, B. E. (2018). Reduced stress and improved physical functional ability in elderly with mental health problems following a horticultural therapy program. Complementary Therapies in Medicine, 38, 19-23.Hwang, H. (2019). Factors influencing death anxiety among rural elderly. Journal of Health Informatics and Statistics, 44(2), 111-116.Jose, S., George, N., & Dante, G. (2018). Life satisfaction as a predictor of death anxiety among the elderly people. Indian Journal of Health and Wellbeing, 9(6), 829-832.Kim, K. H., Kwon, H. J., Choi, M. H., Park, Y. J., & Kim, S. K. (2010). Psychological and spiritual factors associated with death anxiety of elderly people living at home. Journal of Korean Academy of Psychiatric and Mental Health Nursing, 19(1), 96-105.Kim, Y., & Kim, M. (2019). Factors influencing death anxiety in community-dwelling elderly: based on the ecology theory. The Korean Journal of Hospice and Palliative Care, 22(1), 30-38.Krause, N., Pargament, K. I., & Ironson, G. (2018). In the shadow of death: Religious hope as a moderator of the effects of age on death anxiety. The Journals of Gerontology: Series B, 73(4), 696-703.Kübler-Ross, E. (2002). On death and dying; Questions and answers on death and dying; on life after death. Quality Paper Book Club. Kurtulan, M. H., & Karaırmak, Ö. (2016). Examination of the relationship among death anxiety, spirituality, religious orientation and existential anxiety. Spiritual Psychology and Counseling, 1(2), 206-217.Lehto, R. H., & Stein, K. F. (2009). Death anxiety: an analysis of an evolving concept. Research and theory for nursing practice, 23(1), 23–41.López‐Cerdá, E., Carmona‐Torres, J. M., & Rodríguez‐Borrego, M. A. (2019). Social support for elderly people over 65 years in Spain. International nursing review, 66(1), 104-111.Mahbobi, M., Etemadi, M., Khorasani, E., & Ghiasi, M. (2012). The Relationship between spiritual health and social anxiety in chemical veterans. Journal of Military Medicine, 14(3), 186-91Mehri Nejad, S. A., Ramezan Saatchi, L., & Paydar, S. (2017). Death anxiety and its relationship with social support and adherence to religion in the elderly. Salmand: Iranian Journal of Ageing, 11(4), 494-503. [Persian].Menzies, R. E., & Dar-Nimrod, I. (2017). Death anxiety and its relationship with obsessive-compulsive disorder. Journal of Abnormal Psychology, 126(4), 367.Michaelson, V., Brooks, F., Jirásek, I., Inchley, J., Whitehead, R., King, N., Walsh, S., Davison, C., Mazur, J., & Pickett, W. (2016). Developmental patterns of adolescent spiritual health in six countries. SSM-population health, 2, 294-303.Moser, S., Luxenberger, W., & Freidl, W. (2017). The influence of social support and coping on quality of life among elderly with age-related hearing loss. American Journal of Audiology, 26(2), 170-179.Poordad, S., Momeni, K., & karami, J. (2019). Death anxiety and its relationship with social support and gratitude in older adults. Salmand: Iranian Journal of Ageing, 14(1), 26-39. [Persian].Rajabi, G.R., & Bahrani, M. (2001). Factor analysis of death anxiety scale questions. Journal of Psychology, 5 (4), 331-341. [Persian].Razavi, V. (2015). Relationship between social support and hope and death anxiety among the old people of Tehran Omid Cultural Center. International Journal of Life Sciences, 9(2), 65-70.Rocha, A. C. A. L. D., & Ciosak, S. I. (2014). Chronic disease in the elderly: spirituality and coping. Revista da Escola de Enfermagem da USP, 48(2), 87-93.Rostami, M., nosrati, K., Mahdinejad Gorji, G., kabiri, M. (2020). Death anxiety in the elderly: the role of psychological hardiness and practical commitment to prayer. Aging Psychology, 5(4), 309-320. [Persian]Russac, R. J., Gatliff, C., Reece, M., & Spottswood, D. (2007). Death anxiety across the adult years: An examination of age and gender effects. Death studies, 31(6), 549-561.Saber, F. M., & Nusratabadi, M. (2014). Social support and quality of life related to health in the elderly covered by the welfare of Kerman city. Journal of Health and Development, 3 (3), 189-199. [Persian].Saini, P., Patidar, A. B., Kaur, R., Kaur, M., & Kaur, J. (2016). Death anxiety and its associated factors among elderly population of Ludhiana city, Punjab. Indian Journal of, 30(1), 101-10.Sarason, B. R., Sarason, I. G., & Pierce, G. R. (1990). Social support: An interactional view. John Wiley & Sons. Seo, J. H., & Noh, Y. G. (2019). Influences of social support and health promotion behavior on aging anxiety among middle-aged women. Journal of Digital Convergence, 17(11), 339-347.Seyedfatemi N., Rezaie M., Givari A., & Hosseini F. (2006). Prayer and spiritual well-being in cancer patients. Health Monitor Journal of the Iranian Institute for Health Sciences Research, 5(4), 0-0. [Persian].Sharma, P., Asthana, H. S., Gambhir, I. S., & Ranjan, J. K. (2019). Death anxiety among elderly people: role of gender, spirituality and mental health

DOAJ (DOAJ: Directory of Open Access Journals) · 11 citationsread the source →

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

Background: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. Methods: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. Findings: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. Interpretation: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. Funding: National Institute for Health Research, Health Technology Assessment programme.

The lancet. Psychiatry · randomised controlled trial · 192 citationsread the source →

Internet-delivered interpretation training reduces worry and anxiety in individuals with generalized anxiety disorder: A randomized controlled experiment.

Objective: Generalized anxiety disorder (GAD) is a debilitating condition, characterized by negative interpretations about ambiguous situations. This study tested whether entirely internet-delivered interpretation training [cognitive bias modification (CBM)] versus control promotes positive interpretations and reduces worry and anxiety in individuals with GAD, with or without depression. Method: A two-arm (CBM; control) parallel-group randomized controlled experiment. Assessments were preintervention (T0), postintervention (T1), 1-month (T2) postintervention, and 3-month (T3) postintervention. Participants with GAD (with or without comorbid depression) were randomly allocated to either CBM (n = 115) or control (n = 115). Participants, but not researchers, were blind to allocated condition. Participants completed up to 10 online CBM or control sessions across 1 month. Interpretation bias [coprimary outcomes: scrambled sentence test (SST), recognition test (RT)], and number of negative thought intrusions during a breathing focus task were measured at T0 and T1. Self-reported levels of worry [Penn State Worry Questionnaire-trait (PSWQ trait); Penn State Worry Questionnaire-past week (PSWQ weekly)], anxiety [Generalized Anxiety Disorder scale (GAD-7)], depression [Patient Health Questionnaire (PHQ-9)], rumination [Ruminative Response Scale (RRS)], and repetitive negative thinking [RNT; Repetitive Thinking Questionnaire-trait (RTQ-trait)] were assessed at T0-T3. Results: The per-protocol analyses included N = 186 participants (CBM n = 94; control n = 92). As predicted, we found moderate-to-large training effects on the primary outcome of interpretation bias at T1. Secondary outcomes of negative thought intrusions at T1 and self-reported symptoms at T2 were all significantly lower in the CBM versus control condition. All but one effect (trait RNT) were sustained at T3. Conclusions: In this randomized controlled study, we found that fully online interpretation training ameliorated core features of GAD in individuals with or without comorbid depression up to 3 months posttraining. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Journal of consulting and clinical psychology · randomised controlled trial · 24 citationsread the source →

Effectiveness of a bite-sized web-based intervention to improve healthcare worker wellbeing: A randomized clinical trial of WISER.

Importance: Problems with the wellbeing of healthcare workers (HCWs) are widespread and associated with detrimental consequences for the workforce, organizations, and patients. Objective: This study tested the effectiveness of the Web-based Implementation for the Science of Enhancing Resilience (WISER) intervention, a positive psychology program, to improve six dimensions of the wellbeing of HCWs. Design: We conducted a randomized controlled trial of HCWs between 1 April 2018 and 22 July 2019. Cohort 1 received WISER daily for 10 days. Cohort 2 acted as a waitlist control before receiving WISER. Setting: Web-based intervention for actively employed HCWs across the United States. Participants: Eligibility criteria included being ≥18 years old and working as a HCW. Each participant was randomized to start the intervention or serve as a waitlist control for 14 days before starting the intervention. Interventions: Cohorts received links via 10 texts exposing them to introductory videos and positive psychology exercises (3 good things, cultivating awe, random acts of kindness, cultivating relationships, and gratitude letters). Main outcomes and measures: The primary outcome was emotional exhaustion; secondary outcomes included depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. All outcomes were assessed at baseline, 1-week post-intervention (primary endpoint), and 1, 6, and 12-month post-intervention. Outcomes were measured using six validated wellbeing instruments, rescaled to 100-point scales for comparison. Six items assessed participants' WISER experience. The analysis employed mixed-effects models. Results: In cohorts 1 and 2, 241 and 241 initiated WISER, and 178 (74%) and 186 (77%) completed the 6-month follow-up, respectively. Cohort populations were similar at baseline, mostly female (81; 76%) and nurses (34; 32%) or physicians (22; 23%), with 1-10 years of experience in their current position (54; 52%). Relative to control, WISER significantly improved depressive symptoms [-7.5 (95%CI: -11.0, -4.0), p < 0.001], work-life integration [6.5 (95%CI: 4.1, 8.9), p < 0.001], happiness [5.7 (95%CI: 3.0, 8.4), p < 0.001], emotional thriving [6.4 (95%CI: 2.5, 10.3), p = 0.001], and emotional recovery [5.3 (95%CI: 1.7, 8.9), p = 0.004], but not emotional exhaustion [-3.7 (95%CI: -8.2, 0.8), p = 0.11] at 1 week. Combined cohort results at 1, 6, and 12 months showed that all six wellbeing outcomes were significantly improved relative to baseline (p < 0.05 for all). Favorable impressions of WISER were reported by 87% of participants at the 6-month post-assessment. Conclusion and relevance: WISER improved HCW depressive symptoms, work-life integration, happiness, emotional thriving, and emotional recovery. Improvements in all HCW wellbeing outcomes endured at the 1-, 6-, and 12-month follow-ups. HCW's impressions of WISER were positive. Clinical trials number: https://clinicaltrials.gov/ct2/show/, identifier: NCT02603133. Web-based Implementation for the Science of Enhancing Resilience Study (WISER).

Frontiers in public health · randomised controlled trial · 17 citationsread the source →

Protocol for a randomized controlled trial comparing the Circle of Security-parenting (COS-P) with treatment as usual in child mental health services

BACKGROUND: The quality of a child's attachment to its primary caregiver plays an important role for its long-term socioemotional development. While 'secure' attachment is associated with better outcomes, 'insecure' attachment is associated with a higher risk of externalizing and internalizing symptoms. Children referred to mental health services show much higher rates of insecure attachment than the general population, yet the parent-child relationship is rarely in treatment focus. Attachment quality is closely associated with parental sensitive responsiveness that is target of attachment-based interventions like Circle of Security (COS). COS has shown to improve attachment quality and the well-being of both children and parents. No randomized controlled trials have investigated the effect of COS on parental sensitivity and child psychiatric symptoms in child mental health services. OBJECTIVES: To investigate whether COS-Parenting (COS-P) can increase observed maternal sensitivity and decrease children's psychiatric symptoms as an add on to treatment as usual (TAU). METHODS: In a randomized controlled parallel superiority trial COS-P is compared with TAU for parents of children referred to child mental health services (n = 186). Families are randomized 2:1 to intervention or control group, if their child is between 3 and 8 years old and scores ≥ 93d percentile on both the CBCL total score and the oppositional defiant disorder or conduct disorder subscale. Primary outcome is maternal sensitivity, secondary and exploratory outcomes include, among others, child psychiatric symptoms, parental stress and coping with children's negative emotions. Outcomes and adverse events are assessed before (T0) and after 10 weeks of treatment (T1) and 6 months later (T2). Regression analysis and /or ANOVA will be used for all outcomes. PERSPECTIVES: Targeting the parent-child relation has the potential to reduce psychiatric symptoms in children. This trial will provide valuable information if attachment-based interventions like COS-P can enhance treatment as usual in child mental health services. TRAIL REGISTRATION: ClinicalTrials.gov Identifier: NCT03578016.

PLoS ONE · clinical trial · 8 citationsread the source →

Changing network support for drinking: initial findings from the network support project.

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N = 210) recruited from the community were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM; a control condition). Analysis of drinking rates for 186 participants at 15 months indicated a significant interaction effect of Treatment x Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.

Journal of consulting and clinical psychology · randomised controlled trial · 78 citationsread the source →

Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial.

Background: Despite increasing public health concerns regarding obesity, few safe and effective drug treatments are available. Combination treatment with sustained-release naltrexone and bupropion was developed to produce complementary actions in CNS pathways regulating bodyweight. The Contrave Obesity Research I (COR-I) study assessed the effect of such treatment on bodyweight in overweight and obese participants. Methods: Men and women aged 18-65 years who had a body-mass index (BMI) of 30-45 kg/m(2) and uncomplicated obesity or BMI 27-45 kg/m(2) with dyslipidaemia or hypertension were eligible for enrolment in this randomised, double-blind, placebo-controlled, phase 3 trial undertaken at 34 sites in the USA. Participants were prescribed mild hypocaloric diet and exercise and were randomly assigned in a 1:1:1 ratio to receive sustained-release naltrexone 32 mg per day plus sustained-release bupropion 360 mg per day combined in fixed-dose tablets (also known as NB32), sustained-release naltrexone 16 mg per day plus sustained-release bupropion 360 mg per day combined in fixed-dose tablets (also known as NB16), or matching placebo twice a day, given orally for 56 weeks. The trial included a 3-week dose escalation. Randomisation was done by use of a centralised, computer-generated, web-based system and was stratified by study centre. Co-primary efficacy endpoints at 56 weeks were percentage change in bodyweight and proportion of participants who achieved a decrease in bodyweight of 5% or more. The primary analysis included all randomised participants with a baseline weight measurement and a post-baseline weight measurement while on study drug (last observation carried forward). This study is registered with ClinicalTrials.gov, number NCT00532779. Findings: 1742 participants were enrolled and randomised to double-blind treatment (naltrexone 32 mg plus bupropion, n=583; naltrexone 16 mg plus bupropion, n=578; placebo, n=581). 870 (50%) participants completed 56 weeks of treatment (n=296; n=284; n=290, respectively) and 1453 (83%) were included in the primary analysis (n=471; n=471; n=511). Mean change in bodyweight was -1.3% (SE 0.3) in the placebo group, -6.1% (0.3) in the naltrexone 32 mg plus bupropion group (p<0.0001 vs placebo) and -5.0% (0.3) in the naltrexone 16 mg plus bupropion group (p<0.0001 vs placebo). 84 (16%) participants assigned to placebo had a decrease in bodyweight of 5% or more compared with 226 (48%) assigned to naltrexone 32 mg plus bupropion (p<0.0001 vs placebo) and 186 (39%) assigned to naltrexone 16 mg plus bupropion (p<0.0001 vs placebo). The most frequent adverse event in participants assigned to combination treatment was nausea (naltrexone 32 mg plus bupropion, 171 participants [29.8%]; naltrexone 16 mg plus bupropion, 155 [27.2%]; placebo, 30 [5.3%]). Headache, constipation, dizziness, vomiting, and dry mouth were also more frequent in the naltrexone plus bupropion groups than in the placebo group. A transient increase of around 1.5 mm Hg in mean systolic and diastolic blood pressure was followed by a reduction of around 1 mm Hg below baseline in the naltrexone plus bupropion groups. Combination treatment was not associated with increased depression or suicidality events compared with placebo. Interpretation: A sustained-release combination of naltrexone plus bupropion could be a useful therapeutic option for treatment of obesity. Funding: Orexigen Therapeutics.

Lancet (London, England) · randomised controlled trial · 622 citationsread the source →

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

JAMA Network Open · cohort or longitudinal · 176 citationsread the source →

Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: the effect of emotion regulation and experiential avoidance.

Backgrounds: Dialectical behavior therapy skills training (DBT-ST) is an effective treatment for alcohol use disorder (AUD). AUD frequently co-occurs with other addictive behaviors. Objective: s: These secondary analyses of prior studies on the effectiveness of a 3-month DBT-ST program for AUD investigated pre- post-treatment changes in the severity of concurrent addictive behaviors. The study hypothesized that emotion regulation and experiential avoidance should be the key therapeutic mechanisms involved in the treatment of addictive behaviors. Methods: The research included 186 individuals (110 males; 76 females) with a primary diagnosis of AUD. Mediational models were performed considering shorter PROMIS questionnaire subscales (i.e., gambling, sex, shopping, food binging, and starvation) as dependent variables. The difficulties in emotion regulation scale and acceptance and action questionnaire-II total scores were independent and mediator variables, respectively. Results: Clinical variables significantly improved during the treatment, independent of baseline levels. Changes in emotion regulation showed significant total effects on improvements in addictive behaviors. Significant indirect effects of changes in experiential avoidance were detected considering compulsive buying and dysfunctional eating behaviors. Conclusion: The DBT-ST was a feasible treatment for several addictive behaviors frequently reported by individuals with AUD. The improvements in emotion regulation and experiential avoidance were relevant therapeutic mechanisms involved in the treatment of these conditions. Future controlled trials and follow-up studies are recommended to support the efficacy of DBT-ST as a stand-alone intervention for the treatment of different classes of addictive behaviors.

The American journal of drug and alcohol abuse · 14 citationsread the source →

Association of tiered restrictions and a second lockdown with COVID-19 deaths and hospital admissions in England: a modelling study.

Background: A second wave of COVID-19 cases in autumn, 2020, in England led to localised, tiered restrictions (so-called alert levels) and, subsequently, a second national lockdown. We examined the impact of these tiered restrictions, and alternatives for lockdown stringency, timing, and duration, on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and hospital admissions and deaths from COVID-19. Methods: We fit an age-structured mathematical model of SARS-CoV-2 transmission to data on hospital admissions and hospital bed occupancy (ISARIC4C/COVID-19 Clinical Information Network, National Health Service [NHS] England), seroprevalence (Office for National Statistics, UK Biobank, REACT-2 study), virology (REACT-1 study), and deaths (Public Health England) across the seven NHS England regions from March 1, to Oct 13, 2020. We analysed mobility (Google Community Mobility) and social contact (CoMix study) data to estimate the effect of tiered restrictions implemented in England, and of lockdowns implemented in Northern Ireland and Wales, in October, 2020, and projected epidemiological scenarios for England up to March 31, 2021. Findings: We estimated a reduction in the effective reproduction number (Rt) of 2% (95% credible interval [CrI] 0-4) for tier 2, 10% (6-14) for tier 3, 35% (30-41) for a Northern Ireland-stringency lockdown with schools closed, and 44% (37-49) for a Wales-stringency lockdown with schools closed. From Oct 1, 2020, to March 31, 2021, a projected COVID-19 epidemic without tiered restrictions or lockdown results in 280 000 (95% projection interval 274 000-287 000) hospital admissions and 58 500 (55 800-61 100) deaths. Tiered restrictions would reduce hospital admissions to 238 000 (231 000-245 000) and deaths to 48 600 (46 400-50 700). From Nov 5, 2020, a 4-week Wales-type lockdown with schools remaining open-similar to the lockdown measures announced in England in November, 2020-was projected to further reduce hospital admissions to 186 000 (179 000-193 000) and deaths to 36 800 (34 900-38 800). Closing schools was projected to further reduce hospital admissions to 157 000 (152 000-163 000) and deaths to 30 300 (29 000-31 900). A projected lockdown of greater than 4 weeks would reduce deaths but would bring diminishing returns in reducing peak pressure on hospital services. An earlier lockdown would have reduced deaths and hospitalisations in the short term, but would lead to a faster resurgence in cases after January, 2021. In a post-hoc analysis, we estimated that the second lockdown in England (Nov 5-Dec 2) reduced Rt by 22% (95% CrI 15-29), rather than the 32% (25-39) reduction estimated for a Wales-stringency lockdown with schools open. Interpretation: Lockdown measures outperform less stringent restrictions in reducing cumulative deaths. We projected that the lockdown policy announced to commence in England on Nov 5, with a similar stringency to the lockdown adopted in Wales, would reduce pressure on the health service and would be well timed to suppress deaths over the winter period, while allowing schools to remain open. Following completion of the analysis, we analysed new data from November, 2020, and found that despite similarities in policy, the second lockdown in England had a smaller impact on behaviour than did the second lockdown in Wales, resulting in more deaths and hospitalisations than we originally projected when focusing on a Wales-stringency scenario for the lockdown. Funding: Horizon 2020, UK Medical Research Council, and the National Institute for Health Research.

The Lancet. Infectious diseases · 109 citationsread the source →

Racial, Ethnic, and Sex Diversity in Academic Medical Leadership.

Importance: For the past 50 years, significant gaps have existed in gender and racial diversity across various medical specialties, despite the many benefits of a diverse physician workforce. One proposed approach to increasing diversity is top-down diversification, in which diverse leadership results in increased minority and female workforce representation. Objective: To investigate the changes in academic medical leadership diversity from 2007 to 2019 and to assess the recent leadership diversity of various specialties compared with the averages across all specialties. Design, setting, and participants: This was a cross-sectional analysis of physicians in varying academic roles in 2007, 2019, and 2020. Demographic data were collected via specialized reports from the Association of American Medical Colleges. Included were 4 primary care specialties (internal medicine, family medicine, pediatrics, obstetrics/gynecology [OB/GYN] and 4 surgical specialties (orthopedic surgery, neurologic surgery, otolaryngology [ENT], general surgery). Study participants were faculty, program directors, and chairpersons. Data were analyzed for the years 2007, 2019, and 2020. Intervention: Self-reporting of demographic information to residency programs collected via the Graduate Medical Education Track Survey. Main outcomes and measures: Proportions of each race/ethnicity and sex among cohorts of participants and comparisons between them. Results: The total number of individuals investigated included 186 210 faculty from 2019 (79 441 female [42.7%]), 6417 program directors from 2020 (2392 female [37.3%]), 1016 chairpersons from 2007 (89 female [8.8%]), and 2424 chairpersons from 2019 (435 female [17.9%]). When comparing chairperson diversity from 2007 to 2019, only internal medicine and general surgery experienced significant increases in minority (aggregate category used throughout the investigation to refer to anyone who self-identified as anything other than non-Hispanic White) representation (90% increase [11.7 percentage points, from 13.0% in 2007 to 24.7% in 2019]; P = .01 and 96% increase [13.0 percentage points, from 13.5% in 2007 to 26.5% in 2019]; P < .001), respectively; meanwhile, several specialties saw significant increases in female representation during this period (family medicine by 107.4%, P =.002; pediatrics by 83.1%, P =.006; OB/GYN by 53.2%, P =.045; orthopedic surgery by +4.1 percentage points, P =.04; general surgery by 226.9%, P =.005). In general, surgical specialties had lower leadership diversity than the average diversity of all residency programs, whereas primary care specialties had similar or increased diversity. Conclusions and relevance: Study results suggest that some specialties have made significant contributions toward bridging diversity gaps whereas others continue to lag behind. Our recommendations to improve academic medical leadership diversity include programs and institutions (1) publishing efforts and outcomes of diversity representation, (2) incorporating a representative demographic for leadership selection committees, and (3) actively promoting the importance of diversity throughout the selection process.

JAMA network open · 27 citationsread the source →

The relationship between women's attachment style and perinatal mood disturbance: implications for screening and treatment.

To investigate women's attachment style in relation to risk for pregnancy-specific distress and perinatal depression. During the 2nd trimester, 186 women were evaluated for Axis I psychiatric disorders. In the 3rd trimester they self-reported: attachment style, pregnancy experience, current life stress, and symptoms of depression and anxiety. At 4 months post partum, a sub-sample of them (n = 56) repeated the self-report questionnaires. Wariness of attachments (high on fear dimension) was associated with greater 'hassles' compared to 'uplifts' in the assessment of pregnancy (r = 0.31, p <or= 0.001) while attachment security was negatively related to this ratio (r = -0.31, p <or= 0.001). Healthy women, versus women with a psychiatric diagnosis, scored higher on security (t = (150) -3.47, p <or= 0.001) and lower on attachment fear (t = (150) -2.32, p <or= 0.05). Using multiple regression models, there was a significant main effect of fearful attachment style on prenatal depressive symptoms (beta = 1.7, p <or= 0.05), and of fearful and secure attachment styles for postpartum depression (beta = -2.88, p <or= 0.05, beta = -3.78, p <or= 0.05, respectively), even in the context of other known risk factors (in the two models, F(8, 106) = 29.33, p <or= 0.0001, F(3, 33) = 10.85, p <or= 0.0001, respectively). A hierarchical regression showed that attachment security uniquely contributed to the risk for postpartum depression, beyond depression during pregnancy (R2 change from 0.25 to 0.35). An approach to perinatal psychiatric disorders that includes psychological factors such as attachment could improve screening, and provide pregnant women with specifically-tailored psychosocial interventions focused on modifying attachment schemas.

Archives of women's mental health · 50 citationsread the source →