Search the source libraries

Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis.

Background: Depressive disorders are common in children and adolescents. Antidepressants, psychotherapies, and their combination are often used in routine clinical practice; however, available evidence on the comparative efficacy and safety of these interventions is inconclusive. Therefore, we sought to compare and rank all available treatment interventions for the acute treatment of depressive disorders in children and adolescents. Methods: We did a systematic review and network meta-analysis. We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, PsycINFO, ProQuest, CINAHL, LiLACS, international trial registries, and the websites of regulatory agencies for published and unpublished randomised controlled trials from database inception until Jan 1, 2019. We included placebo-controlled and head-to-head trials of 16 antidepressants, seven psychotherapies, and five combinations of antidepressant and psychotherapy that are used for the acute treatment of children and adolescents (≤18 years old and of both sexes) with depressive disorder diagnosed according to standard operationalised criteria. Trials recruiting participants with treatment-resistant depression, bipolar disorder, psychotic depression, treatment duration of less than 4 weeks, or an overall sample size of fewer than ten patients were excluded. We extracted data following a predefined hierarchy of outcome measures, and assessed risk of bias and certainty of evidence using validated methods. Primary outcomes were efficacy (change in depressive symptoms) and acceptability (treatment discontinuation due to any cause). We estimated summary standardised mean differences (SMDs) or odds ratios (ORs) with credible intervals (CrIs) using network meta-analysis with random effects. This study was registered with PROSPERO, number CRD42015020841. Findings: From 20 366 publications, we included 71 trials (9510 participants). Depressive disorders in most studies were moderate to severe. In terms of efficacy, fluoxetine plus cognitive behavioural therapy (CBT) was more effective than CBT alone (-0·78, 95% CrI -1·55 to -0·01) and psychodynamic therapy (-1·14, -2·20 to -0·08), but not more effective than fluoxetine alone (-0·22, -0·86 to 0·42). No pharmacotherapy alone was more effective than psychotherapy alone. Only fluoxetine plus CBT and fluoxetine were significantly more effective than pill placebo or psychological controls (SMDs ranged from -1·73 to -0·51); and only interpersonal therapy was more effective than all psychological controls (-1·37 to -0·66). Nortriptyline (SMDs ranged from 1·04 to 2·22) and waiting list (SMDs ranged from 0·67 to 2·08) were less effective than most active interventions. In terms of acceptability, nefazodone and fluoxetine were associated with fewer dropouts than sertraline, imipramine, and desipramine (ORs ranged from 0·17 to 0·50); imipramine was associated with more dropouts than pill placebo, desvenlafaxine, fluoxetine plus CBT, and vilazodone (2·51 to 5·06). Most of the results were rated as "low" to "very low" in terms of confidence of evidence according to Confidence In Network Meta-Analysis. Interpretation: Despite the scarcity of high-quality evidence, fluoxetine (alone or in combination with CBT) seems to be the best choice for the acute treatment of moderate-to-severe depressive disorder in children and adolescents. However, the effects of these interventions might vary between individuals, so patients, carers, and clinicians should carefully balance the risk-benefit profile of efficacy, acceptability, and suicide risk of all active interventions in young patients with depression on a case-by-case basis. Funding: National Key Research and Development Program of China.

The lancet. Psychiatry · systematic review · 248 citationsread the source →

Clinical impact of 20% worsening on Timed 25-foot Walk and 9-hole Peg Test in multiple sclerosis.

Introduction: Quantitative tests of motor function, like the Timed 25-foot Walk (T25FW) and 9-hole Peg Test (9HPT), are increasingly being applied as outcome measures in multiple sclerosis (MS) clinical trials. The quantitative nature of the data has a favorable impact on responsiveness, but the clinical impact of the changes is uncertain. The goal of this study was to assess whether a change on T25FW and 9HPT does indeed have a clinical meaning. This was accomplished by comparing 20% changes on these quantitative measurements to concomitant changes on the Guy's Neurological Disability Scale (GNDS), a scale which measures patient-perceived daily life disability. Methods: From a longitudinal database, we selected patients with at least two measurements of T25FW, 9HPT and GNDS with a minimal time interval of 350 days. In those patients who experienced at least a 20% change on T25FW or 9HPT, GNDS score changes were examined more closely. Results: Of 527 patients, 143 experienced a >20% worsening on their T25FW and 71 on their 9HPT, respectively. Patients with a 20% increase in T25FW or 9HPT had more GNDS worsening than patients without such an increase. GNDS worsening associated with an increase in T25FW was mainly due to an increase in perceived disability related to lower extremity function and fatigue; GNDS worsening associated with an increase in 9HPT was more diffuse with respect to domains involved. Conclusion: Worsening on T25FW or 9HPT has a clinical impact on disability, as perceived by MS patients during daily life functioning.

Multiple sclerosis (Houndmills, Basingstoke, England) · cohort or longitudinal · 138 citationsread the source →

Smoking cessation support delivered via mobile phone text messaging (txt2stop): a single-blind, randomised trial.

Background: Smoking cessation programmes delivered via mobile phone text messaging show increases in self-reported quitting in the short term. We assessed the effect of an automated smoking cessation programme delivered via mobile phone text messaging on continuous abstinence, which was biochemically verified at 6 months. Methods: In this single-blind, randomised trial, undertaken in the UK, smokers willing to make a quit attempt were randomly allocated, using an independent telephone randomisation system, to a mobile phone text messaging smoking cessation programme (txt2stop), comprising motivational messages and behavioural-change support, or to a control group that received text messages unrelated to quitting. The system automatically generated intervention or control group texts according to the allocation. Outcome assessors were masked to treatment allocation. The primary outcome was self-reported continuous smoking abstinence, biochemically verified at 6 months. All analyses were by intention to treat. This study is registered, number ISRCTN 80978588. Findings: We assessed 11,914 participants for eligibility. 5800 participants were randomised, of whom 2915 smokers were allocated to the txt2stop intervention and 2885 were allocated to the control group; eight were excluded because they were randomised more than once. Primary outcome data were available for 5524 (95%) participants. Biochemically verified continuous abstinence at 6 months was significantly increased in the txt2stop group (10·7% txt2stop vs 4·9% control, relative risk [RR] 2·20, 95% CI 1·80-2·68; p<0·0001). Similar results were obtained when participants that were lost to follow-up were treated as smokers (268 [9%] of 2911 txt2stop vs 124 [4%] of 2881 control [RR 2·14, 95% CI 1·74-2·63; p<0·0001]), and when they were excluded (268 [10%] of 2735 txt2stop vs 124 [4%] of 2789 control [2·20, 1·79-2·71; p<0·0001]). No significant heterogeneity was shown in any of the prespecified subgroups. Interpretation: The txt2stop smoking cessation programme significantly improved smoking cessation rates at 6 months and should be considered for inclusion in smoking cessation services. Funding: UK Medical Research Council, Primary Care Research Networks.

Lancet (London, England) · randomised controlled trial · 520 citationsread the source →

Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans: A Randomized Clinical Trial.

Importance: Documentation rates of patients' medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to planning in busy primary care settings. Objective: To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation. Design, setting, and participants: This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year. Interventions: Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements. Main outcomes and measures: The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician. Results: The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 [95% CI, 1.03-2.51]; P = .04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up). Conclusions and relevance: Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources. Trial registration: clinicaltrials.gov Identifier: NCT01550731.

JAMA internal medicine · randomised controlled trial · 181 citationsread the source →

mHealth Interventions To Support Self-Management In HIV: A Systematic Review.

Background: Self-management is an important aspect of long-term HIV treatment. Mobile technologies offer the potential to efficiently deliver interventions to facilitate HIV self-management. The last comprehensive review of such mHealth interventions was conducted in 2011. Given the rapidly evolving field, a need was identified for an updated review of the literature. Objective: The study aimed to describe and evaluate current evidence-based mHealth interventions to support self-management in HIV. Method: Eight online databases (Medline, Scopus, Embase, PsycINFO, Cochrane, Global Health CAB, IEEE explore, Web of Science) were systematically searched for papers describing and evaluating mHealth HIV self-management interventions. Reference lists of relevant papers were also searched. Data on intervention content and evaluation methodology were extracted and appraised by two researchers. Results: 41 papers were identified evaluating 28 interventions. The majority of these interventions (n=20, 71%) had a single focus of either improving adherence (n=16), increasing engagement in care (n=3) or supporting smoking cessation (n=1), while just 8 (29%) were more complex self-management interventions, targeting a range of health-related behaviours. Interventions were predominantly delivered through SMS messaging. They significantly impacted on a range of outcomes including adherence, viral load, mental health and social support. Conclusion: Since the last major review of mHealth interventions in HIV, there has been a shift from exploratory acceptability/feasibility studies to impact evaluations. While overall the interventions impacted on a range of outcomes, they were generally limited in scope, failing to encompass many functions identified as desirable by people living with HIV. Participant incentives may limit the generalizability of findings.

The open AIDS journal · review · 97 citationsread the source →

The relationship between self-reported interoception and anxiety: A systematic review and meta-analysis.

Interoception, the processing of internal bodily sensations, is associated with various mental health conditions. In particular, anxiety is often considered to be the prototypical interoceptive disorder. However, empirical evidence is mixed, with meta-analytic work reporting no relationship between anxiety and cardiac interoceptive accuracy. Less explored, however, are the mixed results relating to anxiety and self-reported interoception. This meta-analysis of 71 studies explored the relationship between self-report measures of interoception and anxiety. Across 12 measures (20 subscales), anxiety was associated with increased negative evaluations of, frequency of, and sensitivity to, bodily signals. Anxiety was also associated with greater (negative) attention to bodily signals, and difficulties describing bodily signals and emotions. However, anxiety was not associated with the use of bodily signals to inform emotions (e.g., noticing emotionally induced bodily signals). Results are discussed considering the overlap between anxiety and interoception questionnaires, the lack of specificity of certain measures, and the potential confound of individual differences in questionnaire interpretation. We also discuss limitations of anxiety measures and the clinical relevance of findings.

Neuroscience and biobehavioral reviews · meta-analysis · 27 citationsread the source →

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more).

Background: Prelabour rupture of membranes (PROM) at term is managed expectantly or by planned early birth. It is not clear if waiting for birth to occur spontaneously is better than intervening, e.g. by inducing labour. Objectives: The objective of this review is to assess the effects of planned early birth (immediate intervention or intervention within 24 hours) when compared with expectant management (no planned intervention within 24 hours) for women with term PROM on maternal, fetal and neonatal outcomes. Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (9 September 2016) and reference lists of retrieved studies. Selection criteria: Randomised or quasi-randomised controlled trials of planned early birth compared with expectant management (either in hospital or at home) in women with PROM at 37 weeks' gestation or later. Data collection and analysis: Two review authors independently assessed trials for inclusion, extracted the data, and assessed risk of bias of the included studies. Data were checked for accuracy. Main results: Twenty-three trials involving 8615 women and their babies were included in the update of this review. Ten trials assessed intravenous oxytocin; 12 trials assessed prostaglandins (six trials in the form of vaginal prostaglandin E2 and six as oral, sublingual or vaginal misoprostol); and one trial each assessed Caulophyllum and acupuncture. Overall, three trials were judged to be at low risk of bias, while the other 20 were at unclear or high risk of bias. Primary outcomes: women who had planned early birth were at a reduced risk of maternal infectious morbidity (chorioamnionitis and/or endometritis) than women who had expectant management following term prelabour rupture of membranes (average risk ratio (RR) 0.49; 95% confidence interval (CI) 0.33 to 0.72; eight trials, 6864 women; Tau² = 0.19; I² = 72%; low-quality evidence), and their neonates were less likely to have definite or probable early-onset neonatal sepsis (RR 0.73; 95% CI 0.58 to 0.92; 16 trials, 7314 infants;low-quality evidence). No clear differences between the planned early birth and expectant management groups were seen for the risk of caesarean section (average RR 0.84; 95% CI 0.69 to 1.04; 23 trials, 8576 women; Tau² = 0.10; I² = 55%; low-quality evidence); serious maternal morbidity or mortality (no events; three trials; 425 women; very low-quality evidence); definite early-onset neonatal sepsis (RR 0.57; 95% CI 0.24 to 1.33; six trials, 1303 infants; very low-quality evidence); or perinatal mortality (RR 0.47; 95% CI 0.13 to 1.66; eight trials, 6392 infants; moderate-quality evidence). Secondary outcomes: women who had a planned early birth were at a reduced risk of chorioamnionitis (average RR 0.55; 95% CI 0.37 to 0.82; eight trials, 6874 women; Tau² = 0.19; I² = 73%), and postpartum septicaemia (RR 0.26; 95% CI 0.07 to 0.96; three trials, 263 women), and their neonates were less likely to receive antibiotics (average RR 0.61; 95% CI 0.44 to 0.84; 10 trials, 6427 infants; Tau² = 0.06; I² = 32%). Women in the planned early birth group were more likely to have their labour induced (average RR 3.41; 95% CI 2.87 to 4.06; 12 trials, 6945 women; Tau² = 0.05; I² = 71%), had a shorter time from rupture of membranes to birth (mean difference (MD) -10.10 hours; 95% CI -12.15 to -8.06; nine trials, 1484 women; Tau² = 5.81; I² = 60%), and their neonates had lower birthweights (MD -79.25 g; 95% CI -124.96 to -33.55; five trials, 1043 infants). Women who had a planned early birth had a shorter length of hospitalisation (MD -0.79 days; 95% CI -1.20 to -0.38; two trials, 748 women; Tau² = 0.05; I² = 59%), and their neonates were less likely to be admitted to the neonatal special or intensive care unit (RR 0.75; 95% CI 0.66 to 0.85; eight trials, 6179 infants), and had a shorter duration of hospital (-11.00 hours; 95% CI -21.96 to -0.04; one trial, 182 infants) or special or intensive care unit stay (RR 0.72; 95% CI 0.61 to 0.85; four trials, 5691 infants). Women in the planned early birth group had more positive experiences compared with women in the expectant management group. No clear differences between groups were observed for endometritis; postpartum pyrexia; postpartum antibiotic usage; caesarean for fetal distress; operative vaginal birth; uterine rupture; epidural analgesia; postpartum haemorrhage; adverse effects; cord prolapse; stillbirth; neonatal mortality; pneumonia; Apgar score less than seven at five minutes; use of mechanical ventilation; or abnormality on cerebral ultrasound (no events).None of the trials reported on breastfeeding; postnatal depression; gestational age at birth; meningitis; respiratory distress syndrome; necrotising enterocolitis; neonatal encephalopathy; or disability at childhood follow-up. In subgroup analyses, there were no clear patterns of differential effects for method of induction, parity, use of maternal antibiotic prophylaxis, or digital vaginal examination. Results of the sensitivity analyses based on trial quality were consistent with those of the main analysis, except for definite or probable early-onset neonatal sepsis where no clear difference was observed. Authors' conclusions: There is low quality evidence to suggest that planned early birth (with induction methods such as oxytocin or prostaglandins) reduces the risk of maternal infectious morbidity compared with expectant management for PROM at 37 weeks' gestation or later, without an apparent increased risk of caesarean section. Evidence was mainly downgraded due to the majority of studies contributing data having some serious design limitations, and for most outcomes estimates were imprecise. Although the 23 included trials in this review involved a large number of women and babies, the quality of the trials and evidence was not high overall, and there was limited reporting for a number of important outcomes. Thus further evidence assessing the benefits or harms of planned early birth compared with expectant management, considering maternal, fetal, neonatal and longer-term childhood outcomes, and the use of health services, would be valuable. Any future trials should be adequately designed and powered to evaluate the effects on short- and long-term outcomes. Standardisation of outcomes and their definitions, including for the assessment of maternal and neonatal infection, would be beneficial.

The Cochrane database of systematic reviews · meta-analysis · 75 citationsread the source →

Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project.

Objective: The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization. Methods: All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital. Results: Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service. Conclusions: A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.

Pediatrics · cohort or longitudinal · 30 citationsread the source →

Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data.

Background: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. Methods: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. Findings: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. Interpretation: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. Funding: Japan Society for the Promotion of Science.

The lancet. Psychiatry · systematic review · 158 citationsread the source →

Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis.

Background: Cancer survival has improved in the past 20 years, affecting the long-term risk of mood disorders. We assessed whether depression and anxiety are more common in long-term survivors of cancer compared with their spouses and with healthy controls. Methods: We systematically searched Medline, PsycINFO, Embase, Science Direct, Ingenta Select, Ovid, and Wiley Interscience for reports about the prevalence of mood disorders in patients diagnosed with cancer at least 2 years previously. We also searched the records of the International Psycho-oncology Society and for reports that cited relevant references. Three investigators independently extracted primary data. We did a random-effects meta-analysis of the prevalences of depression and anxiety in cancer patients compared with spouses and healthy controls. Findings: Our search returned 144 results, 43 were included in the main analysis: for comparisons with healthy controls, 16 assessed depression and ten assessed anxiety; of the comparisons with spouses, 12 assessed depression and five assessed anxiety. The prevalence of depression was 11·6% (95% CI 7·7-16·2) in the pooled sample of 51 381 cancer survivors and 10·2% (8·0-12·6) in 217 630 healthy controls (pooled relative risk [RR] 1·11, 95% CI 0·96-1·27; p=0·17). The prevalence of anxiety was 17·9% (95% CI 12·8-23·6) in 48 964 cancer survivors and 13·9% (9·8-18·5) in 226 467 healthy controls (RR 1·27, 95% CI 1·08-1·50; p=0·0039). Neither the prevalence of depression (26·7% vs 26·3%; RR 1·01, 95% CI 0·86-1·20; p=0·88) nor the prevalence of anxiety (28·0% vs 40·1%; RR 0·71, 95% CI 0·44-1·14; p=0·16) differed significantly between cancer patients and their spouses. Interpretation: Our findings suggest that anxiety, rather than depression, is most likely to be a problem in long-term cancer survivors and spouses compared with healthy controls. Efforts should be made to improve recognition and treatment of anxiety in long-term cancer survivors and their spouses. Funding: None.

The Lancet. Oncology · meta-analysis · 536 citationsread the source →

Iowa gambling task in schizophrenia: a review and new data in patients with schizophrenia and co-occurring cannabis use disorders.

Background: We reviewed previous studies comparing schizophrenia patients and healthy subjects for performance on the Iowa Gambling Task (IGT) (a laboratory task designed to measure emotion-based decision-making), and found mixed results. We hypothesize that deficits in IGT performance in schizophrenia may be more specifically related to concurrent substance use disorders. To test this hypothesis, we compared schizophrenia patients with (SCZ((+))) or without (SCZ((-))) cannabis use disorders, to healthy subjects, on measures of cognition and IGT performance. Methods: A comprehensive battery of cognitive tests and the IGT were administered to three groups of subjects: (1) 13 subjects with DSM-IV diagnosis of schizophrenia and no concurrent substance use disorders (mean age: 28+/-12 (SD); 54% males); (2) 14 subjects with schizophrenia and concurrent cannabis use disorders (mean age: 29+/-9 (SD); 71% males); and (3) 20 healthy subjects (mean age 33+/-10 (SD); 60% males). Results: Compared to the healthy group, both schizophrenia groups were cognitively more impaired, and did worse on IGT performance. There were no differences between SCZ((+)) and SCZ((-)) patients on most of the cognitive tests, and IGT performance. Conclusions: Schizophrenia patients show widespread impairments in several cognitive domains and emotion-based decision-making. These results are consistent with the evidence that schizophrenia reflects a dorsolateral and orbitofrontal/ventromedial prefrontal cortex dysfunction. More intriguing, it appears that the concurrent abuse of cannabis has no compounding effects on cognition, as well as emotion/affect-based decision-making.

Schizophrenia research · 140 citationsread the source →

The effects of volunteering on loneliness among lonely older adults: the HEAL-HOA dual randomised controlled trial.

Background: Previous randomised controlled trials have largely relied on self-reported volunteer work to assess the effects of volunteering and have rarely provided structured volunteering activities during the intervention period. The present study aimed to investigate the effects of social volunteering work over 12 months on loneliness among older adults during the COVID-19 pandemic. Methods: A dual randomised controlled trial was done in Hong Kong to investigate the long-term effects of telephone-delivered psychosocial interventions by older Chinese volunteers who were screened as lonely, for older adult recipients who had low income, lived alone, felt lonely, and were digitally excluded. Participants were included if they were aged 50-70 years; had provided consent to be trained and serve as a volunteer for at least 2 h per week for 6 months; had at least 3 years of secondary school education; had no severe self-reported physical, mental, or cognitive health problems; were not working full or part-time; had engaged in formal volunteering fewer than four times within the past year; and were lonely (ie, had a score of at least 6 on the three-item UCLA Loneliness Scale). Participants were allocated into either the volunteering or control group (psychoeducation programme) using a random number method. The details of group allocation were concealed as the research assistant responsible for randomisation was different to the research assistants responsible for recruitment and assessments (who were masked to the condition). Following a 6-week training, the volunteers delivered a psychosocial intervention to older intervention recipients for 6 months. The primary outcome was loneliness measured with the 20-item UCLA Loneliness Scale and the De Jong Gierveld (DJG) Loneliness Scales at 6 months and 12 months. Assessments were performed before training (baseline; T1), at 6 months (T2), and at 12 months after training (T3). The intention-to-treat principle was used to compare the effects of volunteering between the two groups. The trial was registered in the Clinical Trials Registry of the University of Hong Kong Clinical Trials Centre (HKUCTR-2929). This trial has completed. Findings: Between May 3, 2021, and Oct 6, 2022, a total of 375 individuals were recruited to the trial, including 84 males (22%) and 291 females (78%). 185 were randomly assigned to the volunteering group (56 to deliver a mindfulness intervention, 65 to deliver a behavioural activation intervention, and 64 to deliver a befriending intervention) and 190 were assigned to the control group. 311 (83%) of 375 participants were 60 years or older (median 64 years [SD 4·86]). Participants in the volunteering group reported a significantly lower level of loneliness at T2 (dppc2 ranged from -0·41 to -0·70) compared with T1 than participants in the control condition. There was a significant decrease in loneliness measured using the UCLA Loneliness Scale at T2 in the volunteering group but such a decline was not shown in the control group (condition × time interaction, estimate 0·19 [95% CI 0·08 to 0·29], p=0·00058, dppc2=-0·41). Similarly, when measured with the DJG Loneliness Scale, there was a significantly greater decrease in loneliness in the volunteering group compared with the control group at T2, including a medium to large effect size on total DJG scores (estimate 1·34 [95% CI 0·83 to 1·84], p<0·0001, dppc2=-0·70) and a medium effect size on emotional (estimate 0·63 [0·35 to 0·90], p<0·0001, dppc2=-0·59) and social subscales (estimate 0·71 [95% CI 0·37 to 1·05], p<0·0001, dppc2=-0·58). Although most of the positive effects of volunteering were not sustained at T3, the volunteers who continued to volunteer for more than 2 h per week at T3 reported lower levels of loneliness than those who did not maintain volunteering. Interpretation: This randomised controlled trial demonstrates the beneficial effect of volunteering on reducing loneliness in older adults who feel lonely, and that this benefit can be maintained through continued participation in voluntary work. Future intervention programmes should strengthen older adults' commitment to volunteer. Funding: Research Grants Committee of the Hong Kong Special Administrative Region, China.

The lancet. Healthy longevity · randomised controlled trial · 16 citationsread the source →

Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder: A Randomized Clinical Trial.

Importance: Major depressive disorder (MDD) is a substantial public health burden, but current treatments have limited effectiveness and adherence. Recent evidence suggests that 1 or 2 administrations of psilocybin with psychological support produces antidepressant effects in patients with cancer and in those with treatment-resistant depression. Objective: To investigate the effect of psilocybin therapy in patients with MDD. Design, setting, and participants: This randomized, waiting list-controlled clinical trial was conducted at the Center for Psychedelic and Consciousness Research at Johns Hopkins Bayview Medical Center in Baltimore, Maryland. Adults aged 21 to 75 years with an MDD diagnosis, not currently using antidepressant medications, and without histories of psychotic disorder, serious suicide attempt, or hospitalization were eligible to participate. Enrollment occurred between August 2017 and April 2019, and the 4-week primary outcome assessments were completed in July 2019. A total of 27 participants were randomized to an immediate treatment condition group (n = 15) or delayed treatment condition group (waiting list control condition; n = 12). Data analysis was conducted from July 1, 2019, to July 31, 2020, and included participants who completed the intervention (evaluable population). Interventions: Two psilocybin sessions (session 1: 20 mg/70 kg; session 2: 30 mg/70 kg) were given (administered in opaque gelatin capsules with approximately 100 mL of water) in the context of supportive psychotherapy (approximately 11 hours). Participants were randomized to begin treatment immediately or after an 8-week delay. Main outcomes and measures: The primary outcome, depression severity was assessed with the GRID-Hamilton Depression Rating Scale (GRID-HAMD) scores at baseline (score of ≥17 required for enrollment) and weeks 5 and 8 after enrollment for the delayed treatment group, which corresponded to weeks 1 and 4 after the intervention for the immediate treatment group. Secondary outcomes included the Quick Inventory of Depressive Symptomatology-Self Rated (QIDS-SR). Results: Of the randomized participants, 24 of 27 (89%) completed the intervention and the week 1 and week 4 postsession assessments. This population had a mean (SD) age of 39.8 (12.2) years, was composed of 16 women (67%), and had a mean (SD) baseline GRID-HAMD score of 22.8 (3.9). The mean (SD) GRID-HAMD scores at weeks 1 and 4 (8.0 [7.1] and 8.5 [5.7]) in the immediate treatment group were statistically significantly lower than the scores at the comparable time points of weeks 5 and 8 (23.8 [5.4] and 23.5 [6.0]) in the delayed treatment group. The effect sizes were large at week 5 (Cohen d = 2.5; 95% CI, 1.4-3.5; P < .001) and week 8 (Cohen d = 2.6; 95% CI, 1.5-3.7; P < .001). The QIDS-SR documented a rapid decrease in mean (SD) depression score from baseline to day 1 after session 1 (16.7 [3.5] vs 6.3 [4.4]; Cohen d = 2.6; 95% CI, 1.8-3.5; P < .001), which remained statistically significantly reduced through the week 4 follow-up (6.0 [5.7]; Cohen d = 2.3; 95% CI, 1.5-3.0; P < .001). In the overall sample, 17 participants (71%) at week 1 and 17 (71%) at week 4 had a clinically significant response to the intervention (≥50% reduction in GRID-HAMD score), and 14 participants (58%) at week 1 and 13 participants (54%) at week 4 were in remission (≤7 GRID-HAMD score). Conclusions and relevance: Findings suggest that psilocybin with therapy is efficacious in treating MDD, thus extending the results of previous studies of this intervention in patients with cancer and depression and of a nonrandomized study in patients with treatment-resistant depression. Trial registration: ClinicalTrials.gov Identifier: NCT03181529.

JAMA psychiatry · randomised controlled trial · 900 citationsread the source →

Telehealth Home Monitoring and Postcardiac Surgery for Congenital Heart Disease.

Objectives: To test the effect of a 4-month telehealth home monitoring program (REACH), layered on usual care, on postdischarge outcomes in parents of infants recovering from cardiac surgery and their infants. Methods: Randomized trial of infants discharged from the hospital after cardiac surgery for congenital heart disease. Consecutive infants with complex congenital heart disease undergoing cardiac surgery within 21 days of life were enrolled at 3 university-affiliated pediatric cardiac centers. Results: From 2012 to 2016, 219 parent-infant dyads were enrolled; 109 were randomly assigned to the intervention group and 110 to the control group. At 4 months postdischarge, parenting stress was not significantly different between groups (total Parenting Stress Index in the intervention group was 220 and in the control group was 215; P = .61). The percentages of parents who met posttraumatic stress disorder (PTSD) criteria and parent quality of life inventory scores were also not significantly different between the 2 groups (PTSD in the intervention group was 18% and was 18% in the control group; P =.56; the mean Ulm Quality of Life Inventory for Parents in the intervention group was 71 andwas 70 in the control group; P = .88). Infant growth in both groups was suboptimal (the mean weight-for-age z scores were -1.1 in the intervention group and -1.2 in the control group; P = .56), and more infants in the intervention group were readmitted to the hospital (66% in the intervention group versus 57% in the control group; P < .001). Conclusions: When added to usual care, the REACH intervention was not associated with an improvement in parent or infant outcomes. Four months after neonatal heart surgery, ∼20% of parents demonstrate PTSD symptoms. Suboptimal infant growth and hospital readmissions were common.

Pediatrics · randomised controlled trial · 26 citationsread the source →

A Comprehensive Lifestyle Peer Group-Based Intervention on Cardiovascular Risk Factors: The Randomized Controlled Fifty-Fifty Program.

Background: Cardiovascular diseases stem from modifiable risk factors. Peer support is a proven strategy for many chronic illnesses. Randomized trials assessing the efficacy of this strategy for global cardiovascular risk factor modification are lacking. Objectives: This study assessed the hypothesis that a peer group strategy would help improve healthy behaviors in individuals with cardiovascular risk factors. Methods: A total of 543 adults 25 to 50 years of age with at least 1 risk factor were recruited; risk factors included hypertension (20%), overweight (82%), smoking (31%), and physical inactivity (81%). Subjects were randomized 1:1 to a peer group-based intervention group (IG) or a self-management control group (CG) for 12 months. Peer-elected leaders moderated monthly meetings involving role-play, brainstorming, and activities to address emotions, diet, and exercise. The primary outcome was mean change in a composite score related to blood pressure, exercise, weight, alimentation, and tobacco (Fuster-BEWAT score, 0 to 15). Multilevel models with municipality as a cluster variable were applied to assess differences between groups. Results: Participants' mean age was 42 ± 6 years, 71% were female, and they had a mean baseline Fuster-BEWAT score of 8.42 ± 2.35. After 1 year, the mean scores were significantly higher in the IG (n = 277) than in the CG (n = 266) (IG mean score: 8.84; 95% confidence interval (CI): 8.37 to 9.32; CG mean score: 8.17; 95% CI: 7.55 to 8.79; p = 0.02). The increase in the overall score was significantly larger in the IG compared with the CG (difference: 0.75; 95% CI: 0.32 to 1.18; p = 0.02). The mean improvement in the individual components was uniformly greater in the IG, with a significant difference for the tobacco component. Conclusions: The peer group intervention had beneficial effects on cardiovascular risk factors, with significant improvements in the overall score and specifically on tobacco cessation. A follow-up assessment will be performed 1 year after the final assessment reported here to determine long-term sustainability of the improvements associated with peer group intervention. (Peer-Group-Based Intervention Program [Fifty-Fifty]; NCT02367963).

Journal of the American College of Cardiology · randomised controlled trial · 79 citationsread the source →

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015).

Background: Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning. Methods: The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps. Results: We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials. Conclusions: Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Journal of general internal medicine · review · 55 citationsread the source →

Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration).

Background: Both young and advanced maternal age is associated with adverse birth and child outcomes. Few studies have examined these associations in low-income and middle-income countries (LMICs) and none have studied adult outcomes in the offspring. We aimed to examine both child and adult outcomes in five LMICs. Methods: In this prospective study, we pooled data from COHORTS (Consortium for Health Orientated Research in Transitioning Societies)-a collaboration of five birth cohorts from LMICs (Brazil, Guatemala, India, the Philippines, and South Africa), in which mothers were recruited before or during pregnancy, and the children followed up to adulthood. We examined associations between maternal age and offspring birthweight, gestational age at birth, height-for-age and weight-for-height Z scores in childhood, attained schooling, and adult height, body composition (body-mass index, waist circumference, fat, and lean mass), and cardiometabolic risk factors (blood pressure and fasting plasma glucose concentration), along with binary variables derived from these. Analyses were unadjusted and adjusted for maternal socioeconomic status, height and parity, and breastfeeding duration. Findings: We obtained data for 22 188 mothers from the five cohorts, enrolment into which took place at various times between 1969 and 1989. Data for maternal age and at least one outcome were available for 19 403 offspring (87%). In unadjusted analyses, younger (≤19 years) and older (≥35 years) maternal age were associated with lower birthweight, gestational age, child nutritional status, and schooling. After adjustment, associations with younger maternal age remained for low birthweight (odds ratio [OR] 1·18 (95% CI 1·02-1·36)], preterm birth (1·26 [1·03-1·53]), 2-year stunting (1·46 [1·25-1·70]), and failure to complete secondary schooling (1·38 [1·18-1·62]) compared with mothers aged 20-24 years. After adjustment, older maternal age remained associated with increased risk of preterm birth (OR 1·33 [95% CI 1·05-1·67]), but children of older mothers had less 2-year stunting (0·64 [0·54-0·77]) and failure to complete secondary schooling (0·59 [0·48-0·71]) than did those with mothers aged 20-24 years. Offspring of both younger and older mothers had higher adult fasting glucose concentrations (roughly 0·05 mmol/L). Interpretation: Children of young mothers in LMICs are disadvantaged at birth and in childhood nutrition and schooling. Efforts to prevent early childbearing should be strengthened. After adjustment for confounders, children of older mothers have advantages in nutritional status and schooling. Extremes of maternal age could be associated with disturbed offspring glucose metabolism. Funding: Wellcome Trust and the Bill & Melinda Gates Foundation.

The Lancet. Global health · 316 citationsread the source →

Functional connectivity magnetic resonance imaging classification of autism.

Group differences in resting state functional magnetic resonance imaging connectivity between individuals with autism and typically developing controls have been widely replicated for a small number of discrete brain regions, yet the whole-brain distribution of connectivity abnormalities in autism is not well characterized. It is also unclear whether functional connectivity is sufficiently robust to be used as a diagnostic or prognostic metric in individual patients with autism. We obtained pairwise functional connectivity measurements from a lattice of 7266 regions of interest covering the entire grey matter (26.4 million connections) in a well-characterized set of 40 male adolescents and young adults with autism and 40 age-, sex- and IQ-matched typically developing subjects. A single resting state blood oxygen level-dependent scan of 8 min was used for the classification in each subject. A leave-one-out classifier successfully distinguished autism from control subjects with 83% sensitivity and 75% specificity for a total accuracy of 79% (P = 1.1 × 10(-7)). In subjects <20 years of age, the classifier performed at 89% accuracy (P = 5.4 × 10(-7)). In a replication dataset consisting of 21 individuals from six families with both affected and unaffected siblings, the classifier performed at 71% accuracy (91% accuracy for subjects <20 years of age). Classification scores in subjects with autism were significantly correlated with the Social Responsiveness Scale (P = 0.05), verbal IQ (P = 0.02) and the Autism Diagnostic Observation Schedule-Generic's combined social and communication subscores (P = 0.05). An analysis of informative connections demonstrated that region of interest pairs with strongest correlation values were most abnormal in autism. Negatively correlated region of interest pairs showed higher correlation in autism (less anticorrelation), possibly representing weaker inhibitory connections, particularly for long connections (Euclidean distance >10 cm). Brain regions showing greatest differences included regions of the default mode network, superior parietal lobule, fusiform gyrus and anterior insula. Overall, classification accuracy was better for younger subjects, with differences between autism and control subjects diminishing after 19 years of age. Classification scores of unaffected siblings of individuals with autism were more similar to those of the control subjects than to those of the subjects with autism. These findings indicate feasibility of a functional connectivity magnetic resonance imaging diagnostic assay for autism.

Brain : a journal of neurology · 284 citationsread the source →

Effect of immunotherapy time-of-day infusion on overall survival among patients with advanced melanoma in the USA (MEMOIR): a propensity score-matched analysis of a single-centre, longitudinal study.

Background: The dependence of the adaptive immune system on circadian rhythm is an emerging field of study with potential therapeutic implications. We aimed to determine whether specific time-of-day patterns of immune checkpoint inhibitor infusions might alter melanoma treatment efficacy. Methods: Melanoma Outcomes Following Immunotherapy (MEMOIR) is a longitudinal study of all patients with melanoma who received ipilimumab, nivolumab, or pembrolizumab, or a combination of these at a single tertiary cancer centre (Winship Cancer Institute of Emory University, Atlanta, GA, USA). For this analysis, we collected deidentified participant-level data from the MEMOIR database for adults (age ≥18 years) diagnosed with stage IV melanoma between 2012 and 2020. Those who received fewer than four infusions were excluded. Standard of care doses were used, with modifications at the treating physicians' discretion. The primary outcome was overall survival, defined as death from any cause and indexed from date of first infusion of immune checkpoint inhibitor. We calculated the association between overall survival and proportion of infusions of immune checkpoint inhibitors received after 1630 h (a composite time cutoff derived from seminal studies of the immune-circadian rhythm to represent onset of evening) using Cox regression and propensity score-matching on age, Eastern Cooperative Oncology Group performance status, serum lactate dehydrogenase concentration, and receipt of corticosteroids and radiotherapy. Treatment-related adverse events that led to change or discontinuation of immune checkpoint inhibitors were also assessed. Findings: Between Jan 1, 2012, and Dec 31, 2020, 481 patients with melanoma received treatment with immune checkpoint inhibitors at the study centre, of whom 299 had stage IV disease and were included in this study; median follow-up was 27 months (IQR 14 to 47). In the complete unmatched sample, 102 (34%) patients were female and 197 (66%) were male, with a median age of 61 years (IQR 51 to 72). Every additional 20% of infusions of immune checkpoint inhibitors received after 1630 h (among all infusions received by a patient) conferred an overall survival hazard ratio (HR) of 1·31 (95% CI 1·00 to 1·71; p=0·046). A propensity score-matched analysis of patients who did (n=73) and did not (n=73) receive at least 20% of their infusions of immune checkpoint inhibitors after 1630 h (54 [37%] of 146 patients were women and 92 [63%] were men, with a median age of 58 years [IQR 48 to 68]) showed that having at least 20% of infusions in the evening was associated with shorter overall survival (median 4·8 years [95% CI 3·9 to not estimable] vs not reached; HR 2·04 [1·04 to 4·00; p=0·038]). This result remained robust to multivariable proportional hazards adjustment with (HR 1·80 [1·08 to 2·98; p=0·023]) and without (2·16 [1·10 to 4·25; p=0·025]) inclusion of the complete unmatched study sample. The most common adverse events were colitis (54 [18%] of 299 patients), hepatitis (27 [9%]), and hypophysitis (15 [5%]), and there were no treatment-related deaths. Interpretation: Our findings are in line with an increasing body of evidence that adaptive immune responses are less robust when initially stimulated in the evening than if stimulated in the daytime. Although prospective studies of the timing of immune checkpoint inhibitor infusions are warranted, efforts towards scheduling infusions before mid-afternoon could be considered in the multidisciplinary management of advanced melanoma. Funding: National Institutes of Health, American Society for Radiation Oncology and Melanoma Research Alliance, and Winship Cancer Institute.

The Lancet. Oncology · clinical trial · 146 citationsread the source →

Randomized controlled trial of once-per-week intermittent fasting for health improvement: the WONDERFUL trial.

Aims: Low-density lipoprotein cholesterol (LDL-C) predicts heart disease onset and may be reduced by intermittent fasting. Some studies, though, reported that fasting increased LDL-C; however, no study evaluated LDL-C as the primary endpoint. This randomized controlled trial evaluated the effect of low-frequency intermittent fasting on LDL-C and other biomarkers. Methods and results: Adults aged 21-70 years were enrolled who were not taking a statin, had modestly elevated LDL-C, had ≥1 metabolic syndrome feature or type 2 diabetes, and were not taking anti-diabetic medication (N = 103). Water-only 24-h fasting was performed twice weekly for 4 weeks and then once weekly for 22 weeks; controls ate ad libitum. The primary outcome was 26-week LDL-C change score. Secondary outcomes (requiring P ≤ 0.01) were 26-week changes in homeostatic model assessment of insulin resistance (HOMA-IR), Metabolic Syndrome Score (MSS), brain-derived neurotrophic factor (BDNF), and MicroCog general cognitive proficiency index (GCPi). Intermittent fasting (n = 50) and control (n = 53) subjects were, respectively, aged 49.3 ± 12.0 and 47.0 ± 9.8 years, predominantly female (66.0% and 67.9%), and overweight (103 ± 24 and 100 ± 21 kg) and had modest LDL-C elevation (124 ± 19 and 128 ± 20 mg/dL). Drop-outs (n = 12 fasting, n = 20 control) provided an evaluable sample of n = 71 (n = 38 fasting, n = 33 control). Intermittent fasting did not change LDL-C (0.2 ± 16.7 mg/dL) vs. control (2.5 ± 19.4 mg/dL; P = 0.59), but it improved HOMA-IR (-0.75 ± 0.79 vs. -0.10 ± 1.06; P = 0.004) and MSS (-0.34 ± 4.72 vs. 0.31 ± 1.98, P = 0.006). BDNF (P = 0.58), GCPi (P = 0.17), and weight (-1.7 ± 4.7 kg vs. 0.2 ± 3.5 kg, P = 0.06) were unchanged. Conclusions: A low-frequency intermittent fasting regimen did not reduce LDL-C or improve cognitive function but significantly reduced both HOMA-IR and MSS. Trial registration: clinicaltrials.gov, NCT02770313.

European heart journal open · 30 citationsread the source →

Baseline comprehensive geriatric assessment is associated with toxicity and survival in elderly metastatic breast cancer patients receiving single-agent chemotherapy: results from the OMEGA study of the Dutch breast cancer trialists' group.

Aim: To evaluate the association between baseline comprehensive geriatric assessment (CGA) or the Groningen Frailty Indicator (GFI) and toxicity in elderly metastatic breast cancer (MBC) patients treated with first-line palliative chemotherapy. Patients and methods: MBC patients (≥65 years) were randomized between pegylated liposomal doxorubicine or capecitabine. CGA included instrumental activities of daily living (IADL), cognition using the mini-mental state examination (MMSE), mood using the geriatric depression scale (GDS), comorbidity using the Charlson index, polypharmacy and nutritional status using the body mass index. Frailty on CGA was defined as one or more of the following: IADL ≤ 13, MMSE ≤ 23, GDS ≥ 5, BMI ≤ 20, ≥5 medications or Charlson ≥2. The cut-off for frailty on the GFI was ≥4. Results: Of the randomized 78 patients (median age 75.5 years, range 65.8-86.8 years), 73 were evaluable for CGA; 52 (71%) had one or more geriatric conditions. Grade 3-4 chemotherapy-related toxicity was experienced by 19% of patients without geriatric conditions compared to 56% of patients with two geriatric conditions and 80% of those with three or more (p = 0.002). Polypharmacy was the only individual factor significantly associated with toxicity (p = 0.001). GFI had a sensitivity of 69% and a specificity of 76% for frailty on CGA, and was not significantly associated with survival or toxicity. Conclusion: In this study of elderly patients with MBC, the number of geriatric conditions correlated with grade 3-4 chemotherapy-related toxicity. Therefore, in elderly patients for whom chemotherapy is being considered, a CGA could be a useful addition to the decision-making process.

Breast (Edinburgh, Scotland) · randomised controlled trial · 91 citationsread the source →

Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial.

Importance: Tadalafil is used to treat erectile dysfunction after prostate cancer treatment, but its role as a preventive agent is undefined. Objectives: To determine primarily whether tadalafil preserved erectile function in men treated with radiotherapy for prostate cancer, and secondarily to determine whether participant- or partner-reported overall sexual function and sexual and marital satisfaction were affected. Design, setting, and participants: Stratified, placebo-controlled, double-blind, parallel-group study with 1:1 randomization at 76 community-based and tertiary medical sites in the United States and Canada. Two hundred forty-two participants with intact erectile function scheduled to receive radiotherapy for prostate cancer were recruited between November 2009 and February 2012 with follow-up through March 2013. Interventions: One hundred twenty-one participants were assigned 5 mg of tadalafil daily and 121 were assigned placebo for 24 weeks starting with external radiotherapy (63%) or brachytherapy (37%). Participant-reported International Index of Erectile Function response before radiotherapy and at weeks 2 and 4, between weeks 20 and 24, between weeks 28 and 30, and 1 year thereafter. Participants and partners could respond also to the Sexual Adjustment Questionnaire and to the Locke Marital Adjustment Test before radiotherapy, between weeks 20 and 24 and weeks 28 and 30, and at 1 year. Main outcomes and measures: Primary outcome was off-drug spontaneous erectile function 28 to 30 weeks after radiotherapy started. Secondary end points were spontaneous erection at 1 year; overall sexual function and satisfaction; marital adjustment; and partner-reported satisfaction and marital adjustment at 28 to 30 weeks and 1 year, predictors of tadalafil response; and adverse events. Results: Among 221 evaluable participants, 80 (79%; 95% CI, 70%-88%) assigned to receive tadalafil retained erectile function between weeks 28 and 30 compared with 61 (74%; 95% CI, 63%-85%) assigned to receive placebo (P = .49); an absolute difference of 5% (95% CI, -9% to 19%). A significant difference was also not observed at 1 year (72%; 95% CI, 60%-84% vs 71%; 95% CI, 59%-84%; P = .93). Tadalafil was not associated with significantly improved overall sexual function or satisfaction; a significant difference was not observed in any domain subscale. Partners of men assigned tadalafil noted no significant effect on sexual satisfaction, and marital adjustment was not significantly improved in participants or partners. Conclusions and relevance: Among men undergoing radiotherapy for prostate cancer, daily use of tadalafil compared with placebo did not result in improved erectile function. These findings do not support daily use of tadalafil to prevent erectile dysfunction in these patients. Trial registration: clinicaltrials.gov Identifier: NCT00931528.

JAMA · randomised controlled trial · 44 citationsread the source →

Impact of fatigue as the primary determinant of functional limitations among patients with post-COVID-19 syndrome: a cross-sectional observational study.

Objectives: To describe self-reported characteristics and symptoms of treatment-seeking patients with post-COVID-19 syndrome (PCS). To assess the impact of symptoms on health-related quality of life (HRQoL) and patients' ability to work and undertake activities of daily living. Design: Cross-sectional single-arm service evaluation of real-time user data. Setting: 31 post-COVID-19 clinics in the UK. Participants: 3754 adults diagnosed with PCS in primary or secondary care deemed suitable for rehabilitation. Intervention: Patients using the Living With Covid Recovery digital health intervention registered between 30 November 2020 and 23 March 2022. Primary and secondary outcome measures: The primary outcome was the baseline Work and Social Adjustment Scale (WSAS). WSAS measures the functional limitations of the patient; scores of ≥20 indicate moderately severe limitations. Other symptoms explored included fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), depression (Patient Health Questionnaire-Eight Item Depression Scale), anxiety (Generalised Anxiety Disorder Scale, Seven-Item), breathlessness (Medical Research Council Dyspnoea Scale and Dyspnoea-12), cognitive impairment (Perceived Deficits Questionnaire, Five-Item Version) and HRQoL (EQ-5D). Symptoms and demographic characteristics associated with more severe functional limitations were identified using logistic regression analysis. Results: 3541 (94%) patients were of working age (18-65); mean age (SD) 48 (12) years; 1282 (71%) were female and 89% were white. 51% reported losing ≥1 days from work in the previous 4 weeks; 20% reported being unable to work at all. Mean WSAS score at baseline was 21 (SD 10) with 53% scoring ≥20. Factors associated with WSAS scores of ≥20 were high levels of fatigue, depression and cognitive impairment. Fatigue was found to be the main symptom contributing to a high WSAS score. Conclusion: A high proportion of this PCS treatment-seeking population was of working age with over half reporting moderately severe or worse functional limitation. There were substantial impacts on ability to work and activities of daily living in people with PCS. Clinical care and rehabilitation should address the management of fatigue as the dominant symptom explaining variation in functionality.

BMJ open · cohort or longitudinal · 81 citationsread the source →

Risk Factors, Imaging Findings, and Sex Differences in Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is increasingly being recognized. However, data supporting diagnosis and management are scarce. We analyze a contemporary and comprehensive SCAD registry to advance the understanding of SCAD risk factors, angiographic appearance, and gender differences. This is a retrospective analysis of a prospectively populated database of SCAD patients seen at the Massachusetts General Hospital (MGH) between June 2013 and October 2017. Core laboratory analysis of both coronary angiograms and computerized tomographic (CT) angiography of the extracoronary vessels was performed. Of the 113 patients, 87% were female and mean age was 47 ± 10 years. Traditional cardiovascular risk factors including hypertension, hyperlipidemia, and smoking were present in 27%, 14%, and 22% of patients. Among females, 14%, 8%, and 9% had a history of gestational hypertension, pre-eclampsia, and gestational diabetes, respectively. Fifteen percent had used fertility treatment and 47% of postmenopausal women had used hormone replacement therapy. Angiography showed multivessel SCAD in 42%, severe coronary artery tortuosity in 59%, and extracoronary vascular abnormalities in 100% of patients with complete CT angiographic imaging. Gender differences revealed a self-reported depression and anxiety prevalence of 20% and 32%, respectively, in women compared with 0% in men. Type 1 SCAD was more commonly diagnosed in men than women (71% vs 29%, p <0.01). In conclusion, we highlight under-recognized features of SCAD including (1) relation with pregnancy complications and exposure to hormonal therapy; (2) diffuse, multivessel process in tortuous coronaries on a background of extracoronary arterial abnormalities; and (3) gender differences highlighting the role of mental health as well as potential underdiagnoses in men.

The American journal of cardiology · cohort or longitudinal · 74 citationsread the source →

Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients.

Importance: Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information. Objective: To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). Design, setting, and participants: Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009. Main outcomes and measures: Discordance about prognosis, defined as a difference between a physician's and a surrogate's prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician's prognostic estimate and a surrogate's best guess of that estimate); differences in belief (any difference between a surrogate's actual estimate and their best guess of the physician's estimate). Results: Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient's prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates' prognostic estimates were much more accurate than chance alone, but physicians' prognostic estimates were statistically significantly more accurate than surrogates' (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19). Conclusions and relevance: Among critically ill patients, discordant expectations about prognosis were common between patients' physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians' assessments of patients' prognoses and differences in beliefs about patients' prognoses.

JAMA · cohort or longitudinal · 151 citationsread the source →

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team.

Aim: To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand. Methods: Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010. Results: Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%). Conclusions: The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death.

Archives of disease in childhood · cohort or longitudinal · 63 citationsread the source →

Depression and anxiety disorders in pediatric epilepsy.

Purpose: This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables. Methods: A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children, aged 5 to 16 years. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist. Results: Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation. Conclusions: These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.

Epilepsia · cohort or longitudinal · 201 citationsread the source →

Rotating shift work and menstrual cycle characteristics.

Background: Shift workers who experience sleep disturbances and exposure to light at night could be at increased risk for alterations in physiologic functions that are circadian in nature. Methods: We investigated rotating shift work and menstrual cycle patterns in the Nurses' Health Study II using cross-sectional data collected in 1993 from 71,077 nurses aged 28-45 years who were having menstrual periods and were not using oral contraceptives. Log-binomial regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs). Results: Eight percent of participants reported working rotating night shifts for 1-9 months, 4% for 10-19 months, and 7% for 20+ months during the previous 2 years. Irregular cycles (>7 days variability) were reported by 10% of participants. Seventy percent of women reported menstrual cycles of 26-31 days, 1% less than 21 days, 16% 21-25 days, 11% 32-39 days, and 1% 40+ days. Women with 20+ months of rotating shift work were more likely to have irregular cycles (adjusted RR = 1.23 [CI = 1.14-1.33]); they were also more likely to have cycle length <21 days (1.27 [0.99-1.62]) or 40+ days (1.49 [1.19-1.87]) (both compared with 26-31 days). For irregular patterns and for 40+ day cycles, there was evidence of a dose response with increasing months of rotating shift work. Moderately short (21-25 days) or long (32-39 days) cycle lengths were not associated with rotating shift work. Conclusions: Shift work was modestly associated with menstrual function, with possible implications for fertility and other cycle-related aspects of women's health.

Epidemiology (Cambridge, Mass.) · cohort or longitudinal · 117 citationsread the source →

Vitamin D deficiency is associated with functional decline and falls in frail elderly women despite supplementation.

We examined the impact of daily supplementation on vitamin D deficiency, function, and falls in female long-term care residents. Initial vitamin D deficiency was associated with greater functional decline and increased fall risk despite guideline-recommended supplementation, highlighting the importance of preventing vitamin D deficiency in frail elderly. Introduction: Institute of Medicine (IOM) guidelines recommend 800 IU vitamin D daily for older adults and maintaining serum 25-hydroxyvitamin D [25(OH) D] above 20 ng/ml for optimal skeletal health. The adequacy of IOM guidelines for sustaining function and reducing falls in frail elderly is unknown. Methods: Female long-term care residents aged ≥65 enrolled in an osteoporosis clinical trial were included in this analysis (n = 137). Participants were classified based on baseline 25(OH) D levels as deficient (<20 ng/ml, n = 26), insufficient (20-30 ng/ml, n = 40), or sufficient (>30 ng/ml, n = 71). Deficient women were provided initial vitamin D repletion (50,000 IU D3 weekly for 8 weeks). All were supplemented with 800 IU vitamin D3 daily for 24 months. Annual functional assessments included Activities of Daily Living (ADLs), Instrumental ADL (IADL), physical performance test (PPT), gait speed, cognition (SPMSQ), and mental health (PHQ-9). We used linear mixed models for analysis of functional measures and logistic regression for falls. Results: Daily supplementation maintained 25(OH) D levels above 20 ng/ml in 95% of participants. All groups demonstrated functional decline. Women initially deficient had a greater decline in physical function at 12 (IADL -2.0 ± 0.4, PPT -3.1 ± 0.7, both p < 0.01) and 24 months (IADL -2.5 ± 0.6, ADL -2.5 ± 0.6, both p < 0.01), a larger increase in cognitive deficits at 12 months (1.7 ± 0.4: p = 0.01) and more fallers (88.5%, p = 0.04) compared to those sufficient at baseline, despite supplementation to sufficient levels. Conclusions: IOM guidelines may not be adequate for frail elderly. Further study of optimal 25(OH) D levels for maintaining function and preventing falls is needed.

Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA · 29 citationsread the source →

Moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit.

Introduction: Healthcare workers in intensive care units often experience moral distress, depression, and stress-related symptoms. These conditions can lower staff retention and influence the quality of patient care. This study aimed to evaluate the prevalence of moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit (PICU) in Hong Kong. Methods: A cross-sectional questionnaire survey was conducted in the PICU of the Hong Kong Children's Hospital; healthcare workers (doctors, nurses and allied health professionals) were invited to participate. The Revised Moral Distress Scale (MDS-R) Paediatric Version and Depression Anxiety and Stress Scale-21 items were used to assess moral distress and psychological status, respectively. Demographic characteristics were examined in relation to moral distress, depression, anxiety, and stress scores to identify risk factors for poor psychological outcomes. Correlations of moral distress with depression, anxiety, and stress were examined. Results: Forty-six healthcare workers completed the survey. The overall median MDS-R moral distress score was 71. Nurses had a significantly higher median moral distress score, compared with doctors and allied health professionals (102 vs 47 vs 20). Nurses also had the highest median anxiety and stress scores (11 and 20, respectively). Moral distress scores were correlated with depression (r=0.445; P=0.002) and anxiety scores (r=0.417; P<0.05). Healthcare workers intending to quit their jobs had significantly higher moral distress scores (P<0.05). Conclusion: Among PICU healthcare workers, nurses had the highest level of moral distress. Moral distress was associated with greater depression, anxiety, and intention to quit. Healthcare workers need support and a sustainable working environment to cope with moral distress.

Hong Kong medical journal = Xianggang yi xue za zhi · 7 citationsread the source →

Parental Adjustment following Pediatric Burn Injury: The Role of Guilt, Shame, and Self-Compassion.

Objective: The purpose of this study was to examine the association between factors: guilt, shame, self-compassion, and parents' psychological adjustment to their child's burn injury. Methods: Participants were 91 parents and primary caregivers (63 mothers, 25 fathers, 3 other) of 71 children recruited on the ward or at outpatient clinics during the first 8 weeks following their child's burn injury. In 20 cases, both parents participated, while for 51 children only one parent participated. Participants completed questionnaires which assessed adjustment (symptoms of depression, anxiety, and posttraumatic stress syndrome [PTSS]) as well as guilt, shame, and self-compassion. Results: Multilevel analysis indicated that feelings of guilt and shame were associated with poorer adjustment in parents, while parents who rated high in self-compassion reported fewer symptoms of depression and PTSS. Guilt and shame showed a differing pattern of effects with shame explaining more variance for anxiety and depression. Length of hospitalization predicted PTSS; however, the remaining injury factors (size of burn, requiring a skin graft) were unrelated to parental adjustment. Conclusions: Health-care professionals should pay close attention to families' subjective injury experiences. Screening for psychological distress should be offered to all families regardless of the size and severity of the burn injury.

Journal of pediatric psychology · 39 citationsread the source →

Self-reported prevalence, description and management of pain in adults with haemophilia: methods, demographics and results from the Pain, Functional Impairment, and Quality of life (P-FiQ) study.

Introduction: Haemophilia is characterized by frequent haemarthrosis, leading to acute/chronic joint pain. Aim: To assess self-reported prevalence, description and management of pain in adult males with mild-to-severe haemophilia and history of joint pain/bleeding. Methods: Participants completed a pain survey and five patient-reported outcome instruments assessing pain, functional impairment and health-related quality of life (HRQoL). Results: Of 381 participants enrolled, median age was 34 years; 77% had haemophilia A, 71% had severe disease and 65% were overweight/obese. Many (56%) were not receiving routine infusions; 30% never received routine infusions. During the prior 6 months, 20% experienced acute pain, 34% chronic pain and 32% both acute/chronic pain. Subjects with both acute/chronic pain (vs. none, acute or chronic) were more likely to be depressed (30% vs. 0-15%), obese (35% vs. 20-29%) and have lower HRQoL (mean EQ-5D visual analog scale, 69 vs. 83-86) and function (median overall Hemophilia Activities List, 60 vs. 88-99). Most common analgesics used for acute/chronic pain during the prior 6 months were acetaminophen (62%/55%) and non-steroidal anti-inflammatory drugs (34%/49%); most common non-pharmacologic strategies were ice (65%/33%) and rest (51%/33%). Hydrocodone-acetaminophen was the most common opioid for both acute/chronic pain (30%); other long-acting opioids were infrequently used specifically for chronic but not acute pain (morphine, 7%; methadone, 6%; fentanyl patch, 2%). Conclusion: Patients with chronic pain, particularly those with both acute/chronic pain, frequently experience psychological issues, functional disability and reduced HRQoL. Treatment strategies for acute pain (e.g. routine infusions to prevent bleeding) and for chronic pain (e.g. long-acting opioids) may be underused.

Haemophilia : the official journal of the World Federation of Hemophilia · 86 citationsread the source →

Digital cognitive behavioural therapy for insomnia and primary care costs in England: an interrupted time series analysis.

Background: Sleepio is an automated digital program that delivers digital cognitive behavioural therapy for insomnia (dCBT-I). Sleepio has been proven effective in improving sleep difficulties; however, evidence for the possible impact of Sleepio use on healthcare costs in the UK has not, to the authors' knowledge, previously been developed. Aim: To identify the effect of a population-wide rollout of Sleepio in terms of primary care costs in the NHS in England. Design & setting: The study was conducted in the Thames Valley region of England, where access to Sleepio was made freely available to all residents between October 2018 and January 2020. The study relies on a quasi-experimental design, using an interrupted time series (ITS) to compare the trend in primary care costs before and after the rollout of Sleepio. Method: Primary care data for people with relevant characteristics from nine general practices in Buckinghamshire was used. Primary care costs include general practice contacts and prescriptions. Segmented regression analysis was used to estimate primary and secondary outcomes. Results: For the 10 705 patients included in the sample, the total saving over the 65-week follow-up period was £71 027. This corresponds to £6.64 per person in the sample or around £70.44 per Sleepio user. Secondary analyses suggest that savings may be driven primarily by reductions in prescribing. Conclusion: Sleepio rollout reduced primary care costs. National adoption of Sleepio may reduce primary care costs by £20 million in the first year. The expected impact on primary care costs in any particular setting will depend on the uptake of Sleepio.

BJGP open · 16 citationsread the source →

Voluntary medical male circumcision in selected provinces in South Africa: Outcomes from a programmatic setting.

Introduction: Voluntary medical male circumcision (VMMC) remains an effective biomedical intervention for HIV prevention in high HIV prevalence countries. In South Africa, United States Agency for International Development VMMC partners provide technical assistance to the Department of Health, at national and provincial levels in support of the establishment of VMMC sites as well as in providing direct VMMC services at site level since April 2012. We describe the outcomes of the Right to Care (RTC) VMMC program implemented in South Africa from 2012 to 2017. Methods: This retrospective study was undertaken at RTC supported facilities across six provinces. Young males aged ≥10 years who presented at these facilities from 1 July 2012 to 31 September 2017 were included. Outcomes were VMMC uptake, HIV testing uptake and rate of adverse events (AEs). Using a de-identified observational database of these clients, summary statistics of the demographic characteristics and outcomes were calculated. Results: There were a total 1,001,226 attendees of which 998,213 (99.7%) were offered VMMC and had a median age of 15 years (IQR = 12-23 years). Of those offered VMMC, 99.6% (994,293) consented, 96.7% (965,370) were circumcised and the majority (46.3%) were from Gauteng province. HIV testing uptake was 71% with a refusal rate of 15%. Of the newly diagnosed HIV positives, 64% (6,371 / 9,972) referrals were made. The rate of AEs, defined as bleeding, infection, and insufficient skin removal) declined from 3.26% in 2012 to 1.17% in 2017. There was a reduction in infection-related AEs from 2,448 of the 2,602 adverse events (94.08%) in 2012 to 129 of the 2,069 adverse events (6.23%) in 2017. Conclusion: There was a high VMMC uptake with a decline in AEs over time. Adolescent men contributed the most to the circumcised population, an indication that the young population accesses medical circumcision more. VMMC programs need to implement innovative demand creation strategies to encourage older males (20-34 years) at higher risk of HIV acquisition to get circumcised for immediate impact in reduction of HIV incidence. HIV prevalence in the total population increased with increasing age, notably in clients above 25 years.

PloS one · 11 citationsread the source →

Knowledge, attitudes, and practices of Palestinian people relating to organ donation in 2016: a cross-sectional study.

Background: Organ transplantation is the treatment of choice for organ failure, but organs are scarce and their availability is affected by relational ties, religious beliefs, cultural influences, body integrity, medical mistrust, and other factors. This aim of this study was to assess the knowledge, attitudes, and practices of Palestinian population with respect to organ donation. Methods: In this cross-sectional study, we used a validated questionnaire delivered by land telephone to collect data on the knowledge, attitudes, and practices relating to organ donation in the general population of the West Bank. Stratified sampling and simple random sampling were applied using data obtained from the Palestinian Telecommunication Group in 2016. Stata version 20 was used for statistical analysis, and a p value less than 0·05 was considered significant. Ethics approval was obtained from the Institutional Review Board of An-Najah National University, and all participants gave verbal informed consent. Findings: The questionnaire was completed by 385 (68%) of 565 people approached (mean age 42 years [SD 14·13]). 266 (69%) respondents were married, 311 (80%) were employed, and 375 (97%) were Muslim. 136 (35%) respondents were university students or post-graduates. Half of participants lived in urban areas. Local religious clergy were reported as being the source of general information by 150 (40%) participants. 273 (71%) respondents had adequate knowledge about organ donation, TV being the main source of information for 207 (60%) participants. 70 (26%) respondents would consider donation only after death, and 342 (67%) respondents would only consider donating to a close family member, whereas 341 (100%) respondents believed that their organ could be misused and 219 (64%) believed organ donation carries a health risk. 135 (49%) respondents preferred to donate to a recipient of the same religion. 266 (78%) individuals believed that organ donation should be promoted in the occupied Palestinian territory, although 188 (55%) reported organ donation to be culturally unacceptable. Religious beliefs and fears of complications were the main obstacles to organ donation. An adequate level of knowledge was associated with the female sex (p=0·008), level of education (p=0·046), monthly income (p=0·041), and marital status (p=0·012), whereas a positive attitude to organ donation was associated with religious score (p=0·015), marital status (p=0·031), and knowledge score (p=0·003). A high level of knowledge was associated with employment and the perception of organ donation as permitted in religion, whereas a positive attitude was associated with single marital status, high level of knowledge, and residence in cities. Interpretation: Despite adequate knowledge and positive attitudes towards organ donation, a comprehensive study is necessary to fully understand the local characteristics that influence organ donation by Palestinians and to better inform decision makers and future policies. Funding: None.

Lancet (London, England) · 15 citationsread the source →

The associations of socioeconomic status, social activities, and loneliness with depressive symptoms in adults aged 50 years and older across 24 countries: findings from five prospective cohort studies.

Background: Depression is the leading cause of mortality among mental health disorders. Evidence about the associations of socioeconomic status, social activities, and loneliness with depression is scarce. We aimed to identify whether social activities and loneliness mediate the association between socioeconomic status and depression, and the extent of interactive or joint relationships between social activities, loneliness, and socioeconomic status on depression. Methods: In this population-based, cross-national cohort study we used data from five nationally representative surveys across 24 countries between Feb 15, 2008, and Feb 27, 2019: the Health and Retirement Study (HRS); the English Longitudinal Study of Ageing (ELSA); the Survey of Health, Ageing and Retirement in Europe (SHARE); the China Health and Retirement Longitudinal Study (CHARLS); and the Mexican Health and Ageing Study (MHAS). We included participants who were aged 50 years and older with reported information on socioeconomic status, social activities, and loneliness at baseline, and who had been assessed at least twice. We excluded participants with depressive symptoms at baseline; those with missing data on depressive symptoms and covariates; and those lost to follow-up. We defined socioeconomic status as high and low using latent class analysis based on family income, education, and employment status. Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D) or EURO-D. We applied Cox proportional hazard models to estimate the association of socioeconomic status with depression. We used random-effects models to obtain pooled results. Joint and interactive effects of socioeconomic status, social activities, and loneliness on depression were explored, and the mediating roles of social activities and loneliness in the association between socioeconomic status and depression were explored using causal mediation analysis. Findings: A total of 69 160 participants were included in our study and, during a median follow-up of 5 years, a total of 20 237 participants developed depression with a pooled incidence of 7·2 (95% CI 4·4-10·0) per 100 person-years. Compared with participants with high socioeconomic status, those with low socioeconomic status had a higher risk of depression (pooled hazard ratio [HR] 1·34; 95% CI 1·23-1·44). The proportion of the associations between socioeconomic status and depression mediated by social activities and loneliness were 6·12% (1·14-28·45) and 5·54% (0·71-27·62), respectively. We only observed a significant multiplicative interaction of socioeconomic status and loneliness with depression (pooled HR 0·84; 0·79-0·90). Compared with participants with high socioeconomic status and who were socially active and not lonely, those with low socioeconomic status and who were socially inactive and lonely had a higher risk of depression (pooled HR 2·45; 2·08-2·82). Interpretation: Social inactivity and loneliness positively mediated a small proportion of the association between socioeconomic status and depression, indicating that other approaches in addition to interventions targeting social isolation and loneliness are required to mitigate the risk of depression in older adults. Additionally, the joint effects of socioeconomic status, social activities, and loneliness highlight the benefits of simultaneous and integrated interventions to reduce the global burden of depression. Funding: National Natural Science Foundation of China.

The lancet. Healthy longevity · 98 citationsread the source →

Effects of Sleep Deprivation on the Cognitive Performance of Nurses Working in Shift.

Introduction: Sleep deprivation and altered circadian rhythm affects the cognitive performance of an individual. Quality of sleep is compromised in those who are frequently involved in extended working hours and shift work which is found to be more common among nurses. Cognitive impairment leads to fatigability, decline in attention and efficiency in their workplace which puts their health and patients' health at risk. Aim: To find out the prevalence of sleep deprivation and its impact on cognition among shift working nurses. Materials and methods: Sleep deprivation among 97 female and three male healthy nurses of age 20-50 years was assessed by Epworth sleepiness scale (ESS). Cognition was assessed by Montreal Cognitive Assessment (MoCA) questionnaire. Mobile applications were used to test their vigilance, reaction time, photographic memory and numerical cognition. The above said parameters were assessed during end of day shift and 3-4 days after start of night shift. Results: Poor sleep quality was observed among 69% of shift working nurses according to ESS scores. The cognitive performance was analysed using Wilcoxon signed rank test. The MoCA score was found to be lesser among 66% of nurses during night (25.72) than day (26.81). During the night, 32% made more mathematical errors. It was also found that, 71%, 83% and 68% of the nurses scored lesser during night in the Stroop's colour test, vigilance test and memory tests respectively. Thus, impairment in cognitive performance was statistically significant (p<0.001) among shift working nurses. Conclusion: Cognitive performance was found to be impaired among shift working nurses, due to poor sleep quality and decreased alertness during wake state. Thus, shift work poses significant cognitive risks in work performance of nurses.

Journal of clinical and diagnostic research : JCDR · 49 citationsread the source →

Social integration and mental health - a decomposition approach to mental health inequalities between the foreign-born and native-born in Sweden.

Background: The increasing mental health inequalities between native- and foreign-born persons in Sweden is an important public health issue. Improving social integration has been stressed as a key strategy to combat this development. While a vast amount of studies have confirmed the importance of social integration for good mental health, less is known about the role of different types of social integration, and how they relate to mental health inequalities. This study aimed to examine the extent to which indicators of social integration explained mental health inequalities between the native- and foreign-born. Methods: Based on the Health on Equal Terms survey from 2011/2015 in Västra Götaland, Sweden (n = 71,643), a non-linear Oaxaca-Blinder decomposition analysis was performed comparing native- and foreign-born individuals from Nordic-, European- and non-European countries. The General Health Questionnaire was used to assess psychological distress, while 11 items assessed employment conditions and economic disparities, social relations, and experiences of discrimination to measure different aspects of social integration. Results: Differences in social integration explained large proportions of observed mental health differences between the native- and foreign-born. Important indicators included low levels of social activity (20%), trust in others (17%) and social support (16%), but also labour market disadvantages, such as being outside the labour market (15%), unemployment (10%) and experiencing financial strain (16%). In analyses stratified by region of origin, low trust in others and discrimination contributed to the mental health gap between the native-born and European-born (17 and 9%, respectively), and the native-born and non-European-born (19 and 10%, respectively). Precarious labour market position was a particularly important factor in the mental health gap between the native-born and Nordic-origin (22%), and non-European origin (36%) populations. Conclusion: Social integration factors play a central role in explaining the mental health inequality between natives and migrants in Sweden. Our findings suggest that public health actions targeting mental health gaps could benefit from focusing on inequalities in social and economic recourses between natives and migrants in Sweden. Areas of priority include improving migrants' financial strain, as well as increasing trust in others and social support and opportunities for civic engagement.

International journal for equity in health · 47 citationsread the source →

Cognitive and psychiatric symptom trajectories 2-3 years after hospital admission for COVID-19: a longitudinal, prospective cohort study in the UK.

Background: COVID-19 is known to be associated with increased risks of cognitive and psychiatric outcomes after the acute phase of disease. We aimed to assess whether these symptoms can emerge or persist more than 1 year after hospitalisation for COVID-19, to identify which early aspects of COVID-19 illness predict longer-term symptoms, and to establish how these symptoms relate to occupational functioning. Methods: The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study of adults (aged ≥18 years) who were hospitalised with a clinical diagnosis of COVID-19 at participating National Health Service hospitals across the UK. In the C-Fog study, a subset of PHOSP-COVID participants who consented to be recontacted for other research were invited to complete a computerised cognitive assessment and clinical scales between 2 years and 3 years after hospital admission. Participants completed eight cognitive tasks, covering eight cognitive domains, from the Cognitron battery, in addition to the 9-item Patient Health Questionnaire for depression, the Generalised Anxiety Disorder 7-item scale, the Functional Assessment of Chronic Illness Therapy Fatigue Scale, and the 20-item Cognitive Change Index (CCI-20) questionnaire to assess subjective cognitive decline. We evaluated how the absolute risks of symptoms evolved between follow-ups at 6 months, 12 months, and 2-3 years, and whether symptoms at 2-3 years were predicted by earlier aspects of COVID-19 illness. Participants completed an occupation change questionnaire to establish whether their occupation or working status had changed and, if so, why. We assessed which symptoms at 2-3 years were associated with occupation change. People with lived experience were involved in the study. Findings: 2469 PHOSP-COVID participants were invited to participate in the C-Fog study, and 475 participants (191 [40·2%] females and 284 [59·8%] males; mean age 58·26 [SD 11·13] years) who were discharged from one of 83 hospitals provided data at the 2-3-year follow-up. Participants had worse cognitive scores than would be expected on the basis of their sociodemographic characteristics across all cognitive domains tested (average score 0·71 SD below the mean [IQR 0·16-1·04]; p<0·0001). Most participants reported at least mild depression (263 [74·5%] of 353), anxiety (189 [53·5%] of 353), fatigue (220 [62·3%] of 353), or subjective cognitive decline (184 [52·1%] of 353), and more than a fifth reported severe depression (79 [22·4%] of 353), fatigue (87 [24·6%] of 353), or subjective cognitive decline (88 [24·9%] of 353). Depression, anxiety, and fatigue were worse at 2-3 years than at 6 months or 12 months, with evidence of both worsening of existing symptoms and emergence of new symptoms. Symptoms at 2-3 years were not predicted by the severity of acute COVID-19 illness, but were strongly predicted by the degree of recovery at 6 months (explaining 35·0-48·8% of the variance in anxiety, depression, fatigue, and subjective cognitive decline); by a biocognitive profile linking acutely raised D-dimer relative to C-reactive protein with subjective cognitive deficits at 6 months (explaining 7·0-17·2% of the variance in anxiety, depression, fatigue, and subjective cognitive decline); and by anxiety, depression, fatigue, and subjective cognitive deficit at 6 months. Objective cognitive deficits at 2-3 years were not predicted by any of the factors tested, except for cognitive deficits at 6 months, explaining 10·6% of their variance. 95 of 353 participants (26·9% [95% CI 22·6-31·8]) reported occupational change, with poor health being the most common reason for this change. Occupation change was strongly and specifically associated with objective cognitive deficits (odds ratio [OR] 1·51 [95% CI 1·04-2·22] for every SD decrease in overall cognitive score) and subjective cognitive decline (OR 1·54 [1·21-1·98] for every point increase in CCI-20). Interpretation: Psychiatric and cognitive symptoms appear to increase over the first 2-3 years post-hospitalisation due to both worsening of symptoms already present at 6 months and emergence of new symptoms. New symptoms occur mostly in people with other symptoms already present at 6 months. Early identification and management of symptoms might therefore be an effective strategy to prevent later onset of a complex syndrome. Occupation change is common and associated mainly with objective and subjective cognitive deficits. Interventions to promote cognitive recovery or to prevent cognitive decline are therefore needed to limit the functional and economic impacts of COVID-19. Funding: National Institute for Health and Care Research Oxford Health Biomedical Research Centre, Wolfson Foundation, MQ Mental Health Research, MRC-UK Research and Innovation, and National Institute for Health and Care Research.

The lancet. Psychiatry · 46 citationsread the source →

DSM-5-TR prolonged grief disorder and DSM-5 posttraumatic stress disorder are related, yet distinct: confirmatory factor analyses in traumatically bereaved people.

Background: Prolonged grief disorder (PGD) is newly included in the text revision of the DSM-5 (DSM-5-TR). So far, it is unknown if DSM-5-TR PGD is distinguishable from bereavement-related posttraumatic stress disorder (PTSD). Prior research examining the distinctiveness of PTSD and pathological grief focused on non-traumatic loss samples, used outdated conceptualizations of grief disorders, and has provided mixed results. Objective: In a large sample of traumatically bereaved people, we first evaluated the factor structure of PTSD and PGD separately and then evaluated the factor structure when combining PTSD and PGD symptoms to examine the distinctiveness between the two syndromes. Methods: Self-reported data were used from 468 people bereaved due to the MH17 plane disaster (N = 200) or a traffic accident (N = 268). The 10 DSM-5-TR PGD symptoms were assessed with the Traumatic Grief Inventory-Self Report Plus (TGI-SR+). The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used to tap PTSD symptoms. Confirmatory factor analyses were conducted. Results: For PTSD, a seven factor, so-called 'Hybrid' model yielded the best fit. For PGD, a univariate factor model fits the data well. A combined model with PGD items loading on one factor and PTSD items on seven factors (associations between PGD and PTSD subscales r ≥ .50 and ≤.71), plus a higher-order factor (i.e. PTSD factors on a higher-order PTSD factor) (association between higher-order PTSD factor and PGD factor r = .82) exhibited a better fit than a model with all PGD and PTSD symptom loading on a single factor or two factors (i.e. one for PGD and one for PTSD). Conclusions: This is the first study examining the factor structure of DSM-5-TR PGD and DSM-5 PTSD in people confronted with a traumatic loss. The findings provide support that PGD constitutes a syndrome distinguishable from, yet related with, PTSD.

European journal of psychotraumatology · 26 citationsread the source →

Spirituality and mental health

INTRODUCTION All along, the majority position of Psychiatry has been that Psychiatry has nothing to do with religion and spirituality. Religious beliefs and practices have long been thought to have a pathological basis, and psychiatrists over a century have understood them in this light. Religion was considered as a symptom of mental illness. Jean Charcot and Sigmund Freud linked religion with neurosis. DSM3 portrayed religion negatively by suggesting that religious and spiritual experiences are examples of psychopathology. But recent research reports strongly suggest that to many patients, religion and spirituality are resources that help them to cope with the stresses in life, including those of their illness. Many psychiatrists now believe that religion and spirituality are important in the life of their patients. The importance of spirituality in mental health is now widely accepted. As John Turbott[1] puts it, rapprochement between religion and psychiatry is essential for psychiatric practice to be effective. The Royal College of Psychiatrists, London, has a special group on Psychiatry and Spirituality. The American College of Graduate Medical Education mandates in its special requirements for residency training in Psychiatry, that all programs must provide training in religious and spiritual factors that can influence mental health. The World Psychiatric Association recently established a section on psychiatry and religion. Lukoff et al.[2] proposed that the diagnostic entities of religious and psychospiritual problems should be incorporated in DSM4 which has been accepted. DSM4, V 62.89 includes three categories—normal religious and spiritual experiences; religious and spiritual problems leading to mental disturbances; and mental disturbances with a religious and spiritual context. I understand that the Indian Psychiatric Society has formed a task force on spirituality and mental health which is urging the Medical council of India to include taking the spiritual history as part of psychiatric evaluation. Even so the importance of religion and spirituality are not sufficiently recognized by the psychiatric community. Religion does not have a place in most of the psychiatry text books. Only very few psychiatrists make use of religion and spirituality in the therapeutic situation. This paper makes an attempt to bring out the importance of spirituality in mental health. WHAT IS SPIRITUALITY? Spirituality is a globally acknowledged concept. It involves belief and obedience to an all powerful force usually called God, who controls the universe and the destiny of man. It involves the ways in which people fulfill what they hold to be the purpose of their lives, a search for the meaning of life and a sense of connectedness to the universe. The universality of spirituality extends across creed and culture. At the same time, spirituality is very much personal and unique to each person. It is a sacred realm of human experience. Spirituality produces in man qualities such as love, honesty, patience, tolerance, compassion, a sense of detachment, faith, and hope. Of late, there are some reports which suggest that some areas of the brain, mainly the nondominant one, are involved in the appreciation and fulfillment of spiritual values and experiences.[3–5] SPIRITUALITY AND RELIGION Religion is institutionized spirituality. Thus, there are several religions having different sets of beliefs, traditions, and doctrines. They have different types of community-based worship programs. Spirituality is the common factor in all these religions. It is possible that religions can lose their spirituality when they become institutions of oppression instead of agents of goodwill, peace and harmony. They can become divisive instead of unifying. History will tell us that this had happened from time to time. It has been said that more blood has been shed in the cause of religion than any other cause. The medieval holy wars of Europe; the religion-based terrorism and conflicts of modern times are examples. We must remember that the institutions of religion are supposed to help us to practice spirituality in our lives. They need periodical revivals to put spirituality in place. SPIRITUAL DIMENSION IS IMPORTANT IN MENTAL HEALTH Mental health has two dimensions—absence of mental illness and presence of a well-adjusted personality that contributes effectively to the life of the community. Ability to take responsibility for one's own actions, flexibility, high frustration tolerance, acceptance of uncertainty, involvement in activities of social interest, courage to take risks, serenity to accept the things which we cannot change, courage to change the things which we can change, the wisdom to know the difference between the above, acceptance of handicaps, tempered self-control, harmonious relationships to self, others, including Nature and God, are the essential features of mental health. Spirituality is an important aspect of mental health. St. Augustine prayed “O God, thou created us in thy image and our hearts will be restless until they find their rest in Thee.” Though Sigmund Freud looked upon religion as an illusion and neurosis, Carl Jung considered the psyche as a carrier of truth, powerfully rooted in the unconscious mind. Religion is important, directly and indirectly, in the etiology, diagnosis, symptomatology, treatment and prognosis of psychiatric disturbances. Lack of spirituality can interfere with interpersonal relationships, which can contribute to the genesis of psychiatric disturbance. Psychiatric symptoms can have a religious content. For example, the loss of interest in religious activities is a common symptom of depression. Too much and distorted religious practices are common in schizophrenia. It is well recognized that some religious states and experiences are misdiagnosed as symptoms of psychiatric illness. Visions and possession states are examples. The spiritual background of the patient will help in the diagnosis of psychiatric disturbance. They are important in the treatment of psychiatric disturbance because spiritual matters can be profitably incorporated in psychotherapy. Spirituality is important in the prognosis of psychiatric conditions. In the spiritual perspective, a differentiation must be made between cure and healing. Cure is the removal of symptoms. Healing is the healing of the whole person. Adversity often produces maturity. Hence in psychotherapy, the patient must be helped to accept the handicap and transform the handicap to a life of usefulness. SOME SIGNIFICANT CLINICAL AND RESEARCH FINDINGS Recent studies show that religious beliefs and practices are supportive to cope with stresses in life and are beneficial to mental health. Thomas Ashby Wills,[6] Professor of Epidemiology and population health at Albert Einstein College of Medicine developed a scale that determines how important is religion to people. This was administered to 1182 children in New York. It was found that religiosity kept children from smoking, drinking and drug abuse by buffering the impact of life stresses. Gene H. Brody,[7] a research professor of child and family development at the University of Georgia, Athens, found that parents who were more involved in church activities were more likely to have harmonious marital relationships and better parenting skills. That in turn enhanced children's competence, self-regulation, psychosocial adjustment and school performance. Miller et al.[8] made a 10-year follow up study on depressed mothers and their offsprings and reported that maternal religiosity and mother-child concordance in religiosity were protective against depression in the offspring. They also reported that low level of religiosity was associated with substance abuse in the offsprings.[9] J. Scott Tonigan,[10] a research professor of psychiatry at the University of New Mexico, followed up 226 patients of alcohol dependence and reported that spirituality predicts behavior such as honesty and responsibility which in turn promoted alcohol abstinence. Wagner and King[11] conducted a study involving three groups—one group of patients who had psychotic illness, one group of formal care givers, and a third group of informal caregivers. The existential needs were the most important for the patient group, while the other groups considered material needs such as housing and work as more important. Neeleman and King[12] surveyed the psychiatric practices of 231 psychiatrists in London. 73% had no religious affiliation, 28% had belief in God, 61% believed that religion can protect against mental illness, and 48% asked patients about their religious practices. Baetz et al.[13] surveyed 1204 psychiatrists and 157 psychiatric patients in Canada. 54% of psychiatrists believed in God, 47% asked patients regarding their religious beliefs, and 55% consulted clergy for the management of patients. Among the patients, 71% believed in God, and 24% preferred psychiatrists who were religious. In an Australian survey, a large majority of patients with psychiatric illness wanted their therapists to be aware of their spiritual beliefs and needs and believed that their spiritual practices helped them to cope better.[14] Mathai and North[15] constructed a questionnaire, consisting of 5 questions and gave it to 70 parents of children attending child and adolescent mental health clinic. They reported that majority of the parents believed that spiritual concerns were important and that therapists should consider their spiritual beliefs in the management of the problems of the children. In USA, Curlin et al.[16] conducted a study of psychiatrists and compared them with physicians from other specialities in their religious affiliations and found that psychiatrists showed less religious affiliations. Several empirical studies on psychiatrists' religious characteristics have indicated that psychiatrists are significantly less religious than the general population, their patients and other physicians.[17],[18] In a 12-year follow up of all articles appearing in American Journal of Psychiatry and Archives of General Psychiatry, 72% of the religious commitment variables were beneficial to mental health; participation in religious services, social support, prayer and relationship with God were beneficial in 92% of citations.[19] Similar findings were reported in a review of the Journal of Family Practice.[20] In a British epidemiological study, church going and active religion were found to be protective to vulnerability for depression by Brown and Prudo.[21] In a detailed study on suicide in Netherlands, Kerkoff [quoted by Sims[22]] reported that there was a decline in suicidal rate, which was concurrent with a religious revival. A study on the factors in the course and outcome of schizophrenia was conducted in the Department of psychiatry, Christian Medical College, Vellore.. It was a collaborative study among three centers—Vellore, Madras and Lucknow. A two-year and five-year follow up showed that those patients who spent more time in religious activities tended to have a better prognosis.[23],[24] The above reports strongly suggest that religious beliefs and practices of psychiatric patients should be given importance. The sense of hope and spiritual support that patients get by discussing religious matters help them to cope better. They also suggest that the importance of religion and spirituality is not sufficiently recognized by the psychiatric community. Mental health workers must take it seriously since psychiatry cannot afford to ignore the importance of spirituality and religion in psychiatry. Sims[22] gives two case histories which drives home this fact. One is the case of Jim who suffered from Korsakov's psychosis. He was so deteriorated that he mistook his wife for a hat. In the ward, others considered him as desolate individual. But his behavior in the chapel was normal. In absolute concentration and attention, he would partake Holy Communion. He did not forget anything nor did he show any signs of Korsakov's psychosis. The other patient had chronic schizophrenia. He used to hear a voice commanding him to jump out of the window. His simple devout mother had taught him to resist the voice by praying to God. His mind was destroyed, but the capacity for spiritual life was present. Unfortunately, on the final occasion, he was too late to pray and he lost his life. Sims makes a comment, “It is unfortunate that we as psychiatrists can be so crass as to neglect this area of life which is clearly important to many of our patients.” Andresen,[25] in an editorial, has pointed out that our civilization's “loss of soul” may cause psychiatric symptoms such as depression, obsessions, addictions, and violence. She has suggested that it is the responsibility of psychiatrists to remind the medical fraternity the necessity of putting back the soul in medical ethics and the fact that spirituality is of vital importance for the mental health of people. WHAT CAN WE DO? As pointed out earlier, spiritual values and religious practices are important in the lives of our patients. Many of their problems may centre round existential preoccupations. It is therefore important that we incorporate spirituality and religious practices in our treatment protocol. We must propagate the Bio-psycho-socio-spiritual model in our approach in psychiatry. Harold Koening,[26] in his paper Religion and Mental health: what should psychiatrists do?, has made some suggestions in this area. Psychiatric history should be catered to the patients' spiritual orientation and religious practices. When we take psychiatric history, we usually ask for the denomination the patient belongs. We do not try to find out how the patient experiences religion. What does religion and spirituality mean to the patient. The psychiatric history should gather information about patient's religious background and experiences in the past and what role religion plays in coping with life stresses. Has patient had any past negative religious experiences? Has he got spiritual and social support from the congregation which he attends? How active is he in the religious congregation? Some religious beliefs can be in conflict with the proposed treatment. Some religious groups are against any type of treatment. Some religious conflicts and frustrations may be contributing to the present psychiatric problem. Sexual abuse by religious workers, traumatic events which turned the patient away from religious beliefs and activities, unanswered prayers, etc. are examples. There are some questionnaires that can be used to take a history of spirituality and religious experiences.[152728] Discussion with the patient on spiritual matters and religious experiences will strengthen the therapeutic relationship. It can also lead to reversal effect of a personal growth of the therapist. We should respect and support patients' religious beliefs if these help them to cope better or do not adversely affect their mental health. For example, if a patient says that his discipline of fasting and prayer helps him to cope better, then this has to be encouraged. We should also challenge the beliefs that can adversely affect mental health. This has to be done very tactfully. It is better to be neutral till we understand the patients and the issues involved well and a good therapeutic relationship is formed. Patients may wish to discuss with the therapist regarding their subjective experiences and existential needs. We should spend time in listening to them. Partnership with the religious workers is an useful area. Leavy and King[29] in their paper, The devil in the detail: partnership between psychiatry and faith based organizations, brings out the importance of such a partnership. They have reported that in UK, the clergy continue to have a central role in several communities and the utility of their involvement in the care of people with mental health problems is increasing. They have argued the importance of examining the form and parameters of partnership between the mental health team and the faith-based communities. For this partnership to be effective, the mental health workers must be spiritually oriented and the religious workers must be better informed about mental health and illness. As referred to earlier, some religious experiences are often misdiagnosed as symptoms of mental illness and vice versa, some psychiatric symptoms are explained as spiritual experiences. According to Sims,[22] phenomena such as faith, prayer and magic can lend themselves to description and definition using Jasperian phenomenology which can lead to a clear differentiation of normal and pathological religious experiences. This emphasizes the importance of psycho-pastoral partnership. One example of such a partnership is the Bangalore psycho-pastoral association, which runs a very efficient half-way home for psychiatric patients. Recognizing the importance of this, the World Council of Churches has formed an Advisory group on mental health and faith communities, which has been active in the exploration of strategies for an effective partnership between mental health services and faith communities. There can be problems in such a partnership. The religious workers may be reluctant to get involved in secular programs, leaving their spiritual fortress. Some of them can have incorrect ideas about the causes of mental illness, which can interfere with the treatment program. Some others can be against medical treatment. Mental health workers can also be prejudiced against the patients' religious beliefs and practices. As referred to earlier, research findings suggest that majority of psychiatrists do not give importance to the spiritual and religious experiences of patients. According to Neelman and Persaud,[30] this may be due to the following factors. Psychiatrists are by and large less religious than other physicians; psychiatrists often come to know of spirituality through the pathological religious symptoms of patients, which make them prejudiced against spirituality; psychiatrists tend to have a biological approach to mental illness, which ignores spiritual dimension; and psychiatrists may think that religion and spirituality cause dependence and guilt feelings. All these can be minimized with dialogue and periodical orientation programs. As John Turbott[31] puts it, psychiatry as a whole can only benefit if the concepts and vocabulary of religion and spirituality are more widely known and discussed among its practitioners. It is also true that conflicts and problems arise more with religious experiences and not with spirituality Praying with the patient is a controversial area. Many psychiatrists will argue that it is a dangerous ground upon which to tread. If at all it is done, it should be done only after a strong therapeutic relationship is established and only if the patient asks for it. Praying for the patient can be beneficial. Research. Although there is substantial body of literature that describes the connection between mental health and spirituality, we must develop theoretical models to understand their relationship in practice. The statistical findings reported earlier were mainly the results of surveys. High-quality evidence-based research is required to make the clinical applications more objective and effective. There are ample opportunities to do research in this area. Phenomena such as meditation, religious faith, and concepts are all What are their to normal life and psychiatric What are the which influence spiritual experiences? If spirituality is to mental health and if religious beliefs and experiences are important in the life of the psychiatric it is only that we should include religious concepts in psychotherapy. For example, some and can be profitably used to help the patient to cope with life situation. The spiritual concepts are incorporated in the treatment of out of the to spirituality. describes a which is called This is a treatment spiritual values to behavior which was developed and promoted at the University of areas are meaning and purpose and The patient is through to meaning and This with examining the of life such as and the patient to the patient is to the of of and in life. The the patient's that and and The involves a on after examining and one's in life. meaning is by meaning for each This is by and factors life and illness The are of and The use of meditation, and with of beliefs and on symptoms form the of the treatment. When the patient negative is the treatment about each about The are depression and adolescent show that produces

Indian Journal of Psychiatry · editorial or comment · 106 citationsread the source →

Bullying and Suicide: A Public Health Approach

Several recent studies have found an association between bullying and depression [[1]Wang J. Iannotti R.J. Luk J.W. Nansel T.R. Co-occurrence of victimization from five subtypes of bullying: Physical, verbal, social exclusion, spreading rumors, and cyber.J Pediatr Psychol. 2010; 35: 1103-1112Crossref PubMed Scopus (223) Google Scholar] or bullying and suicide-related behaviors [[2]Kim Y.S. Leventhal B. Suicide and bullying. A review. Int J Adolesc Med Health. 2008; 20: 133-154Crossref PubMed Scopus (324) Google Scholar], and one study found evidence consistent with a causal link, at least for girls [3Klomek A.B. Sourander A. Niemela S. et al. Childhood bullying behaviors as a risk for suicide attempts and completed suicides: A population-based birth cohort study.J Am Acad Child Adolesc Psychiatry. 2009; 48: 254-261Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar, 4Klomek A.B. Sourander A. Gould A. The association of suicide and bullying in childhood to young adulthood: A review of cross-sectional and longitudinal research findings. Can J Psychiatry. 2010; 55: 282-288PubMed Google Scholar]. These studies, in conjunction with extensive media coverage of the deaths by suicide of several young people who were victims of bullying, led the Centers for Disease Control and Prevention (CDC) to convene an expert panel focusing on the relationship between bullying involvement and suicide-related behaviors. The purpose of the panel, held in September 2010, was to synthesize the latest research about the relationship between youth involvement in bullying (youth who bully, youth who are bullied, and those who bully and are bullied) and suicide-related behaviors (attempts, fatalities, and risk factors associated with suicide, such as depression). Experts on the topics of bullying and suicide presented their research about the relationship between these two behaviors; their work is contained in this supplement. The panel and this special issue provide clarity around the complicated issues of bullying and suicide among youth. Three key themes emerged: (1) bullying among youth is a significant public health problem; it is prevalent and frequently has detrimental effects; (2) there is a strong association between bullying and suicide-related behaviors, but this relationship is often mediated by other factors, including depression and delinquency; and (3) there are public health strategies that can be applied to the prevention of bullying and suicide. Bullying is a significant public health problem because it is prevalent and harmful. Between 20% and 56% of young people are involved in bullying annually [5Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2011. MMWR, Surveillance Summaries 2012;61(no. SS-4). Available at: www.cdc.gov/mmwr/pdf/ss/ss6104.pdf. Google Scholar, 6Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 7Kowalski R.M. Limber S.P. Psychological, physical, and academic correlates of cyberbullying and traditional bullying.J Adolesc Health. 2013; 53: S13-S20Abstract Full Text Full Text PDF PubMed Scopus (768) Google Scholar]. Thus, in a classroom of 30 students, between 6 and 17 students are involved in bullying as a victim, perpetrator, or both (bully-victim). The specific rate of bullying victimization and perpetration varies according to age, type of bullying, time period over which bullying behaviors are assessed, and by subgroup. Younger (middle school-aged) children are more likely to be involved in bullying than high school-aged children [[8]Robers S. Zhang J. Truman J. Indicators of school crime and safety: 2011 (NCES 2012-002/NCJ 236021). National Center for Education Statistics, U.S. Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice, Washington, DC2012Google Scholar]. Verbal bullying is generally more prevalent than physical or cyber-bullying and bullying is more likely to occur over a longer time period—“ever” or over the “past year” as opposed to “the past few months” [[9]David-Ferdon C. Hertz M.F. Electronic media and youth violence: A CDC issue brief for researchers. Centers for Disease Control, Atlanta, GA2009Google Scholar]. Specific subgroups are more likely to be victimized. For example, bullying victimization is more prevalent upon lesbian and gay youth—60% report victimization during the past 30 days prior to the survey compared with 28.8% of heterosexual youth [[10]Hatzenbuehler M.L. Keyes K.M. Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth.J Adolesc Health. 2013; 53: S21-S26Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar]. For young people involved in bullying in any capacity—youth who bully others, who are bullied, or who both bully and are bullied, this involvement is correlated with poor mental and physical health and engagement in other risk behaviors. Youth who are bullied are more likely to be depressed or anxious [[11]Fekkes M. Pijpers F. Fredriks A.M. et al. Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics. 2006; 117: 1568-1574Crossref PubMed Scopus (426) Google Scholar], have lower academic achievement, report feeling like they do not belong at school [[12]Glew G.M. Fan M. Katon W. et al. Bullying, psychosocial adjustment, and academic performance in elementary school. Arch Pediatr Adolesc Med. 2005; 159: 1026-1031Crossref PubMed Scopus (384) Google Scholar], have poorer social and emotional adjustment, greater difficulty making friends, poorer relationships with classmates, and greater loneliness [[13]Nansel T.R. Overpeck M. Pilla M. et al. Bullying behavior among U.S. youth: Prevalence and association with psychosocial adjustment.JAMA. 2001; 285: 2094-2100Crossref PubMed Scopus (2743) Google Scholar]. Bully-victims are more likely than those who bully, those who are bullied, or their uninvolved peers to report being physically hurt by a family member, to witness family violence, and exhibit suicide-related behaviors [[14]McKenna M. Hawk E. Mullen J. Hertz M. The association between bullying behavior and health risks among middle school and high school students in Massachusetts, 2009.Morbidity and Mortality Weekly Review. 2011; 60: 465-471PubMed Google Scholar]. Those who bully others are more likely to drink alcohol and use cigarettes, to have poorer academic achievement and poorer perceived school climate, but to also report greater ease of making friends [[13]Nansel T.R. Overpeck M. Pilla M. et al. Bullying behavior among U.S. youth: Prevalence and association with psychosocial adjustment.JAMA. 2001; 285: 2094-2100Crossref PubMed Scopus (2743) Google Scholar]. Involvement in bullying can also have long-lasting, detrimental effects months or even years after the bullying occurs. Young people who are bullied are more likely than uninvolved youth to develop depression and anxiety and report abdominal pain and feeling tense over the course of a school year [[11]Fekkes M. Pijpers F. Fredriks A.M. et al. Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics. 2006; 117: 1568-1574Crossref PubMed Scopus (426) Google Scholar]. One study examining the impact of bullying victimization of those who were between 9, 11, and 13 years of age when they were victimized found, that over a 7-year period, youth who were bullied were more likely to develop generalized anxiety and panic disorder as adults while bully-victims were more likely to subsequently suffer from depression, panic disorder, and suicidality [[15]Copeland W.E. Wolke D. Angold A. Costello E.J. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence.JAMA Psychiatry. 2013; 70: 419-426Crossref PubMed Scopus (746) Google Scholar]. Another longitudinal study found that those who were perpetrators of bullying at age 14 were more likely to receive a diagnosis of antisocial personality disorder, to have low job status at age 18 years, and to use drugs at ages 27–32 years [[16]Farrington D.P. Ttofi M.M. Bullying as a predictor of offending, violence and later life outcomes. Crim Behav Ment Health. 2011; 21: 90-98Crossref PubMed Scopus (169) Google Scholar]. The articles in this special issue generally show a strong association between involvement in bullying behaviors and suicide-related behaviors. In Espelage and Holt's work with middle school students, suicidal ideation and attempts were significantly more prevalent among victims, bully-victims and perpetrators, with rates of ideation and attempts among those involved as a victim, perpetrator, or bully-victims three to five times higher than the rate of uninvolved youth [[17]Espelage D.L. Holt M.K. Suicidal ideation and school bullying experiences after controlling for depression and delinquency.J Adolesc Health. 2013; 53: S27-S31Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar]. Likewise, in Borowsky's study of 6th, 9th, and 12th graders, 1.2% of uninvolved youth made a suicide attempt, compared with 5% for those who frequently bullied others verbally or socially; 6.5% for those who were frequent victims of verbal/social bullying; and 11.1% for those who were frequent bully-victims of verbal/social bullying [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. In Kowalski and Limber's paper, depression, anxiety, self-esteem, self-reported health problems, absences from school, leaving school because of illness, and grades were, with only one exception, significantly related to students' involvement in cyber-bullying others, being cyber-bullied, bullying others through traditional means, and being bullied through traditional means [[7]Kowalski R.M. Limber S.P. Psychological, physical, and academic correlates of cyberbullying and traditional bullying.J Adolesc Health. 2013; 53: S13-S20Abstract Full Text Full Text PDF PubMed Scopus (768) Google Scholar]. Those who witness bullying but are not directly involved are also at increased risk. Rivers and Noret [[18]Rivers I. Noret N. Potential suicide ideation and its association with observing bullying at school.J Adolesc Health. 2013; 53: S32-S36Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar] report that students who observed bullying behavior were significantly more likely than those uninvolved in bullying to report symptoms of interpersonal sensitivity (feelings of being hurt and feelings of inferiority) and greater helplessness. However, the papers in this issue also convey the complexity of the relationship between bullying and suicide-related behaviors. In Espelage and Holt's work [[17]Espelage D.L. Holt M.K. Suicidal ideation and school bullying experiences after controlling for depression and delinquency.J Adolesc Health. 2013; 53: S27-S31Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar], after controlling for delinquency and depression there was no increased risk of suicide-related behaviors for perpetrators; the increased risk did remain for victims. Klomek's [[19]Klomek A.B. Kleinman M. Altschuler E. et al. Suicidal adolescents' experiences with bullying perpetration and victimization during high school as risk factors for later depression and suicidality.J Adolesc Health. 2013; 53: S37-S42Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar] comparison of young people with bullying involvement and psychiatric symptoms (depression, suicidality, or substance use) at an initial screen to those with psychiatric symptoms but no bullying involvement found, at 2-year follow-up, that only perpetrators of bullying were significantly more likely to be functionally impaired than bullying-uninvolved students. In King's study of hospitalized suicidal youth, those who reported perpetrating bullying were more likely than uninvolved youth to have severe suicidal thoughts and psychosocial impairment, and to abuse substances. However, at 12-month follow-up, only the difference in psychosocial impairment remained. Interestingly, over the course of 1-year treatment for the suicidality, the rate of bullying perpetration declined [[20]King C.A. Horwitz A. Berona J. Jiang Q. Acutely suicidal adolescents who engage in bullying behavior: 1-year trajectories.J Adolesc Health. 2013; 53: S43-S50Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. In Karch's analysis of suicide fatalities among youth, bullying involvement was one of a myriad of factors precipitating a death by suicide. A quarter of young suicide victims had school problems, but only 12.4% of these school problems were attributed to bullying [[21]Karch D.L. Logan J. McDaniel D.D. et al. Precipitating circumstances of suicide among youth aged 10–17 years by sex: Data from the National Violent Death Reporting System, 16 States, 2005–2008.J Adolesc Health. 2013; 53: S51-S53Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar]. Other salient circumstances included depressed mood and/or other current mental health problems (37%); intimate partner problems (25%); history of suicide attempts (18%); and substance abuse problems (16%). Suicide attempts and substance use were risk factors that co-occurred with suicide ideation in Borowsky et al. as well [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. Across all groups (victims, perpetrators, and bully-victims) a history of self-harm within the prior year and greater emotional distress (feelings of sadness, hopelessness, worry, stress, or pressure) drastically increased risk for suicide. For victims and bully-victims, a history of sexual abuse, a mental health problem, or running away from home in the past year increased the likelihood of suicidal thinking or behavior [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. More than half of the youth who were bully-victims and who expressed suicidal ideation or reported making an attempt also witnessed family violence, had a history of physical abuse, smoked cigarettes, used marijuana, skipped school because of safety concerns, or carried a weapon at school. Youth who were involved in bullying and reported suicide-related thoughts or behaviors also had higher mean scores for distractibility/impulsivity and lower mean scores for parent connectedness, connectedness to other adults, perceived caring by teachers, perceived caring by friends, liking school, academic achievement, physical activity, perceived school safety, and perceived neighborhood safety [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. Across all three bullying-involved groups, parent connectedness (feeling like you can talk to mom/dad about problems; that mom/dad care about you) was protective for suicidal ideation and attempts. Other protective factors for victims included stronger connections to nonparental adults, stronger perceived caring by friends, and liking school. For bully-victims, greater perceived caring by friends was also protective [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. That there is a relationship between bullying and depression and that this relationship may help to explain the relationship between bullying and suicide is fairly consistent across papers. However, the direction of this relationship is unclear. Do youth who are bullied become depressed or are depressed youth more likely to be bullied? A study from the Netherlands suggests the answer may be “both.” Researchers found that victims of bullying had significantly higher chances of developing new psychosomatic and psychosocial problems over the course of a school year compared with children who were not bullied. However, children with preexisting depressive symptoms or anxiety were also significantly more likely to be newly victimized over the course of the school year [[11]Fekkes M. Pijpers F. Fredriks A.M. et al. Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics. 2006; 117: 1568-1574Crossref PubMed Scopus (426) Google Scholar]. Despite the complexity of the relationship between bullying and suicide, there is no doubt that bullying involvement can have detrimental effects and prevention of bullying could improve health and mental health outcomes for many youth. The findings in these articles underscore the complexity of the relationship between bullying and suicide. A critical difference distinguishes an association between bullying and suicide from a causal relationship, with significant implications for prevention. Conveying that bullying alone causes suicide at best minimizes, and at worst ignores, the other factors that may contribute to death by suicide. This neglect may result in too narrow a focus of preventive action. We echo the call made by others for an integrated approach to preventing suicide and youth violence by focusing on shared risk and protective factors including individual coping skills, family and school social support, and supportive school environments [[22]Lubell K.M. Vetter J.B. Suicide and youth violence prevention: The promise of an integrated approach. Aggression and Violent Behavior. 2006; 11: 167-175Crossref Scopus (71) Google Scholar]. Strengthening social connectedness and ensuring access to supportive adults may pay dividends in impacting both bullying and suicide behaviors. Supportive home and school environments where young people feel connected are just one overlapping protective factor. Borowksy's findings regarding connection to parents, other adults, school, and friends reflect the need for multiple strategies that focus on both the school and home environments and that move beyond the individual skill-building level to foster supportive environments [[6]Borowsky I.W. Taliaferro L.A. McMorris B.J. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors.J Adolesc Health. 2013; 53: S4-S12Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. The case for a supportive environment on bullying and suicide prevention is supported by Hatzenbuehler's work. In the paper contained in this special issue, he reports findings that lesbian and gay youths living in counties with fewer school districts with antibullying policies that specifically mentioned sexual orientation as a protected group were nearly two times more likely to have attempted suicide in the past year compared with those living in counties where more districts had these policies [[10]Hatzenbuehler M.L. Keyes K.M. Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth.J Adolesc Health. 2013; 53: S21-S26Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar]. Williams and Guerra reported that youth who describe their school climate as being trusting, fair, and pleasant have lower involvement in verbal, physical, and Internet bullying perpetration [[23]Williams K.R. Guerra N.G. Prevalence and predictors of internet bullying.J Adolesc Health. 2007; 41: S14-S21Abstract Full Text Full Text PDF PubMed Scopus (669) Google Scholar]. As reflected in CDC's strategic direction on suicide [[24]Centers for Disease Control and Prevention (CDC). Connectedness as a strategic direction for the prevention of suicidal behavior. Available at: http://www.cdc.gov/violenceprevention/pdf/suicide_strategic_direction-one-pager-a.pdf. Google Scholar], approaches intended to build connections between youth and school and home environments, as well as communities, are essential to suicide prevention. Sources of Strength is a school-based suicide-prevention program that trains youth opinion leaders to change the norms and behaviors of their peers by conducting well-defined messaging activities with adult mentoring, as well as increasing perceptions of adult support for suicidal youths and the acceptability of seeking help M. et of the Sources of Strength suicide prevention program by leaders in high J Health. 2010; PubMed Scopus Google Scholar]. work also the of connections to support prevention. As an example, the youth suicide prevention found that who reported a stronger connection to youth in their program were as likely to suicidal youth. the research also that the bullying prevention are A of school bullying strategies that school approaches that included multiple and at of school more often reduced victimization and bullying than the that only included or social groups A review of school-based to Pediatr Adolesc Med. 2007; PubMed Scopus Google Scholar]. there is about the prevention of bullying and suicide, there is also do not studies over the past two have the of bullying prevention However, studies have in the States, these have not A review of school-based to Pediatr Adolesc Med. 2007; PubMed Scopus Google Scholar]. is evidence that youth violence prevention that for such as and also rates of bullying The impact of and on bullying and A Pediatr Adolesc Med. PubMed Scopus Google Scholar]. More work is to strategies that bullying from among youth in the In that depression is a significant risk for bullying and suicide as well as a of other behaviors. We need to to mental among young people and their and to do in and However, the and impact of bullying, it is to move while these strategies are being We can by and strategies that have at increasing protective factors and risk factors associated with both bullying and suicide. is not that bullying in is it that bullying occur in the in and health their focus beyond just to those who are involved in bullying or suicide-related behaviors, but also in strategies to bullying and suicidal behavior from in the

Journal of Adolescent Health · editorial or comment · 170 citationsread the source →

PATHOPHYSIOLOGY OF DEPRESSION: DO WE HAVE ANY SOLID EVIDENCE OF INTEREST TO CLINICIANS?

Major depressive disorder (MDD) is a common and costly disorder which is usually associated with severe and persistent symptoms leading to important social role impairment and increased mortality 1,2. It is one of the most important causes of disability worldwide 3. The high rate of inadequate treatment of the disorder remains a serious concern 1. This review is aimed at summarizing the solid evidence on the etiology and pathophysiology of MDD that is likely relevant for clinical psychiatry. Neurobiological findings are regarded as solid when they are consistent and convergent, i.e., they have been confirmed by several studies using the same method and fit into results from studies using different methodological approaches. Family, twin, and adoption studies provide very solid and consistent evidence that MDD is a familial disorder and that this familiality is mostly or entirely due to genetic factors 4. This important finding suggests that parental social behavior and other familial environmental risk factors are not as important in the pathogenesis of MDD as previously assumed and should not be the major focus of the treatment of the disorder. The above-mentioned studies consistently show that the influence of genetic factors is around 30–40% 4. Non-genetic factors, explaining the remaining 60–70% of the variance in susceptibility to MDD, are individual-specific environmental effects (including measurement error effects and gene-environment interactions). These effects are mostly adverse events in childhood and ongoing or recent stress due to interpersonal adversities, including childhood sexual abuse, other lifetime trauma, low social support, marital problems, and divorce 5,6. These results suggest that there is a huge potential in the prevention of MDD by means of psychosocial interventions (e.g., in schools, at workplace). In addition, these results mirror the clinical practice of empirically validated psychotherapies to treat depression 7,8,9, including interpersonal, psychodynamic and cognitive behavioral psychotherapies and cognitive behavioural analysis system of psychotherapy, which all focus directly or indirectly on interpersonal difficulties and skills. This does not exclude the fact that unidentified non-genetic, non-psychosocial risk factors may also play important roles in some patients (e.g., climatic change, medical conditions). Stress sensitivity in depression is partly gender-specific. While men and women are, in general, equally sensitive to the depressogenic effects of stressful life events, their responses vary depending upon the type of stressor. Specifically, men are more likely to have depressive episodes following divorce, separation, and work difficulties, whereas women are more sensitive to events in their proximal social network, such as difficulty getting along with an individual, serious illness, or death 10. These findings point to the importance of gender-sensitive psychosocial approaches in the prevention and treatment of MDD. In contrast to the very solid evidence from epidemiological studies on broad risk factor domains, there is no solid evidence for specific genes and specific gene-by-environment interactions in the pathogenesis of MDD. Genome-wide association studies have indicated that many genes with small effects are involved in complex diseases, increasing the difficulty in identifying such genes 11. While there has been progress in the search for risk genes for several complex diseases despite this methodological problem 12, psychiatric conditions have turned out to be very resistant to robust gene identification. For example, based on a community-based prospective study, it has been proposed that a specific genetic variation in the promoter region of the serotonin transporter (a target of antidepressant drugs) interacts with stressful life events in the pathogenesis of depression 13. Although there is high clinical and neurobiological plausibility of this interaction, a recent meta-analysis yielded no evidence that the serotonin transporter gene alone or in interaction with psychological stress was associated with the risk of depression 14. The limited success of genetic studies of depression has been related to use of current classification schemas including ICD-10 and DSM-IV. These diagnostic manuals are based on clusters of symptoms and characteristics of clinical course that do not necessarily describe homogenous disorders but instead reflect common final pathways of different pathophysiolgical processes 15,16. The clinician should be aware that family history will continue to be the most solid source of information to estimate the genetic risk of MDD. Corticotropin-releasing hormone (CRH) is released from the hypothalamus in response to the perception of psychological stress by cortical brain regions. This hormone induces the secretion of pituitary corticotropin, which stimulates the adrenal gland to release cortisol into the plasma. The physiologic response to stress is partly gender-specific: women show generally greater stress responsiveness than men, which is consistent with the greater incidence of major depression in women 17. Moreover, men show greater cortisol responses to achievement challenges, whereas women show greater cortisol responses to social rejection challenges 18. Although MDD is considered as a stress disorder, most subjects treated for MDD have no evidence of dysfunctions of the hypothalamic-pituitary-adrenal axis (HPA) 19. However, some subjects with MDD do show abnormalities of that axis and of the extrahypothalamic CRH system 20. Altered stress hormone secretion appeared to be most prominent in depressed subjects with a history of childhood trauma 21. Elevated cortisol may act as a mediator between major depression and its physical long-term consequences such as coronary heart disease, type II diabetes, and osteoporosis 22. The importance of HPA axis dysfunction for the efficacy of antidepressants is a matter of debate 23. This axis is regulated through a dual system of mineralocorticoid (MR) and glucocorticoid (GR) receptors. Decreased limbic GR receptor function 24,25 and increased functional activity of the MR system 26 suggest an imbalance in the MR/GR ratio in stress-related conditions such as MDD. Epigenetic regulation of the glucocorticoid receptors has been associated with childhood abuse 27. Such environmental programming of gene expression may represent one possible mechanism that links early life stress to abnormal HPA axis function and increased risk of MDD in adults. While the CRH stimulation test (dex/CRH test) 28 is a sensitive measure of the HPA axis dysfunction in depression, the specificity of this test for MDD is low. However, non-suppression in the dex/CRH test has consistently predicted increased risk for depressive relapse during clinical remission 23. Additionally, the measurement of waking salivary cortisol concentration has been shown to be a simple and sensitive test for HPA axis hyperactivity in depression 29. Hypercortisolemia is almost exclusively found in subjects with severe and psychotic depression, in whom glucocorticoid antagonists may have some therapeutic effect 30. There is convergent evidence for CRH to play a major role in the pathogenesis of certain types of depression. Levels of CRH in the cerebrospinal fluid are elevated in some depressed subjects 31. Post-mortem studies reported an increased number of CRH secreting neurons in limbic brain regions in depression 32, likely reflecting a compensatory response to increased CRH concentrations 33. In addition, CRH produces a number of physiological and behavioral alterations that resemble the symptoms of major depression, including decreased appetite, disrupted sleep, decreased libido, and psychomotor alterations 34. There is also preliminary evidence that CRH1 receptor antagonists reduce symptoms of depression and anxiety 35. “Sickness behavior” as a result of an activation of the inflammatory response system shares many symptoms with depression, including fatigue, anhedonia, psychomotor retardation, and cognitive impairment. Sickness is mediated by pro-inflammatory cytokines such as interleukin-1α, tumor necrosis factor-α, and interleukin-6, which activate the HPA axis and impair the central serotonin system 36. The prevalence of depression as an unwanted effect of recombinant interferons is around 30% 37. In animals, blocking pro-inflammatory cytokine-mediated signaling produces antidepressant-like effects 38. Clinical data suggest that cytokines may play a role in the pathophysiology of a subgroup of depressed subjects, particularly those with comorbid physical conditions 36. The antidepressant enhancing effect of acetylsalicylic acid 39 points to the possible clinical relevance of psychoneuroimmunology in clinical depression research. Taken together, the laboratory tests with the highest potential to be clinically useful in the care of depressed individuals are based on abnormalities of the neuroendocrine and neuroimmune systems. Despite the large amount of basic science data suggesting that the HPA axis is importantly involved in the pathophysiology of depression, the effect of pharmacological modulation of this neuroendocrine system as antidepressant therapy has been disappointing. The link between childhood trauma and a permanently altered physiologic stress system points to the use of specific psychotherapies in the treatment of depressed patients with a history of early life trauma 40. Most of the serotonergic, noradrenergic and dopaminergic neurons are located in midbrain and brainstem nuclei and project to large areas of the entire brain. This anatomy suggests that monoaminergic systems are involved in the regulation of a broad range of brain functions, including mood, attention, reward processing, sleep, appetite, and cognition. Almost every compound that inhibits monoamine reuptake, leading to an increased concentration of monoamines in the synaptic cleft, has been proven to be a clinically effective antidepressant 19. Inhibiting the enzyme monoamine oxidase, which induces an increased availability of monoamines in presynaptic neurons, also has antidepressant effects. These observations led to the pharmacologically most relevant theory of depression, referred to as the monoamine-deficiency hypothesis. The monoamine-deficiency theory posits that the underlying pathophysiological basis of depression is a depletion of the neurotransmitters serotonin, norepinephrine or dopamine in the central nervous system. Serotonin is the most extensively studied neurotransmitter in depression. The most direct evidence for an abnormally reduced function of central serotonergic system comes from studies using tryptophan depletion, which reduces central serotonin synthesis. Such a reduction leads to the development of depressive symptoms in subjects at increased risk of depression (subjects with MDD in full remission, healthy subjects with a family history of depression) 41,42, possibly mediated by increased brain metabolism in the ventromedial prefrontal cortex and subcortical brain regions 42. Experimentally reduced central serotonin has been associated with mood congruent memory bias, altered reward-related behaviors, and disruption of inhibitory affective processing 16, all of which add to the clinical plausibility of the serotonin deficiency hypothesis. There is also evidence for abnormalities of serotonin receptors in depression, with the most solid evidence pointing to the serotonin-1A receptor, which regulates serotonin function. Decreased availability of this receptor has been found in multiple brain areas of patients with MDD 43, although this abnormality is not highly specific for MDD and has been found in patients with panic disorder 44 and temporal lobe epilepsy 45, possibly contributing to the considerable comorbidity among these conditions. However, there is no explanation for the mechanism of serotonin loss in depressed patients, and studies of serotonin metabolites in plasma, urine and cerebrospinal fluid, as well as post-mortem research on the serotonergic system in depression, have yielded inconsistent results. There is preliminary evidence that an increased availability of the brain monoamine oxidase, which metabolizes serotonin, may cause serotonin deficiency 46. In addition, loss-of-function mutations in the gene coding for the brain-specific enzyme tryptophan hydroxylase-2 may explain the loss of serotonin production as a rare risk factor for depression 47. Dysfunction of the central noradrenergic system has been hypothesized to play a role in the pathophysiology of MDD, based upon evidence of decreased norepinephrine metabolism, increased activity of tyrosine hydroxylase, and decreased density of norepinephrine transporter in the locus coeruleus in depressed patients 48. In addition, decreased neuronal counts in the locus coeruleus, increased alpha-2 adrenergic receptor density, and decreased alpha-1 adrenergic receptor density have been found in the brains of depressed suicide victims post-mortem 49. Since there is no method to selectively deplete central norepinephrine and no imaging tool to study the central norepinephrine system, solid evidence for abnormalities of this system in depression is lacking. While the classical theories of the neurobiology of depression mainly focused on serotonin and norepinephrine, there is increasing interest in the role of dopamine 50. Dopamine reuptake inhibitors (e.g., nomifensine) and dopamine receptor agonists (e.g., pramipexole) had antidepressant effects in placebo-controlled studies of MDD 51. In the cerebrospinal fluid and jugular vein plasma, levels of dopamine metabolites were consistently reduced in depression, suggesting decreased dopamine turnover 52. Striatal dopamine transporter binding and dopamine uptake were reduced in MDD, consistent with a reduction in dopamine neurotransmission 53. Degeneration of dopamine projections to the striatum in Parkinson's disease was associated with a major depressive syndrome in about one half of cases, which usually preceded the appearance of motor signs 54. Experimentally reduced dopaminergic transmission into the accumbens has been associated with anhedonic symptoms and performance deficits on a reward processing task in subjects at increased risk of depression 55,56. These findings are consistent with the clinical observation that depressed patients have a blunted reaction to positive reinforcers and an abnormal response to negative feedback 57. Almost all established antidepressants target the monoamine systems 58. However, full and partial resistance to these drugs and their delayed onset of action suggest that dysfunctions of monoaminergic neurotransmitter systems found in MDD represent the downstream effects of other, more primary abnormalities. Despite this limitation, the monoamine-deficiency hypothesis has proved to be the most clinically relevant neurobiological theory of depression. New findings on the role of dopamine in depression emphasize the scientific potential of this theory, and promising reports of antidepressant effects of drugs that modulate the dopaminergic system (e.g., pramipexole, modafinil) in difficult-to-treat depression underline its clinical relevance 51,59. Although many historical attempts to localize mental functions have failed, they have considerably contributed to a modern neuroscientific understanding of mental disorders 60. The development of neuroimaging techniques has opened up the potential to investigate structural and functional abnormalities in living depressed patients. Unfortunately, the diversity of imaging techniques used, the relatively small and heterogeneous study samples studied, and the limited overlap of results across imaging paradigms 61 make it difficult to reliably identify neuronal regions or networks with consistently abnormal structure or function in MDD. Functional imaging studies have provided the most limited overlap of findings. This may be due to methodological limitations and/or the complexity of neurocircuitry involved in MDD. A recent meta-analytic study found the best evidence for abnormal brain activity in MDD in lateral frontal and temporal cortices, insula, and cerebellum. In these brain regions activity was decreased at rest, they showed a relative lack of activation during induction of negative emotions, and an increase in activity following treatment with serotonin reuptake inhibitors. Opposite changes may exist in ventromedial frontal areas, striatum and possibly other subcortical brain regions 61. More solid evidence has been provided by structural imaging and post-mortem studies. A recent meta-analytic study on brain volume abnormalities in MDD revealed relatively large volume reductions in the ventromedial prefrontal cortex, particularly in the left anterior cingulate and in the orbitofrontal cortex. Moderate volume reductions were found in the lateral prefrontal cortex, hippocampus and striatum 62. Post-mortem studies consistently identified a reduction in glia cell density in dorsal, orbital and subgenual prefrontal cortices, as well as in the amygdala 63,64. Overall, functional, structural and post-mortem studies suggest that structural and functional abnormalities in the left subgenual cingulate cortex are the most solid neuroanatomical finding in MDD. Volume reduction in this region was found early in illness and in young adults at high familial risk for MDD 65, suggesting a primary neurobiological abnormality associated with the etiology of the illness. Humans with lesions that include the subgenual prefrontal cortex showed abnormal autonomic responses to social stimuli 66, and rats with left-sided lesions in this region had increased sympathetic arousal and corticosterone responses to restraint stress 67. Most importantly, chronic deep brain stimulation to reduce the potentially elevated activity in the subgenual cingulated cortex produced clinical benefits in patients with treatment-resistant depression 68. In summary, despite the considerable heterogeneity of findings from neuroimaging studies, there is convergent evidence for the presence of abnormalities in the subgenual prefrontal cortex in some patients with MDD. Neuroanatomical research in depression is of great clinical interest, since novel antidepressant treatments such as deep brain stimulation can target specific brain regions. In addition, there are promising leads for neuroimaging findings to predict the likelihood of responses to specific treatments 69. Risk factors for depressive episodes change during the course of the illness. The first depressive episode is usually “reactive”, i.e., triggered by important psychosocial stressors, while subsequent episodes become increasingly “endogenous”, i.e., triggered by minor stressors or occurring spontaneously 70. There is consistent evidence that the volume loss of the hippocampus and other brain regions is related to the duration of depression 71, suggesting that untreated depression leads to hippocampal volume loss, possibly resulting in increased stress sensitivity 72 and increased risk of recurrence 73. Glucocorticoid neurotoxicity, glutamatergic toxicity, decreased neurotrophic factors, and decreased neurogenesis have been proposed as possible mechanisms explaining brain volume loss in depression. There is no solid evidence on of these since there are no imaging to directly and neurotrophic processes in neurotrophic factor has considerable Specifically, studies have shown between and in hippocampal as well as expression of following antidepressant treatment The clinician should be aware of the potentially effect of depression and treat depressed patients as early and as A of studies consistently showed reductions in acid concentrations in the prefrontal and cortex in depression This may reflect stress since psychological stress to presynaptic of prefrontal neurotransmission low concentration may reflect reduction in the density and of In addition, chronic stress may reduce receptor possibly through changes in evidence of the hypothesis of depression the lack of effects of drugs on depressive symptoms and prefrontal concentration in subjects with MDD of evidence suggest a dysfunction of the neurotransmitter system in a of the receptor produced and large antidepressant effects in patients with treatment-resistant MDD inhibitors of release (e.g., antidepressant abnormal levels were found in depressed subjects as by and there is evidence for abnormal signaling in post-mortem Since is the major neurotransmitter involved in almost every brain the of the specific role of in depression (e.g., there are promising leads that the receptor is involved in MDD and are diagnostic for MDD, suggesting regulation in depressed patients. In addition, some depressive symptoms may show psychomotor of of positive and negative and a subgroup of patients with MDD may have a disorder In healthy young subjects, changes in the of the had specific effects on subsequent mood In depressed patients, of can have antidepressant on these abnormalities have been hypothesized to be associated with MDD The association between of the and in cortisol in some subjects with and the effect of antidepressants on of and to the of this hypothesis Despite of the many promising the and genetic of this hypothesis are It remains to be antidepressant effects of such as directly to of on these abnormalities have been hypothesized to be associated with MDD The association between of the and in cortisol in some subjects with and the effect of antidepressants on of and to the of this hypothesis Despite of the many promising the and genetic of this hypothesis are It remains to be antidepressant effects of such as directly to of The and of the neurobiological of depression are in 1. The many theories of depression and the relatively low response rate of all antidepressant treatments a hypothesis of and suggest that depression is a clinically and heterogeneous disorder. This research on of the response to therapeutic interventions using such as neuroimaging and neuroendocrine tests in with for with to stress sensitivity and antidepressant The of of therapeutic will for the development of that has the potential to interventions and to up pathways in the of novel therapeutic approaches.

World Psychiatry · editorial or comment · 607 citationsread the source →

Total sleep time in Muslim football players is reduced during Ramadan: a pilot study on the standardized assessment of subjective sleep-wake patterns in athletes.

Ramadan is a period in which Muslims fast during daylight hours and is associated with disturbances in sleep-wake behaviour and adverse effects on physical and mental health in normal volunteers. Studies using athletes are rare and remain equivocal as to whether Ramadan influences sleep-wake patterns. Notably, the standardized assessment of subjective sleep quality and daytime sleepiness in athletes has not been established. This study employed the Arabic version of the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Epworth Sleepiness Scale in nine football players aged 20-35 years (mean ± s: 26 ± 4) one week before and during the last week of Ramadan. Compliance rates with self-administration were high (71%) and the results demonstrated a robust decline in total sleep time (before Ramadan: 6.6 ± 2 h; at the end of Ramadan: 5.3 ± 1 h; P < 0.05, effect size 0.81). Compared with previous research, the study questionnaires offer improved methodology, including less time constraints plus standardization in scoring. Thus, this study demonstrates a framework for greater reproducibility and reliability in the assessment of subjective sleep-wake patterns in athletes before and during Ramadan.

Journal of sports sciences · 42 citationsread the source →

Violence towards health care workers in a Public Health Care Facility in Italy: a repeated cross-sectional study.

Background: Violence at work is one of the major concerns in health care activities. The aim of this study was to identify the prevalence of physical and non-physical violence in a general health care facility in Italy and to assess the relationship between violence and psychosocial factors, thereby providing a basis for appropriate intervention. Methods: All health care workers from a public health care facility were invited to complete a questionnaire containing questions on workplace violence. Three questionnaire-based cross-sectional surveys were conducted. The response rate was 75% in 2005, 71% in 2007, and 94% in 2009. The 2009 questionnaire contained the VIF (Violent Incident Form) for reporting violent incidents, the DCS (demand/control/support) model for job strain, the Colquitt 20 item questionnaire for perceived organizational justice, and the GHQ-12 General Health Questionnaire for the assessment of mental health. Results: One out of ten workers reported physical assault, and one out of three exposure to non-physical violence in the workplace in the previous year. Nurses and physicians were the most exposed occupational categories, whereas the psychiatric and emergency departments were the services at greatest risk of violence. Workers exposed to non-physical violence were subject to high job strain, low support, low perceived organizational justice, and high psychological distress. Conclusion: Our study shows that health care workers in an Italian local health care facility are exposed to violence. Workplace violence was associated with high demand and psychological disorders, while job control, social support and organizational justice were protective factors.

BMC health services research · 149 citationsread the source →

Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence.

Background: Stress urinary incontinence (SUI) leads to considerable physical and psychological morbidity. The highest prevalence reported was found in Caucasian Americans (range 23% -67%) and the lowest in Singaporean females (4.8%). The study assessed the prevalence, perceptions, predisposing factors and health seeking behaviour of women with SUI in an Asian setting which may have different sociocultural implications. Methods: 400 consecutive women >20 years of age attending the outpatient department of a tertiary care hospital in Sri Lanka, for non-urinary conditions were studied over a 3 week period using an interviewer administered questionnaire. SUI was diagnosed on clinical history alone when leakage of urine occurred either with coughing, sneezing, walking or lifting heavy objects. The severity was graded using the Finnish Gynaecological Society's Urinary Incontinence Severity Score (UISS). Data were analysed using SPSS version 20. Odds ratios were calculated using univariate and multivariate analysis. Results: Ninety three (23.33%) had SUI and only 12 (12.9%) had sought treatment. The prevalence among women >50 years of age was 34.71% ( n = 121) compared to 18.28% (n = 279) in those ≤50 years. 25 (26.88%) had mild SUI, 66 (70.97%) moderate and 2 (2.15%) severe as per UISS. SUI was perceived as an illness by 210 (52.5%). SUI was significantly associated with pregnancy, parity, vaginal delivery, complicated labour, diabetes mellitus, chronic cough, constipation and faecal incontinence (p < 0.05).Among those affected main reasons for not seeking medical advice included; being embarrassed (n = 27, 33.33%), not knowing that it is remediable (n = 23, 28.40%), perceiving SUI to be a normal consequence of childbirth (n = 19, 23.46%) and having to attend to needs of the family (n = 12, 14.81%). None who had been pregnant (n = 313) had received advice on postnatal pelvic floor exercises. SUI interfered with social activities (71;76.34%), sexual function (21; 22.58%) and resulted in despair (67; 72.09%). It was associated with clinically diagnosed candidiasis (50; 53.76%) and soreness in the perineal region (49; 52.69%). Conclusions: SUI is a common and neglected gynaecological problem with poor healthcare seeking behaviour. Community based education may help to minimize the occurrence and improve the quality of life of those affected.

BMC women's health · 46 citationsread the source →

Activation of the cholinergic anti-inflammatory pathway ameliorates postoperative ileus in mice.

Background & aims: We previously showed that intestinal inflammation is reduced by electrical stimulation of the efferent vagus nerve, which prevents postoperative ileus in mice. We propose that this cholinergic anti-inflammatory pathway is mediated via alpha7 nicotinic acetylcholine receptors expressed on macrophages. The aim of this study was to evaluate pharmacologic activation of the cholinergic anti-inflammatory pathway in a mouse model for postoperative ileus using the alpha7 nicotinic acetylcholine receptor-agonist AR-R17779. Methods: Mice were pretreated with vehicle, nicotine, or AR-R17779 20 minutes before a laparotomy (L) or intestinal manipulation (IM). Twenty-four hours thereafter gastric emptying was determined using scintigraphy and intestinal muscle inflammation was quantified. Nuclear factor-kappaB transcriptional activity and cytokine production was assayed in peritoneal macrophages. Results: Twenty-four hours after surgery IM led to a delayed gastric emptying compared with L (gastric retention: L(saline) 14% +/- 4% vs IM(saline) 38% +/- 10%, P = .04). Pretreatment with AR-R17779 prevented delayed gastric emptying (IM(AR-R17779) 15% +/- 4%, P = .03). IM elicited inflammatory cell recruitment (L(saline) 50 +/- 8 vs IM(saline) 434 +/- 71 cells/mm(2), P = .001) which was reduced by AR-R17779 pretreatment (IM(AR-R17779) 231 +/- 32 cells/mm(2), P = .04). An equimolar dose of nicotine was not tolerated. Subdiaphragmal vagotomy did not affect the anti-inflammatory properties of AR-R17779. In peritoneal macrophages, both nicotinic agonists reduced nuclear factor kappaB transcriptional activity and proinflammatory cytokine production, with nicotine being more effective than AR-R17779. Conclusions: AR-R17779 treatment potently prevents postoperative ileus, whereas toxicity limits nicotine administration to ineffective doses. Our data further imply that nicotinic inhibition of macrophage activation may involve other receptors in addition to alpha7 nicotinic acetylcholine receptor.

Gastroenterology · 174 citationsread the source →

Cognitive behavioural therapy with behavioural analysis for pharmacological treatment-resistant chronic insomnia.

This study aimed to determine whether (1) cognitive behavioural therapy with behavioural analysis for insomnia (CBTi-BA) is more effective for insomnia and co-morbid depressive symptoms than treatment as usual (TAU) and (2) whether CBTi-BA promotes earlier reduction of the daily dose of hypnotic medication in chronic insomnia resistant to pharmacological treatment. A total of 63 patients with chronic insomnia aged 20-77 years who already received hypnotic medication regularly were assigned to two interventions: combined therapy or TAU alone. The subjects provided demographic information and completed self-rating scales for insomnia and depressive symptoms. After treatment, the combined therapy group showed significant decreases in the symptoms of both insomnia and depression and significant reductions in the daily dose of hypnotic medication compared with the group receiving TAU alone. In the combined therapy group, 71% of the participants reported a reduction in insomnia to normal levels and 79% succeeded in decreasing the daily dose of hypnotics to 50% or less of the baseline dose. These results revealed that CBTi-BA can reduce insomnia and depressive symptoms as well as the daily dose of hypnotic medication in patients with chronic insomnia resistant to pharmacological treatment.

Psychiatry research · 10 citationsread the source →

Taking a Spiritual History Allows Clinicians to Understand Patients More Fully

Journal of Palliative MedicineVol. 3, No. 1 Innovations in End-of-Life CareTaking a Spiritual History Allows Clinicians to Understand Patients More FullyDr. Christina Puchalski and Anna L. RomerDr. Christina Puchalski and Anna L. RomerPublished Online:19 Apr 2005https://doi.org/10.1089/jpm.2000.3.129AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byVerbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two Danish hospices4 January 2022 | BMC Palliative Care, Vol. 21, No. 1Implementation of an Educational Toolkit to Increase Nurse Competence in Spirituality and Spiritual Care of Oncology Patients8 November 2022 | Journal of Holistic Nursing, Vol. 5Posicionamento sobre a Saúde Cardiovascular nas Mulheres – 2022Arquivos Brasileiros de Cardiologia, Vol. 119, No. 5Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention15 October 2022 | Family Practice, Vol. 29Religious and spiritual journeys of LGBT older adults in rural Southern Appalachia25 October 2021 | Journal of Religion, Spirituality & Aging, Vol. 34, No. 4The CASH assessment tool: A window into existential suffering19 May 2021 | Journal of Health Care Chaplaincy, Vol. 28, No. 4Integrating religion/spirituality into professional social work practice27 July 2022 | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 41, No. 4The Concept of Spirituality in the Health Sector: Contributions from the Study of Religion27 September 2022 | International Journal of Latin American Religions, Vol. 12Systematic review: The relationship between religion, spirituality and mental health in adolescents who identify as transgender13 September 2022 | Journal of Gay & Lesbian Mental Health, Vol. 26„Des Lebens Ruf an uns wird niemals enden“ – Sinnzentrierte Interventionen im Überblick30 August 2022 | Zeitschrift für Palliativmedizin, Vol. 23, No. 05Case discussion: The critically ill older adult in spiritual distressGeriatric Nursing, Vol. 47Australian Patient Preferences for the Introduction of Spirituality into their Healthcare Journey: A Mixed Methods Study3 August 2022 | Journal of Religion and Health, Vol. 27Religion, Spirituality, and Ethics in Psychiatric Practice30 March 2022 | Journal of Nervous & Mental Disease, Vol. 210, No. 8Spiritual distress in dialysis: A case report21 July 2022 | Progress in Palliative Care, Vol. 211Interprofessional communication training to address spiritual aspects of cancer care19 July 2022 | Journal of Health Care Chaplaincy, Vol. 29Spirituality in Serious Illness and HealthJAMA, Vol. 328, No. 2What is the role of spiritual care specialists in teaching generalist spiritual care? The perspectives of pastoral care staff in a large Catholic health and aged care organisation.5 July 2022 | Journal of Health Care Chaplaincy, Vol. 63Teaching spirituality to medical students: a systematic review17 June 2021 | Journal of Health Care Chaplaincy, Vol. 28, No. 3Biblical narratives and the planned change process in social work: assessment tool integration of faith and learning5 May 2022 | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 41, No. 3God, spirituality and religion in women dying from gynecological cancer19 July 2021 | Climacteric, Vol. 25, No. 3Palliative Professionals’ Views on the Importance of Religion, Belief, and Spiritual Identities toward the End of Life16 May 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 10“Spirituality is everybody’s business”: an exploration of the impact of spiritual care training upon the perceptions and practice of rehabilitation professionals25 September 2020 | Disability and Rehabilitation, Vol. 44, No. 8A quality improvement project to standardize chaplain documentation in the electronic medical record28 December 2020 | Journal of Health Care Chaplaincy, Vol. 28, No. 2Corrigendum: Spirituality/Religiosity as a Therapeutic Resource in Clinical Practice: Conception of Undergraduate Medical Students of the Paulista School of Medicine (Escola Paulista de Medicina) - Federal University of São Paulo (Universidade Federal de São Paulo)29 March 2022 | Frontiers in Psychology, Vol. 13AD-LAST! An interdisciplinary clinical workshop to improve cultural and spiritual awareness in advance care planning skills15 March 2022 | Palliative and Supportive Care, Vol. 55Hope pictured in drawings by patients newly diagnosed with advanced cancer11 March 2022 | Journal of Clinical Nursing, Vol. 298Addressing spiritual distress in pediatric oncology14 January 2022 | Pediatric Blood & Cancer, Vol. 69, No. 3Exploring the Meaning of Spirituality and Spiritual Care with Help From Viktor Frankl24 June 2021 | Journal of Holistic Nursing, Vol. 40, No. 1Standardized Spiritual Screening Increases Chaplain Referrals Through the EMR: A Nurse-Chaplain Collaboration for Holistic Acute Healthcare23 February 2022 | Journal of Holistic Nursing, Vol. 63Interplay between spirituality and religiosity on the physical and mental well-being of cancer survivors15 September 2021 | Supportive Care in Cancer, Vol. 30, No. 2Top Ten Tips Palliative Care Clinicians Should Know About Spirituality in Serious Illness Allison Kestenbaum, George Fitchett, Paul Galchutt, Dirk Labuschagne, Shelley E. Varner-Perez, Alexia M. Torke, and Arif H. Kamal3 February 2022 | Journal of Palliative Medicine, Vol. 25, No. 2Moving Beyond Spiritual Assessments: A Dynamic, Augustinian Approach to Spiritual Care of the Dying24 January 2022 | Journal of Pastoral Theology, Vol. 29Integrating Spiritual Care in the Frame1 January 2022Evaluation of a Spiritual History with Elderly Multi-Morbid Patients in General Practice—A Mixed-Methods Study within the Project HoPES34 January 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 1Invited Commentary: Religious Service Attendance and Implications for Clinical Care, Community Participation, and Public Health11 May 2021 | American Journal of Epidemiology, Vol. 191, No. 1Use of the Classic Hallucinogen Psilocybin for Treatment of Existential Distress Associated with Cancer1 January 2022Religiousness and Spirituality in Coping with Cancer1 January 2022Spirituality/Religiosity as a Therapeutic Resource in Clinical Practice: Conception of Undergraduate Medical Students of the Paulista School of Medicine (Escola Paulista de Medicina) - Federal University of São Paulo (Universidade Federal de São Paulo)24 December 2021 | Frontiers in Psychology, Vol. 12Patient desire for spiritual assessment is unmet in urban and rural primary care settings31 March 2021 | BMC Health Services Research, Vol. 21, No. 1Australian perspectives on spiritual care training in healthcare: A Delphi study13 July 2021 | Palliative and Supportive Care, Vol. 19, No. 6Defining Spirituality in Healthcare: A Systematic Review and Conceptual Framework18 November 2021 | Frontiers in Psychology, Vol. 12Assessing the Impact of Provider Training and Perceived Barriers on the Provision of Spiritual Care: a Mixed Methods Study12 November 2021 | Journal of Cancer Education, Vol. 5Development of an Instrument to Assess Spirituality: Reliability and Validation of the Attitudes Related to Spirituality Scale (ARES)4 November 2021 | Frontiers in Psychology, Vol. 12Association between Spirituality, Religiosity, Spiritual Pain, Symptom Distress, and Quality of Life among Latin American Patients with Advanced Cancer: A Multicenter Study Marvin O. Delgado-Guay, Alejandra Palma, Eva Duarte, Mónica Grez, Laura Tupper, Diane D. Liu, and Eduardo Bruera27 October 2021 | Journal of Palliative Medicine, Vol. 24, No. 11Spirituality and Vicarious Trauma Among Trauma Clinicians: A Qualitative Study19 October 2021 | Journal of Trauma Nursing, Vol. 28, No. 6Abordando o Sofrimento Existencial na Pessoa com Cancro20 February 2022 | Revista Portuguesa de Psiquiatria e Saúde MentalQuestioning Capacity in an Elderly Jamaican Man with Terminal Cancer Exhibiting Near-Death Awareness: A Case Report and Review of Literature Cynthia X. Pan, Kelly Thomson, Bruno A. Costa, and Jane Morris13 August 2021 | Journal of Palliative Medicine, Vol. 24, No. 9Posicionamento sobre Hipertensão Arterial e Espiritualidade – 20211 September 2021 | Arquivos Brasileiros de Cardiologia, Vol. 117, No. 3The Content, Teaching Methods and Effectiveness of Spiritual Care Training for Healthcare Professionals: A Mixed-Methods Systematic ReviewJournal of Pain and Symptom Management, Vol. 62, No. 3Religiosity and spirituality in psychiatry residency programs: why, what, and how to teach?1 August 2021 | Brazilian Journal of Psychiatry, Vol. 43, No. 4Editorial: children’s life, religiosity and spirituality matter: perspectives of special groups and their related adults16 July 2021 | International Journal of Children's Spirituality, Vol. 26, No. 3Development and protocol for a nurse-led telephonic palliative care programNursing Outlook, Vol. 69, No. 4Psychological Distress Among a Tunisian Community Sample During the COVID-19 Pandemic: Correlations with Religious Coping27 March 2021 | Journal of Religion and Health, Vol. 60, No. 3Optimism and social support as contributing factors to spirituality in Cancer patients3 January 2021 | Supportive Care in Cancer, Vol. 29, No. 6A mixed‐methods approach to comparing perceptions of cancer patients' and cancer care providers' religious and spiritual beliefs, behaviours, and attitudes23 December 2020 | European Journal of Cancer Care, Vol. 30, No. 3Spirituality and religion in residents and inter-relationships with clinical practice and residency training: a scoping review28 May 2021 | BMJ Open, Vol. 11, No. 5Using Simulation to Prepare Students for Medical Mission TripsJournal of Christian Nursing, Vol. 38, No. 2Implementation of a Meaning-Centered Psychotherapy training (MCPT) program for oncology clinicians: a qualitative analysis of facilitators and barriers9 October 2019 | Translational Behavioral Medicine, Vol. 11, No. 1Medical student reflections: Chaplain shadowing as a model for compassionate care training27 September 2020 | Medical Teacher, Vol. 43, No. 1Competence 3: Spiritual Care, Assessment and Planning19 May 2021Psychospirituelle Ressourcen in einer VUCA-Welt: Implikationen für Beratung und Coaching26 May 2021Application and Implementation of the Spiritual Needs Questionnaire in Spiritual Care Processes29 May 2021Spiritual Care in Health Care: Guideline, Models, Spiritual Assessment and the Use of the ©FICA Spiritual History Tool29 May 2021Relevance of Addressing Spiritual Needs for Clinical Support in Palliative Medicine29 May 2021Addressing Spiritual Needs in Faith Community Nursing29 May 2021Sentidos de vida e morte: reflexões de pacientes em cuidados paliativos1 January 2021 | Psicologia USP, Vol. 32Spiritual Care Competencies for Advanced Practice Nurses16 October 2021Introduction to Spirituality16 October 2021Global APN Case Study in Spirituality-Stories of Hope from Australia16 October 2021Four aspects of spiritual care: a phenomenological action research study on practicing and improving spiritual care at two Danish hospices22 October 2021 | Palliative Care and Social Practice, Vol. 15A Holistic Approach to Meeting Physical, Social and Psychological Needs23 December 2020Effectiveness of spiritual care training for rehabilitation professionals: An exploratory controlled trialNeuroRehabilitation, Vol. 47, No. 4Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain9 December 2020 | Pain Medicine, Vol. 196Testing of a (Spiritual) Self-Assessment Tool ((S)SAT) in a Community Hospital Setting23 November 2020 | Journal of Pastoral Care & Counseling: Advancing theory and professional practice through scholarly and reflective publications, Vol. 74, No. 4Genetic counseling graduate training to address religion and spirituality in clinical practice: A qualitative exploration of programs in North America30 May 2020 | Journal of Genetic Counseling, Vol. 29, No. 6The relationship between caregivers’ perceptions of end-of-life care in long-term care and a good resident death15 May 2020 | Palliative and Supportive Care, Vol. 18, No. 6“Give them the door but don’t push them through it”: Family Attitudes Toward Physician-Led Spiritual Care in Pediatric Palliative Medicine12 February 2020 | Journal of Religion and Health, Vol. 59, No. 6Exploring spirituality with older people: (1) rich experiences11 August 2019 | Journal of Religion, Spirituality & Aging, Vol. 32, No. 4Cultural Competency9 September 2020The Urgency of Spiritual Care: COVID-19 and the Critical Need for Whole-Person PalliationJournal of Pain and Symptom Management, Vol. 60, No. 3Spirituality in Recovery From Substance Use DisordersJournal of Psychosocial Nursing and Mental Health Services, Vol. 58, No. 9A Narrative Approach to Spirituality and Spiritual Care in Health Care3 October 2019 | Journal of Religion and Health, Vol. 59, No. 3Neural underpinning of a personal relationship with God and sense of control: A lesion-mapping study25 April 2020 | Cognitive, Affective, & Behavioral Neuroscience, Vol. 20, No. 3Patterns of Religiosity, Death Anxiety, and Hope in a Population of Community-Dwelling Palliative Care Patients in New Zealand—What Gives Hope If Religion Can’t?9 December 2019 | American Journal of Hospice and Palliative Medicine®, Vol. 37, No. 5Pain Management in Patients with Serious IllnessMedical Clinics of North America, Vol. 104, No. 3Varieties of Religious (Non)AffiliationJournal of Nervous & Mental Disease, Vol. 208, No. 5Cuidados paliativos31 August 2020 | PAJAR - Pan American Journal of Aging Research, Vol. 8, No. 1The Invisibility of Spiritual Nursing Care in Clinical Practice28 November 2019 | Journal of Holistic Nursing, Vol. 38, No. 1Spirituality in heart failure: a review of the literature from 2014 to 2019 to identify spiritual care needs and spiritual interventionsCurrent Opinion in Supportive & Palliative Care, Vol. 14, No. 1Plädoyer für einen (berufs-) alltagstauglichen Begriff von Spiritualität9 July 2021 | Spiritual Care, Vol. 0, No. 0Spirituality and mental health17 February 2020 | Journal for the Study of Spirituality, Vol. 10, No. 1Positive Interventions in Substance Use Disorders25 January 2020Spirituality/religion and painA Mother’s Love – Support Despite Disagreeing with Goals of Care10 June 2020Charting Spiritual Care: Psychiatric and Psychotherapeutic Aspects11 August 2020Spirituality5 September 2020CE: Assessing and Managing Spiritual Distress in Cancer SurvivorshipAJN, American Journal of Nursing, Vol. 120, No. 1Health Care Professionals' Reflections on Their Learning as Spiritual Generalists and Integration Into Practice28 October 2020 | Journal of Continuing Education in the Health Professions, Vol. 40, No. 4End-of-Life, Grief, and Bereavement: Strategies to Provide Comfort?3 October 2020Our transformational leader might be replaced, we are extremely stressed out!Management Research Review, Vol. 43, No. 5Navigating the Murky Waters of Hope, Fear, and Spiritual SufferingSurgical Clinics of North America, Vol. 99, No. 5Spirituality and Religion-Relevance and Assessment in the Clinical SettingCurrent Psychiatry Research and Reviews, Vol. 15, No. 2Religion, Belief, and Spirituality in Health Care2 August 2019Faith-Health Collaboration to Improve Community and Population Health12 August 2019 | NAM PerspectivesBrazilian Physicians’ Beliefs and Attitudes Toward Patients’ Spirituality: Implications for Clinical Practice29 September 2018 | Journal of Religion and Health, Vol. 58, No. 4Recent Advances in Cognitive Behavioral Therapy For Digestive Disorders and the Role of Applied Positive Psychology Across the Spectrum of GI CareJournal of Clinical Gastroenterology, Vol. 53, No. 7Preferences, use of and satisfaction with mental health services among a sample of Puerto Rican cancer patients18 July 2019 | PLOS ONE, Vol. 14, No. 7Spirituality as agency and restoration in existential recovery11 April 2018 | Journal of Spirituality in Mental Health, Vol. 21, No. 3Meaning-Centered Interventions for Patients With Advanced or Terminal Cancer18 July 2018 | Cancer Nursing, Vol. 42, No. 4Spiritual and Religious Coping of Medical Decision Makers for Hospitalized Older Adult Patients Saneta M. Maiko, Steven Ivy, Beth Newton Watson, Kianna Montz, and Alexia M. Torke27 March 2019 | Journal of Palliative Medicine, Vol. 22, No. 4Time to follow the evidence – Spiritual care in health careEthics, Medicine and Public Health, Vol. 9How and When Is Role Modeling Effective? The Influence of Mentee Professional Identity on Mentoring Dynamics and Personal Learning Outcomes18 April 2019 | Group & Organization Management, Vol. 44, No. 2Teenagers and Cannabis Use: Why It's a Problem and What Can Be Done About ItJournal of Psychosocial Nursing and Mental Health Services, Vol. 57, No. 3Haken und Ösen: Spiritualität in der klinischen PalliativversorgungWege zum Menschen, Vol. 71, No. 2Approaching Spirituality Using the Patient-Centered Clinical Method27 January 2018 | Journal of Religion and Health, Vol. 58, No. 1Medical Students’ (Dis)comfort with Assessing Religious and Spiritual Needs in a Standardized Patient Encounter10 October 2018 | Journal of Religion and Health, Vol. 58, No. 1Spirituality and Religiosity of Pharmacy Students1 February 2019 | American Journal of Pharmaceutical Education, Vol. 83, No. 1Interprofessional spiritual care in oncology: a literature review16 February 2019 | ESMO Open, Vol. 4, No. 1Physical, Psychological/Psychiatric, Social, and Spiritual Problems and Symptoms13 April 2019Spiritual Assessment in Healthcare: An Overview of Comprehensive, Sensitive Approaches to Spiritual Assessment for Use Within the Interdisciplinary Healthcare Team18 May 2019The Role of the Nurse in Providing Spiritual Care: A Case Study Approach to Exploring Specific Care Provision by Healthcare Workers in the Context of an Interdisciplinary Healthcare Team18 May 2019Teaching and Learning About Spirituality in Healthcare Practice Settings18 May 2019Religion and Spirituality Among Medical Students5 June 2019Spiritual Care: The Role of Health Care Chaplaincy4 September 2019End-of-life milieu of critically sick children admitted to a pediatric hospital: A comparative study of survivors versus nonsurvivorsIndian Journal of Palliative Care, Vol. 25, No. 4Incorporating and Teaching Spirituality into Medical Education: An Overview of the Field and Possible Educational Strategies4 September 2019Religion, Spirituality, and Stress6 March 2019Toward Comprehensive Medicine: Listening to Spiritual and Religious Needs of Patients26 April 2019 | Gerontology and Geriatric Medicine, Vol. 5Din ve Psikoloji Arasındaki Uçurum Gerçekten Ne Kadar Derin? Psikoterapilerdeki Dini İzler15 December 2018 | Cumhuriyet İlahiyat Dergisi, Vol. 22, No. 3Women's Perceptions of Using Short Films to Integrate Spirituality in TherapyJournal of Systemic Therapies, Vol. 37, No. 4Content Validation of Advanced Illness Criteria of a Palliative Care Screening Tool Lauren C. DiLello, Karen Mulvihill, Jennifer Delli Carpini, Riddhi Shah, Julia Hermanowski, and Damanjeet Chaubey29 October 2018 | Journal of Palliative Medicine, Vol. 21, No. 11Understanding, assessing, and in the spiritual of medical and October 2018 | Theology, Vol. 11, No. and of in Living with October 2018 | Journal of & Social Services, Vol. No. for the spirituality as October 2018 | Revista de Vol. 71, No. An of an aged psychiatry March 2018 | Psychiatry, Vol. 26, No. de de vida de de Vol. 25, No. support and with in Care in the Care A Narrative June | Journal of Care Medicine, Vol. No. Care in Cancer: in the of of Clinical Oncology Educational Vol. 3, No. religion/spirituality in clinical practice: A among social and and October | Journal of Clinical Psychology, Vol. 74, No. Spirituality in Care December | Journal of Religion and Health, Vol. 57, No. of to spiritual care at the of a phenomenological exploration from the of palliative care February 2018 | Journal for the Study of Spirituality, Vol. 8, No. Existential Distress in Pediatric Cancer December and Patient Spiritual in the through October of Spirituality in November Psychological/Psychiatric, Social, and Spiritual Problems and July and End-of-Life Care in Cancer in Oncology Nursing, Vol. No. Care in Hospice and Palliative Journal of Hospice and Palliative Care, Vol. 20, No. and Spirituality: Literature review and Journal of Counseling, Vol. 18, No. of the tool existential communication between and cancer August | European Journal of General Practice, Vol. 23, No. Education and of Christian Nursing, Vol. 34, No. Care Interventions in to and Therapy C. and D. September | Journal of Palliative Medicine, Vol. 20, No. in Patients with A Qualitative September | Journal of Research in Nursing and Vol. 14, No. theory on the and in an exploratory case study September | Vol. 69, No. of the of Spirituality and Palliative Care Research and of Pain and Symptom Management, Vol. No. of a spiritual care training program for staff on November | Palliative and Supportive Care, Vol. 15, No. 4Spiritual distress and spiritual care in advanced heart July | Reviews, Vol. and Spiritual Patient Simulation in Nursing, Vol. No. Vol. 42, No. 4The impact of a spiritual in patients with and and their support December | Vol. 26, No. 3The Importance of a Spiritual History in Healthcare Vol. No. About Substance Use DisordersJournal of Psychosocial Nursing and Mental Health Services, Vol. No. and Spiritual Beliefs of April | Journal of Religion and Health, Vol. No. Care Perceptions of and With of Hospice & Palliative Nursing, Vol. 19, No. in Substance Use What to Know to Practice30 November | in Mental Health Nursing, Vol. 38, No. End-of-Life Care to Religious and Vol. No. of Social Education, Vol. 53, No. Nursing Care and of Christian Nursing, Vol. 34, No. 1The of taking a religious and spiritual July | Psychiatry, Vol. 24, No. religion and spirituality in Vol. No. the role of religious in the at the of of Vol. No. care spiritual March | Supportive Care in Cancer, Vol. 24, No. Spiritual Care and the Role of An Review of Literature and April | Journal of Religion and Health, Vol. No. of the Spiritual Needs of of with Is in the June | Journal of Palliative Medicine, Vol. 19, No. Impact of a Tool for Comprehensive Assessment of Palliative Care on Assessment at and of Pain and Symptom Management, Vol. No. from Healthcare Students to Understand Spiritual Assessment in Clinical Practice29 October | Journal of Religion and Health, Vol. No. Spirituality in January | Journal of Religion and Health, Vol. No. 3Development and of to Assess Nurse Provision of Spiritual August 2014 | Journal of Holistic Nursing, Vol. 34, No. and Validation of the Practice Assessment September 2014 | Research on Social Practice, Vol. 26, No. and the Medical A of July | Journal of Health Care Chaplaincy, Vol. 22, No. history taking in palliative care: A controlled September | Palliative Medicine, Vol. 30, No. Is Is Using A and the Life With American in Spiritual March | Journal of in Mental Health, Vol. 11, No. and spiritual in September | International Journal of and Mental Health, Vol. No. 1The of Hospital to and Patients’ Spiritual A May | Journal for the Study of Spirituality, Vol. No. 1The and to March End-of-Life Spiritual March in Holistic Patient Journal of Nursing, Vol. No. of spiritual assessment for older September 2014 | and Vol. No. und der der Care, Vol. No. Spirituality and A for Holistic January | Journal of Religion and Health, Vol. No. and Belief, in Care spiritual history tool by C. M. Puchalski as an for an interdisciplinary in January | Journal for of and Social Vol. 21, No. the of Spiritual A Pain and Palliative Care Service Quality of Pain and Symptom Management, Vol. No. of Spiritual Assessment in September | Vol. No. the of Christian Nursing, Vol. 32, No. 4Spiritual care: is the assessment tool for palliative Journal of Palliative Nursing, Vol. 21, No. und Spiritualität in der September | Vol. 60, No. of September of spirituality assessment in palliative care patients in November 2014 | Progress in Palliative Care, Vol. 23, No. 4The for Spiritual A Mixed-Methods July | Oncology Nursing Vol. 42, No. 4The Integration of Religion and Spirituality in Social Practice: A May | Social Vol. 60, No. 3The and Educational of a Spiritual Life Review for Patients with and June 2014 | Journal of Cancer Education, Vol. 30, No. in Geriatric Palliative in Geriatric Medicine, Vol. No. An for Spiritual Well-Being May | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 34, No. Spiritual Assessment March | Journal of Health Care Chaplaincy, Vol. 21, No. American on Mental Health, and Help April | and Vol. 60, No. of Christian Nursing, Vol. 32, No. the Spiritual Needs and of Oncology Patients in Nursing Practice, Vol. 29, No. Care Training to Healthcare Professionals: A Systematic April | Journal of Pastoral Care & Counseling: Advancing theory and professional practice through scholarly and reflective publications, Vol. 69, No. analysis of spiritual

Journal of Palliative Medicine · 741 citationsread the source →

Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women.

We examined prevalence, incidence, impairment, duration, and course for the proposed DSM-5 eating disorders in a community sample of 496 adolescent females who completed annual diagnostic interviews over 8 years. Lifetime prevalence by age 20 was 0.8% for anorexia nervosa (AN), 2.6% for bulimia nervosa (BN), 3.0% for binge eating disorder (BED), 2.8% for atypical AN, 4.4% for subthreshold BN, 3.6% for subthreshold BED, 3.4% for purging disorder (PD), and combined prevalence of 13.1% (5.2% had AN, BN, or BED; 11.5% had feeding and eating disorders not elsewhere classified; FED-NEC). Peak onset age was 19-20 for AN, 16-20 for BN, and 18-20 for BED, PD, and FED-NEC. Youth with these eating disorders typically reported greater functional impairment, distress, suicidality, mental health treatment, and unhealthy body mass index, though effect sizes were relatively smaller for atypical AN, subthreshold BN, and PD. Average episode duration in months ranged from 2.9 for BN to 11.2 for atypical AN. One-year remission rates ranged from 71% for atypical AN to 100% for BN, subthreshold BN, and BED. Recurrence rates ranged from 6% for PD to 33% for BED and subthrehold BED. Diagnostic progression from subthreshold to threshold eating disorders was higher for BN and BED (32% and 28%) than for AN (0%), suggesting some sort of escalation mechanism for binge eating. Diagnostic crossover was greatest from BED to BN. Results imply that the new DSM-5 eating disorder criteria capture clinically significant psychopathology and usefully assign eating disordered individuals to homogeneous diagnostic categories.

Journal of abnormal psychology · 514 citationsread the source →

The attributable risk of smoking on surgical complications.

Objective: This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes. Summary background data: Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention. Methods: A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression. Results: Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications. Conclusions: This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.

Annals of surgery · 175 citationsread the source →