Search the source libraries

حَدَّثَنَا عَلِيُّ بْنُ حُجْرٍ، قَالَ أَخْبَرَنَا بَقِيَّةُ بْنُ الْوَلِيدِ، عَنْ بَحِيرِ بْنِ سَعْدٍ، عَنْ خَالِدِ بْنِ مَعْدَانَ، عَنْ عَبْدِ اللَّهِ بْنِ أَبِي بِلاَلٍ، عَنْ عِرْبَاضِ بْنِ سَارِيَةَ، أَنَّهُ حَدَّثَهُ أَنَّ النَّبِيَّ صلى الله عليه وسلم كَانَ يَقْرَأُ الْمُسَبِّحَاتِ قَبْلَ أَنْ يَرْقُدَ وَيَقُولُ ‏ "‏ إِنَّ فِيهِنَّ آيَةً خَيْرٌ مِنْ أَلْفِ آيَةٍ ‏"‏ ‏.‏ قَالَ أَبُو عِيسَى هَذَا حَدِيثٌ حَسَنٌ غَرِيبٌ ‏.‏

Narrated 'Irbad bin Sariyah:that the Prophet (ﷺ) would recite the Musabbihat (Chapters 17, 57, 59, 61, 62, 64 & 87) before sleep and say "Indeed there is an Ayah in them that is better than one thousand Ayat

full record with gradings →

Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents.

Background: It is unclear whether alcohol use negatively impacts HCV treatment outcomes in the era of direct antiviral agents (DAAs). We aimed to evaluate the associations between current levels of drinking and treatment response among persons treated for HCV with DAAs in the national Veterans Affairs (VA) healthcare system. Methods: We identified patients who initiated HCV DAAs over 18 months (1/1/14-6/30/15) and had documented alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire within one year prior to initiating therapy. DAAs included: sofosbuvir (SOF), ledipasvir/sofosbuvir (LDV/SOF) or ombitasvir-paritaprevir-ritonavir, and dasabuvir (PrOD). AUDIT-C scores were categorized as 0 (abstinence), 1-3 (low-level drinking) and 4-12 (unhealthy drinking) in men or 0, 1-2 and 3-12 in women. Results: Among 17,487 patients who initiated DAAs, 15,151 (87%) completed AUDIT-C screening: 10,387 (68.5%) were categorized as abstinent, 3422 (22.6%) as low-level drinking and 1342 (8.9%) as unhealthy drinking. There were no significant differences in sustained virologic response (SVR) rates between abstinent (SVR 91%; 95% CI: 91-92%), low-level drinking (SVR 93%; 95% CI 92-94%) or unhealthy drinking (SVR 91%; 95% 89-92) categories in univariable analysis or in multivariable logistic regression models. However, after imputing missing SVR data, unhealthy drinkers were less likely to achieve SVR in multivariable analysis (AOR 0.75, 95% CI 0.60-0.92). Conclusion: Absolute SVR rates were uniformly high among all persons regardless of alcohol use, with only minor differences in those who report unhealthy drinking, which supports clinical guidelines that do not recommend excluding persons with alcohol use.

Drug and alcohol dependence · cohort or longitudinal · 61 citationsread the source →

Pediatric obesity treatment, self-esteem, and body image: A systematic review with meta-analysis.

Background: Pediatric obesity impacts on multiple domains of psychological health, including self-esteem and body image. Objective: To determine the effect of multicomponent pediatric obesity treatment interventions on self-esteem and body image. Methods: A systematic search of published literature up to June 2019 was undertaken using electronic databases MEDLINE, EMBASE, Cochrane Library, and PsychINFO. Eligible studies implemented an obesity treatment intervention, including a dietary and physical activity component with/without a behavioral component, in children and adolescents with overweight/obesity, and assessed self-esteem and/or body image. Data were extracted by one reviewer and cross-checked. Meta-analysis was used to combine outcome data and moderator analysis conducted to identify intervention characteristics influencing outcomes. Results: 64 studies were identified. Meta-analysis of 49 studies (n = 10471) indicated that pediatric obesity treatment results in increased self-esteem postintervention (standardized mean difference, [SE] 0.34 [0.03], P < .001, I2 87%), maintained at follow-up (0.35 [0.05] P < .001, I2 79%, 17 studies). Similarly, meta-analysis of 40 studies (n = 2729) indicated improvements in body image postintervention (0.40 [0.03], P < .001, I2 73%), maintained at follow-up (0.41 [0.08], P < .001, I2 89%, 16 studies). Conclusions: Pediatric obesity treatment improves self-esteem and body image in the short and medium term. These findings may underpin improvements in other psychological outcomes.

Pediatric obesity · meta-analysis · 76 citationsread the source →

The effectiveness of third wave cognitive behavioural therapies for children and adolescents: A systematic review and meta-analysis.

Objectives: Third wave cognitive behavioural therapies are increasingly used with children and adolescents. This meta-analysis aimed to determine the effectiveness of four third-wave interventions (acceptance and commitment therapy, compassion focused therapy, mindfulness-based cognitive therapy, and metacognitive therapy) for youth. Methods: Four electronic databases were used to identify randomized controlled trials, which tested effects related to health, well-being and functioning. Sensitivity analyses considering study quality were conducted and moderators were explored. Results: The results based on 50 RCTs meeting inclusion criteria indicated emotional symptoms/internalizing problems (g = -.68, 95% CI -.98 to -.37, k = 43, N = 3265), behavioural difficulties/externalizing problems (g = -.62, 95% CI -1.01 to -.22, k = 23, N = 1659), interference from difficulties (g = -.46, 95% CI -.87 to -.05, k = 21, N = 1786), third wave processes (g = .39, 95% CI .17 to .62, k = 22, N = 1900), wellbeing/flourishing (g = .76, 95% CI .35 to 1.17, k = 21, N = 1303) and physical health/pain (g = .72, 95% CI .01 to 1.44, k = 9, N = 1171) yielded significant effects. Effect for quality of life (g = .62, 95% CI -.08 to 1.31, k = 12, N = 1271) was non-significant. When analysing only those studies rated moderate-high quality, third wave interventions yielded significant superiority effects compared to controls for emotional symptoms/internalizing problems (g = -.55, 95% CI -.82 to -.27, k = 28, N = 2110), interference from difficulties (g = -.48, 95% CI -.90 to -.05, k = 21, N = 1605), third wave processes (g = .27, 95% CI .11 to .43, k = 18, N = 1692), well-being/flourishing (g = .50, 95% CI .18 to .81, k = 16, N = 1063), and quality of life (g = .32, 95% CI .04 to .60, k = 10, N = 1212). Behavioural difficulties/externalizing problems (g = -.38, 95% CI -.86 to .10, k = 15, N = 1351) and physical health/pain (g = .52, 95% CI -.14 to 1.17, k = 8, N = 1139) ceased to be significant. Widespread heterogeneity raised concerns about generalizability and follow-up data was relatively sparse. Conclusions: This meta-analysis finds promising results for use of third wave CBT with youth, though the review has limitations.

The British journal of clinical psychology · meta-analysis · 19 citationsread the source →

Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England.

Background: We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England. Methods: In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards). Findings: Of the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7-2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3-1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07-1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20-1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05-1·17). Interpretation: Wide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke. Funding: NHS England and the Welsh Government.

The Lancet. Public health · 104 citationsread the source →

Effect of psychological therapy on disease activity, psychological comorbidity, and quality of life in inflammatory bowel disease: a systematic review and meta-analysis.

Background: Inflammatory bowel disease is associated with psychological comorbidity and impaired quality of life. Psychological comorbidity could affect the natural history of inflammatory bowel disease. Psychological therapies might therefore have beneficial effects on disease activity, mood, and quality of life in patients with inflammatory bowel disease. We did a systematic review and meta-analysis examining these issues. Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Embase Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for articles published between 1947 and Sept 22, 2016. Randomised controlled trials (RCTs) recruiting patients with inflammatory bowel disease aged at least 16 years that compared psychological therapy with a control intervention or usual treatment were eligible. We pooled dichotomous data to obtain relative risks of induction of remission in active disease or prevention of relapse of quiescent disease, with 95% CIs. We pooled continuous data to estimate standardised mean differences in disease activity indices, anxiety, depression, perceived stress, and quality-of-life scores in patients dichotomised into those with clinically active or quiescent disease, with 95% CIs. We extracted data from published reports and contacted the original investigators of studies for which the required data were not available. We pooled all data using a random-effects model. Findings: The search identified 1824 studies, with 14 RCTs of 1196 patients eligible for inclusion. The relative risk of relapse of quiescent inflammatory bowel disease with psychological therapy versus control was 0·98 (95% CI 0·77-1·24; p=0·87; I2=50%; six trials; 518 patients). We observed a significant difference in depression scores (standardised mean difference -0·17 [-0·33 to -0·01]; p=0·04; I2=0%; seven trials; 605 patients) and quality of life (0·30 [0·07-0·52]; p=0·01; I2=42%; nine trials; 578 patients) with psychological therapy versus control at the end of therapy for patients with quiescent disease. However, these beneficial effects were lost at final point of follow-up (depression scores -0·11 [-0·27 to 0·05], p=0·17, I2=0%, eight trials, 593 patients; quality of life 0·15 [-0·05 to 0·34], p=0·14, I2=22%, ten trials, 577 patients). When we assessed the effect of individual physiological therapies on quality of life, only cognitive behavioural therapy had any significant beneficial effect (0·37 [0·02-0·72]). We noted no effect on disease activity indices or other psychological wellbeing scores when compared with control in patients with quiescent disease. Dichotomous data for induction of remission and continuous data for change in clinical disease activity indices, depression, anxiety, and perceived stress scores were only reported in one RCT of patients with active disease. Quality of life was assessed in two RCTs of patients with active disease, but was not significantly different between intervention and control groups (0·27 [-0·05 to 0·59]). Interpretation: Psychological therapies, and cognitive behavioural therapy in particular, might have small short-term beneficial effects on depression scores and quality of life in patients with inflammatory bowel disease. Further RCTs of these interventions in patients with coexistent psychological distress are required. Funding: None.

The lancet. Gastroenterology & hepatology · meta-analysis · 163 citationsread the source →

Mental health of migrants with pre-migration exposure to armed conflict: a systematic review and meta-analysis.

Background: Exposure to armed conflict has been associated with negative mental health consequences. We aimed to estimate the prevalence of generalised anxiety disorder, major depressive disorder, and post-traumatic stress disorder among migrants exposed to armed conflict. Methods: In this systematic review and meta-analysis, we searched online databases (Cochrane Library, Embase, LILACS, PsycInfo [via Ovid], PubMed, and Web of Science Core Collection) for relevant observational studies published between Jan 1, 1994, and June 28, 2021. We included studies that used standardised psychiatric interviews to assess generalised anxiety disorder, major depressive disorder, or post-traumatic stress disorder among migrants (refugees or internally displaced persons; aged ≥18 years) with pre-migration exposure to armed conflict. We excluded studies in which exposure to armed conflict could not be ascertained, studies that included a clinical population or people with chronic diseases that can trigger the onset of mental disease, and studies published before 1994. We used a random effects model to estimate each mental health disorder's pooled prevalence and random effects meta-regression to assess sources of heterogeneity. Two independent reviewers assessed the risk of bias for each study using the Joanna Briggs Institute Checklist for Prevalence Studies. The protocol was registered with PROSPERO, CRD42020209251. Findings: Of the 13 935 studies identified, 34 met our inclusion criteria; these studies accounted for 15 549 migrants. We estimated a prevalence of current post-traumatic stress disorder of 31% (95% CI 23-40); prevalence of current major depressive disorder of 25% (17-34); and prevalence of generalised anxiety disorder of 14% (5-35). Younger age was associated with a higher prevalence of current post-traumatic stress disorder (odds ratio 0·95 [95% CI 0·90-0·99]), lifetime post-traumatic stress disorder (0·88 [0·83-0·92]), and current generalised anxiety disorder (0·87 [0·78-0·97]). A longer time since displacement was associated with a lower lifetime prevalence of post-traumatic stress disorder (0·88 [0·81-0·95]) and major depressive disorder (0·81 [0·77-0·86]). Migrating to a middle-income (8·09 [3·06-21·40]) or low-income (39·29 [11·96-129·70]) country was associated with increased prevalence of generalised anxiety disorder. Interpretation: Migrants who are exposed to armed conflict are at high risk of mental health disorders. The mental health-care needs of migrants should be assessed soon after resettlement, and adequate care should be provided, with particular attention paid to young adults. Funding: Marie Skłodowska-Curie Actions (Horizon 2020-COFUND), MinCiencias (Colombia), and Swiss National Science Foundation.

The Lancet. Public health · meta-analysis · 111 citationsread the source →

Interventions for the treatment of metastatic extradural spinal cord compression in adults.

Background: Metastatic extradural spinal cord compression (MESCC) is treated with radiotherapy, corticosteroids, and surgery, but there is uncertainty regarding their comparative effects. This is an updated version of the original Cochrane review published in theCochrane Database of Systematic Reviews (Issue 4, 2008). Objectives: To determine the efficacy and safety of radiotherapy, surgery and corticosteroids in MESCC. Search methods: In March 2015, we updated previous searches (July 2008 and December 2013) of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, CANCERLIT, clinical trials registries, conference proceedings, and references, without language restrictions. We also contacted experts for relevant published, unpublished and ongoing trials. Selection criteria: Randomised controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. Data collection and analysis: Three authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. Where possible, we pooled relative risks with their 95% confidence intervals, using a random effects model if heterogeneity was significant. We assessed overall evidence-quality using the GRADE approach. Main results: This update includes seven trials involving 876 (723 evaluable) adult participants (19 to 87 years) in high-income countries. Most were free of the risk of bias. Different radiotherapy doses and schedulesTwo equivalence trials in people with MESCC and a poor prognosis evaluated different radiotherapy doses and schedules. In one, a single dose (8 Gray (Gy)) of radiotherapy (RT) was as effective as short-course RT (16 Gy in two fractions over one week) in enhancing ambulation in the short term (65% versus 69%; risk ratio (RR) was 0.93, (95% confidence interval (CI) 0.82 to 1.04); 303 participants; moderate quality evidence). The regimens were also equally effective in reducing analgesic and narcotic use (34% versus 40%; RR 0.85, 95% CI 0.62 to 1.16; 271 participants), and in maintaining urinary continence (90% versus 87%; RR 1.03, 95% CI 0.96 to 1.1; 303 participants) in the short term (moderate quality evidence). In the other trial, split-course RT (30 Gy in eight fractions over two weeks) was no different from short-course RT in enhancing ambulation (70% versus 68%; RR 1.02, 95% CI 0.9 to 1.15; 276 participants); reducing analgesic and narcotic use (49% versus 38%; RR 1.27, 95% CI 0.96 to 1.67; 262 participants); and in maintaining urinary continence (87% versus 90%; RR 0.97, 0.93 to 1.02; 275 participants) in the short term (moderate quality evidence). Median survival was similar with the three RT regimens (four months). Local tumour recurrence may be more common with single-dose compared to short-course RT (6% versus 3%; RR 2.21, 95% CI 0.69 to 7.01; 303 participants) and with short-course compared to split-course RT (4% versus 0%; RR 0.1, 95% CI 0.01 to 1.72; 276 participants), but these differences were not statistically significant (low quality evidence). Gastrointestinal adverse effects were infrequent with the three RT regimens (moderate quality evidence), and serious adverse events or post-radiotherapy myelopathy were not noted. We did not find trials comparing radiotherapy schedules in people with MESCC and a good prognosis. Surgery plus radiotherapy compared to radiotherapyLaminectomy plus RT offered no advantage over RT in one small trial with 29 participants (very low quality evidence). In another trial that was stopped early for apparent benefit, decompressive surgery plus RT resulted in better ambulatory rates (84% versus 57%; RR 1.48, 95% CI 1.16 to 1.90; 101 participants, low quality evidence). Narcotic use may also be lower, and bladder control may also be maintained longer than with than RT in selected patients (low quality evidence). Median survival was longer after surgery (126 days versus 100 days), but the proportions surviving at one month (94% versus 86%; RR 1.09, 95% CI 0.96 to 1.24; 101 participants) did not differ significantly (low quality evidence). Serious adverse events were not noted. Significant benefits with surgery occurred only in people younger than 65 years. High dose corticosteroids compared to moderate dose or no corticosteroidsData from three small trials suggest that high-dose steroids may not differ from moderate-dose or no corticosteroids in enhancing ambulation (60% versus 55%; RR 1.08, 95% CI 0.81 to 1.45; 3 RCTs, 105 participants); survival over two years (11% versus 10%; RR 1.11, 95% CI 0.24 to 5.05; 1 RCT, 57 participants); pain reduction (78% versus 91%; RR 0.86, 95% CI 0.62 to 1.20; 1 RCT, 25 participants); or urinary continence (63% versus 53%; RR 1.18, 95% CI 0.66 to 2.13; 1 RCT, 34 participants; low quality evidence). Serious adverse effects were more frequent with high-dose corticosteroids (17% versus 0%; RR 8.02, 95% CI 1.03 to 62.37; 2 RCTs, 77 participants; moderate quality evidence).None of the trials reported satisfaction with care or quality of life in participants. Authors' conclusions: Based on current evidence, ambulant adults with MESCC with stable spines and predicted survival of less than six months will probably benefit as much from one dose of radiation (8 Gy) as from two doses (16 Gy) or eight doses (30 Gy). We are unsure if a single dose is as effective as two or more doses in preventing local tumour recurrence. Laminectomy preceding radiotherapy may offer no benefits over radiotherapy alone. Decompressive surgery followed by radiotherapy may benefit ambulant and non-ambulant adults younger than 65 years of age, with poor prognostic factors for radiotherapy, a single area of compression, paraplegia for less than 48 hours, and a predicted survival of more than six months. We are uncertain whether high doses of corticosteroids offer any benefits over moderate doses or indeed no corticosteroids; but high-dose steroids probably significantly increases the risk of serious adverse effects. Early detection; and treatment based on neurological status, age and estimated survival, are crucial with all treatment modalities. Most of the evidence was of low quality. High-quality evidence from more trials is needed to clarify current uncertainties, and some studies are in progress.

The Cochrane database of systematic reviews · meta-analysis · 39 citationsread the source →

Psychological interventions for antisocial personality disorder.

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

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

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

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

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

Epidemiology of Substance Use among Forced Migrants: A Global Systematic Review.

Introduction: Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research. Methods: Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies. Results: Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use. Conclusion: Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.

PloS one · systematic review · 122 citationsread the source →

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

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

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

The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial.

Background: Although structured psychological treatments are recommended as first-line interventions for depression, only a small fraction of people globally receive these treatments because of poor access in routine primary care. We assessed the effectiveness and cost-effectiveness of a brief psychological treatment (Healthy Activity Program [HAP]) for delivery by lay counsellors to patients with moderately severe to severe depression in primary health-care settings. Methods: In this randomised controlled trial, we recruited participants aged 18-65 years scoring more than 14 on the Patient Health Questionnaire 9 (PHQ-9) indicating moderately severe to severe depression from ten primary health centres in Goa, India. Pregnant women or patients who needed urgent medical attention or were unable to communicate clearly were not eligible. Participants were randomly allocated (1:1) to enhanced usual care (EUC) alone or EUC combined with HAP in randomly sized blocks (block size four to six [two to four for men]), stratified by primary health centre and sex, and allocation was concealed with use of sequential numbered opaque envelopes. Physicians providing EUC were masked. Primary outcomes were depression symptom severity on the Beck Depression Inventory version II and remission from depression (PHQ-9 score of <10) at 3 months in the intention-to-treat population, assessed by masked field researchers. Secondary outcomes were disability, days unable to work, behavioural activation, suicidal thoughts or attempts, intimate partner violence, and resource use and costs of illness. We assessed serious adverse events in the per-protocol population. This trial is registered with the ISRCTN registry, number ISRCTN95149997. Findings: Between Oct 28, 2013, and July 29, 2015, we enrolled and randomly allocated 495 participants (247 [50%] to the EUC plus HAP group [two of whom were subsequently excluded because of protocol violations] and 248 [50%] to the EUC alone group), of whom 466 (95%) completed the 3 month primary outcome assessment (230 [49%] in the EUC plus HAP group and 236 [51%] in the EUC alone group). Participants in the EUC plus HAP group had significantly lower symptom severity (Beck Depression Inventory version II in EUC plus HAP group 19·99 [SD 15·70] vs 27·52 [13·26] in EUC alone group; adjusted mean difference -7·57 [95% CI -10·27 to -4·86]; p<0·0001) and higher remission (147 [64%] of 230 had a PHQ-9 score of <10 in the HAP plus EUC group vs 91 [39%] of 236 in the EUC alone group; adjusted prevalence ratio 1·61 [1·34-1·93]) than did those in the EUC alone group. EUC plus HAP showed better results than did EUC alone for the secondary outcomes of disability (adjusted mean difference -2·73 [-4·39 to -1·06]; p=0·001), days out of work (-2·29 [-3·84 to -0·73]; p=0·004), intimate partner physical violence in women (0·53 [0·29-0·96]; p=0·04), behavioural activation (2·17 [1·34-3·00]; p<0·0001), and suicidal thoughts or attempts (0·61 [0·45-0·83]; p=0·001). The incremental cost per quality-adjusted life-year gained was $9333 (95% CI 3862-28 169; 2015 international dollars), with an 87% chance of being cost-effective in the study setting. Serious adverse events were infrequent and similar between groups (nine [4%] in the EUC plus HAP group vs ten [4%] in the EUC alone group; p=1·00). Interpretation: HAP delivered by lay counsellors plus EUC was better than EUC alone was for patients with moderately severe to severe depression in routine primary care in Goa, India. HAP was readily accepted by this previously untreated population and was cost-effective in this setting. HAP could be a key strategy to reduce the treatment gap for depressive disorders, the leading mental health disorder worldwide. Funding: Wellcome Trust.

Lancet (London, England) · randomised controlled trial · 295 citationsread the source →

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

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

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

The Amagugu intervention for disclosure of maternal HIV to uninfected primary school-aged children in South Africa: a randomised controlled trial.

Background: Increasing populations of children who are HIV-exposed but uninfected will face the challenge of disclosure of parental HIV infection status. We aimed to test the efficacy of an intervention to increase maternal HIV-disclosure to primary school-aged HIV-uninfected children. Methods: This randomised controlled trial was done at the Africa Health Research Institute in KwaZulu-Natal, South Africa. Women who had tested HIV positive at least 6 months prior, had initiated HIV treatment or been enrolled in pretreatment HIV care, and had an HIV-uninfected child (aged 6-10 years) were randomly allocated to either the Amagugu intervention or enhanced standard of care, using a computerised algorithm based on simple randomisation and equal probabilities of being assigned to each group. Lay counsellors delivered the Amagugu intervention, which included six home-based counselling sessions of 1-2 h and materials and activities to support HIV disclosure and parent-led health promotion. The enhanced standard of care included one clinic-based counselling session. Outcome measures at 3 months, 6 months, and 9 months post baseline were done by follow-up assessors who were masked to participants' group and counsellor allocation. The primary outcome was maternal HIV disclosure (full [using the word HIV], partial [using the word virus], or none) at 9 months post baseline. We did the analysis in the intention-to-treat population. This study is registered with ClinicalTrials.gov (NCT01922882). Findings: Between July 1, 2013, and Dec 31, 2014, we randomly assigned 464 participants to the Amagugu intervention (n=235) or enhanced standard of care (n=229). 428 (92%) participants completed the 9 month assessment by Sept 3, 2015. Disclosure at any level was more common in the Amagugu intervention group (n=204 [87%]) than in the enhanced standard-of-care group (n=128 [56%]; adjusted odds ratio 9·88, 95% CI 5·55-17·57; p<0·0001). Full disclosure was also more common in the Amagugu intervention group (n=150 [64%]) than in the enhanced standard-of-care group (n=98 [43%]; 4·13, 2·80-6·11; p<0·0001). Treatment-unrelated adverse effects were reported for 17 participants in the Amagugu intervention group versus six in the enhanced standard-of-care group; adverse effects included domestic violence (five [2%] in the Amagugu intervention group vs one [<1%] in the enhanced standard-of-care group), sexual assault (four [2%] vs one [<1%]), participant illness or death (four [2%] vs four [2%]), and family member illness or death (four [2%] vs none). No treatment-related deaths occurred. Interpretation: The lay-counsellor-driven Amagugu intervention to aid parental disclosure has potential for wide-scale implementation after further effectiveness research and could be adapted to other target populations and other diseases. Further follow-up and effectiveness research is required. Funding: National Institutes of Health.

The lancet. HIV · randomised controlled trial · 19 citationsread the source →

Predisplacement Abuse and Postdisplacement Factors Associated With Mental Health Symptoms After Forced Migration Among Rohingya Refugees in Bangladesh.

Importance: At the end of August 2017, violence and persecution in Myanmar's Rakhine state forced nearly 1 million Rohingyas to flee to Bangladesh for their lives and seek shelter. Many refugees, after their traumatic experiences leaving Myanmar, experience mental health problems. Objectives: To identify the prevalence of posttraumatic stress symptoms (PTSSs) among displaced Rohingya adults and investigate the association of predisplacement abuse and postdisplacement factors with PTSSs. Design, setting, and participants: This cross-sectional analysis from a household survey of 1184 Rohingya adults aged 18 years or older was conducted in 8 refugee camps within Cox's Bazar, Bangladesh, from September 17, 2019, to January 11, 2020. Main outcomes and measures: The Impact of Event Scale-Revised was used to assess PTSSs. The possible range of scores was 0 to 88; moderate PTSSs were classified using a score cutoff of 33 to 38 and severe PTSSs were classified using a score cutoff of 39 and above. Adjusted prevalence ratios (aPRs) were estimated using a multivariable logistic regression model adjusted for potential confounders. Results: Of 1184 participants (625 men [52.8%]; mean [SD] age, 35.1 [13.4] years), 552 (46.6%) had severe PTSSs, and 274 (23.1%) had moderate PTSSs. In Bangladesh, refugees are not legally permitted to work in refugees camps, but 276 of 1165 respondents (23.7%) had temporary paid jobs. Moreover, 113 of the 276 working participants (40.9%) and 430 of the 889 nonworking participants (48.4%) reported severe PTSSs. A total of 496 respondents (41.9%) reported inadequate humanitarian aid for their families, and among them, 281 (56.7%) reported severe PTSSs. A total of 136 of 1177 respondents (11.6%) experienced both physical and sexual abuse in Myanmar, and 87 (64.0%) of them had severe PTSSs. The multivariable analysis showed a reduced risk of PTSSs with appropriate humanitarian assistance (aPR, 0.50; CI, 0.38-0.65). Experiencing both physical and sexual abuse before displacement had a significant association with PTSSs (aPR, 2.09; CI, 1.41-3.07). Opportunities for paid employment in refugee camps also reduced the risks of PTSSs (aPR, 0.69; CI, 0.52-0.91). Conclusions and relevance: The high prevalence of self-reported severe PTSSs in Rohingya refugees suggests that the trauma of displacement and the violent consequences of military crackdowns still exist. In the Rohingya camp settings of Bangladesh, employment opportunity and sufficient humanitarian aid hold promise as potential interventions to reduce the high prevalence of severe PTSSs. Mental health symptoms were more prevalent in adults who experienced physical abuse or physical and sexual abuse before displacement.

JAMA network open · cohort or longitudinal · 35 citationsread the source →

Sex and Gender Disparities in the COVID-19 Pandemic

Journal of Women's HealthVol. 29, No. 4 CommentaryFree AccessSex and Gender Disparities in the COVID-19 PandemicJewel Gausman and Ana LangerJewel GausmanWomen & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. Search for more papers by this author and Ana LangerAddress correspondence to: Ana Langer, MD, Women & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 651 Huntington Avenue, FXB Building 6th Floor Office 643B, Boston, MA 02115 E-mail Address: [email protected]Women & Health Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts. Search for more papers by this authorPublished Online:17 Apr 2020https://doi.org/10.1089/jwh.2020.8472AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail In the case of the ongoing COVID-19 pandemic, sex-disaggregated data suggest that fewer women are dying from the disease than men.1 However, taking this observation at face value oversimplifies the biological, behavioral, and social and systemic factors that may cause differences to emerge with regard to how women and men experience both the disease and its consequences. As governments react with swift and severe measures in their ongoing fight to control the pandemic's spread, it is important to understand how these actions may disproportionately increase the risks for women both directly and indirectly with regard to sex and gender. Pregnant women are often among the most vulnerable groups during public health emergencies. In some cases, pregnant women face increased biological susceptibility to adverse health outcomes, as in the case of some respiratory infections. With other emergent coronaviruses, such as those responsible for severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS), pregnant women who became infected were found to be more likely than nonpregnant women to experience severe complications.2 It is still too early to tell whether this will be the case with COVID-19.In the ongoing pandemic, other factors may have a ripple effect that put women at increased risk even if the disease itself does not. As made clear during the 2014 Ebola outbreak, the consequences of large-scale infectious disease outbreaks on uninfected pregnant women can be dire. Routine prenatal care appointments, if not interrupted or discontinued, may put women at increased risk of exposure to the virus. Overwhelmed hospitals struggling to function with staff and supply shortages may not be able to provide the high quality of care that all pregnant women and their newborns deserve, let alone respond to emergency obstetric complications. Furthermore, there is also a risk that life-saving treatments or vaccines will be denied to pregnant women over concern for fetal safety or a lack of data.3,4The fear of infection, concern for the well-being of friends and loved ones, uncertainty, disruption, and social isolation that have become part and parcel of daily life for many around the world will undoubtedly have profound effects on mental health on the population at large, but being pregnant during a global pandemic is likely to be even more frightening for many women. Although containment strategies, such as those that require women to deliver without a companion present, including partners and doulas, that have already been put into place in some cities in the United States,5 or those that separate newborns from their mothers immediately after birth if the mother is infected with COVID-196 may be clinically important to reduce transmission, they may also have profound short- and long-term mental health implications for women. Among women who have young children, previous research in Ethiopia, India, and Vietnam found that women who experience family-related stressful life events, such as illness or death within the household and financial uncertainty, are more likely to experience episodes of severe mental distress.7 With the ongoing need to social distance, family and community networks may struggle and pregnant and postpartum women may feel even more vulnerable and isolated over a lack of social support. The adverse effects of the pandemic in relation to women's reproductive health are not limited to pregnancy or motherhood. As movement restrictions are put into place, supply chains are disrupted, and businesses are shuttered, some women may be at increased risk of unintended pregnancy should it become difficult to obtain their regular contraceptive method or emergency contraceptives, if needed. Furthermore, some states within the United States have begun to impose restrictions on certain medical procedures that they deem to be elective, including abortion, suggesting they must be delayed until after the pandemic is over.8 Spikes in domestic violence during times of crisis are another area of grave concern for women's health, and as governments continue to put into place more extreme measures to enforce social distancing, for some women, more time at home may mean more time spent with an abusive partner. Fewer social interactions may also mean less accountability for perpetrators and fewer opportunities for others to intervene. Gender-related factors may also increase the impact of the COVID-19 pandemic on women globally. Women constitute a disproportionately high percentage of caregivers in both the formal and informal sectors.9 A large proportion of frontline health care professionals (nurses, community health workers, health technicians, etc.) is women who face a higher risk of infection, morbidity, and death as a result of their profession.9 At the same time, women more frequently serve as the primary caregivers within a household, which may further increase their risk of exposure. In the United States, 65% of unpaid family caregivers are estimated to be women and 80% of them care for someone aged 50 years or older.10 Outside of their caregiving role, women are overrepresented in the informal employment sector. In low-and middle-income countries, two-thirds of women who work do so as part of the informal economy with limited access to health care for themselves and their families.9 Containment and mitigation policies that limit women's ability to perform their duties without offering effective alternatives, such as closing of daycare facilities for their children or not providing paid sick leave, may result in unnecessary exposure to disease and increased family vulnerability. It is urgent that we adopt a gender lens to study the pandemic and its effects, including the policies and actions that are put into place at the global, country, and local levels. This may be especially important in disadvantaged populations and resource-poor communities, where women are especially vulnerable. The public health community must ensure that existing health and social services meant to support women in the face of their unique needs do not disappear in lieu of the all-encompassing focus on stopping the pandemic. Furthermore, we argue that special attention needs to be paid to ensure that informal caregivers are supported, informed, and protected. To avoid making existing gender disparities larger as a result of the pandemic, a special body at the U.S. Centers of Disease Control and Prevention is urgently needed to track sex disaggregated data and analyze policies related to COVID-19 using a gender lens. Author Disclosure StatementNo competing financial interests exist. Funding InformationNo funding was received for this article. References1. Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med 2020;pii: S2213-2600(20)30117-X. Medline, Google Scholar2. Favre G, Pomar L, Musso D, Baud D. 2019-nCoV epidemic: What about pregnancies? Lancet 2020;395:e40. Crossref, Medline, Google Scholar3. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: What obstetricians need to know. Am J Obstet Gynecol 2020;pii: S0002-9378(20)30197-6. Medline, Google Scholar4. Weigel G. Novel coronavirus "COVID-19": Special considerations for pregnant women. Available at: https://www.kff.org/womens-health-policy/issue-brief/novel-coronavirus-covid-19-special-considerations-for-pregnant-women/?utm_source=Global+Health+NOW+Main+List Accessed March 17, 2020. Google Scholar5. Caron C, Syckle KV. Laboring alone: Some hospitals bar partners because of virus fears. The New York Times. 2020. Google Scholar6. American College of Obstetricians and Gynecologists. Practice advisory: Novel coronavirus 2019 (COVID-19). Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019?IsMobileSet=false Accessed March 13, 2020. Google Scholar7. Gausman J, Austin SB, Subramanian S, Langer A. Adversity, social capital, and mental distress among mothers of small children: A cross-sectional study in three low and middle-income countries. PLoS One 2020;15:e0228435. Crossref, Medline, Google Scholar8. Tavernise S. Texas and Ohio include abortion as medical procedures that must be delayed. The New York Times. 2020. Google Scholar9. Langer A, Meleis A, Knaul FM, et al. Women and health: The key for sustainable development. Lancet 2015;386:1165–1210. Crossref, Medline, Google Scholar10. Feinberg L, Reinhard SC, Houser A, Choula R. Valuing the invaluable: 2011 update, the growing contributions and costs of family caregiving. Washington, DC: AARP Public Policy Institute, 2011:32. Google ScholarFiguresReferencesRelatedDetailsCited byMachine learning-based prediction of COVID-19 mortality using immunological and metabolic biomarkers3 February 2023 | BMC Digital Health, Vol. 1, No. 1No fear: Willingness of smartphone activated first responders to assist with cardiac arrest during the COVID-19 pandemicResuscitation Plus, Vol. 13Overlooked sex and gender aspects of emerging infectious disease outbreaks: Lessons learned from COVID-19 to move towards health equity in pandemic response20 February 2023 | Frontiers in Global Women's Health, Vol. 4Anxiety, depression, and stress in youth during lockdown: differences between clinical and community samples13 February 2023 | CES Psicología, Vol. 16, No. 1Correlates of long-COVID-19: the role of demographics, chronic illness, and psychiatric diagnosis in an urban sample8 February 2023 | Psychology, Health & Medicine, Vol. 11Perception of COVID‐19 pandemic restrictions on dental researchers21 September 2022 | Journal of Dental Education, Vol. 87, No. 2Penicillin Allergy Evaluation and Health Equity: A Call to ActionThe Journal of Allergy and Clinical Immunology: In Practice, Vol. 11, No. 2Covid-19 Effects on Psychological Outcomes: How Do Gender Responses Differ?23 August 2021 | Psychological Reports, Vol. 126, No. 1Gendered Consequences of COVID-19 Among Professional Tennis Players24 August 2022 | Journal of Sports Economics, Vol. 24, No. 2Nursing Students' Perception about Gender Inequalities Presented on Social Networks: A Qualitative Study20 January 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 3Laboring Alone: Perinatal Outcomes during Childbirth without a Birth Partner or Other Companion during the COVID-19 Pandemic1 February 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 3Psychological Adjustment Profiles of LGBTQ+ Young Adults Residing with Their Parents during the COVID-19 Pandemic: An International Study11 February 2023 | International Journal of Environmental Research and Public Health, Vol. 20, No. 4The Ups and Downs of Feminist Activist Research: Positional Reflections1 March 2023Freiheit und Autonomie von Frauen in Zeiten der Coronakrise3 March 2023COVID-19 Concerns, Perceived Stress, and Increased Alcohol Use Among Adult Women in the United States18 November 2022 | Clinical Nursing Research, Vol. 32, No. 1"Life is hard": How the COVID-19 pandemic affected daily stressors of womenDialogues in Health, Vol. 1Laboratory predictors for COVID-19 Intensive Care Unit admissions in Trinidad and TobagoDialogues in Health, Vol. 1Sex-related disparities in students' disaster responses in the post-COVID-19 eraInternational Journal of Disaster Risk Reduction, Vol. 83Public perceptions during the first wave of the COVID-19 pandemic in Canada: a demographic analysis of self-reported beliefs, behaviors, and information acquisition9 April 2022 | BMC Public Health, Vol. 22, No. 1Implication of single nucleotide polymorphisms in Interleukin-10 gene (rs1800896 and rs1800872) with severity of COVID-191 October 2022 | Egyptian Journal of Medical Human Genetics, Vol. 23, No. 1Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services—Behavioral Insights from the Federation of Bosnia and Herzegovina3 December 2022 | Behavioral Sciences, Vol. 12, No. 12Gender and age structure of mortality caused by COVID-1923 November 2022 | Innovative Medicine of Kuban, No. 4Using trajectory modeling of spatio-temporal trends to illustrate disparities in COVID-19 death in flint and Genesee County, MichiganSpatial and Spatio-temporal Epidemiology, Vol. 43Neonatologist staffing models: urgent change is needed7 October 2022 | Journal of Perinatology, Vol. 42, No. 11The Structure of the Relationship between Physical Activity and Psychosocial Functioning of Women and Men during the COVID-19 Epidemic in Poland20 September 2022 | International Journal of Environmental Research and Public Health, Vol. 19, No. 19Syndemic aspects between COVID-19 pandemic and social inequalitiesWorld Journal of Methodology, Vol. 12, No. 5Impact of Social and Personal Factors on Psychological Distress in the Spanish Population in the COVID-19 Crisis9 September 2022 | The British Journal of Social Work, Vol. 28(Suppl 1)Levels of Depression and Anxiety Among Informal Caregivers During the COVID-19 Pandemic: A Study Based on the Canadian Longitudinal Study on Aging12 February 2022 | The Journals of Gerontology: Series B, Vol. 77, No. 9Knowledge, attitudes, and practices [KAP] toward COVID-19: A cross-sectional study in the New York Metropolitan Area and California Bay Area10 August 2022 | PLOS ONE, Vol. 17, No. 8Examining the impact of sex differences and the COVID-19 pandemic on health and health care: findings from a national cross-sectional study28 September 2022 | JAMIA Open, Vol. 5, No. 3Combination of cycle threshold time, absolute lymphocyte count and neutrophil:lymphocyte ratio is predictive of hypoxia in patients with SARS-CoV-2 infection11 December 2021 | Transactions of The Royal Society of Tropical Medicine and Hygiene, Vol. 116, No. 7Conflicto trabajo-familia de mujeres en situación de teletrabajo a partir de la contingencia sanitaria por COVID-19 en Chile15 June 2022 | Investigaciones Feministas, Vol. 13, No. 1Impact of COVID-19 restrictions on mental health and physical activity among LGBQAP and heterosexual adults21 December 2021 | Journal of Gay & Lesbian Mental Health, Vol. 26, No. 3Women's Use and Abuse of the News Media during the COVID-19 Pandemic on Mumsnet2 September 2021 | Digital Journalism, Vol. 10, No. 6COVID-19 effects on women's home and work life, family violence and mental health from the Women's Health Expert Panel of the American Academy of NursingNursing Outlook, Vol. 70, No. 4Perceived risk, political polarization, and the willingness to follow COVID-19 mitigation guidelinesSocial Science & Medicine, Vol. 305Racial and Ethnic Disparities in Postpartum Care in the Greater Boston Area During the COVID-19 Pandemic23 June 2022 | JAMA Network Open, Vol. 5, No. 6Access to contraception during the Covid-19 pandemic: barriers and perspectives1 June 2022 | Cadernos Saúde Coletiva, Vol. 30, No. 2Disparities by Sex in COVID-19 Risk and Related Harms Among People with Opioid Use Disorder Caitlin E. Martin, Bhushan Thakkar, DaShaunda D.H. Taylor, and Derek A. Chapman16 May 2022 | Journal of Women's Health, Vol. 31, No. 5Vision 2020: How and for E. A. E. S. and May 2022 | Journal of Women's Health, Vol. 31, No. of women in clinical A for and Clinical Vol. and urban towards pandemic May 2022 | Vol. the The of during a January 2022 | & Psychology, Vol. 32, No. and During the and of the COVID-19 Pandemic in April 2022 | Frontiers in Vol. to Greater With the COVID-19 and to Journal of Health Psychology, Vol. 29, No. of to the of SARS-CoV-2 With Anxiety and A Study of March 2022 | International Journal of Public Health, Vol. in the Impact of COVID-19 Pandemic in in The Gender in Vol. No. 3Women's health and access COVID-19 Outlook, Vol. 70, No. of to COVID-19 Outcomes in a Longitudinal of February 2022 | Vol. No. as March 2022 | Saúde Vol. No. COVID-19 wave in during the of and its with higher February 2022 | PLOS ONE, Vol. 17, No. well-being and during the COVID-19 pandemic in the United A February 2022 | The Social Science Vol. to and February 2022 | Psychology, Vol. women's during the COVID-19 pandemic in June 2021 | and An International Vol. No. an and at the same in work and during the coronavirus April 2021 | International Journal of Psychology, Vol. No. and local A in the time of November 2021 | International Journal of Psychology, Vol. No. and the During June 2021 | & Vol. 26, No. of Medical Care among in the United States during the COVID-19 May 2022 | Journal of Public Health Research, Vol. 11, No. the Gender Disparities in COVID-19 and January 2022 | & Vol. with public health for COVID-19: a study of mothers with young children in the United February 2022 | Journal of in Vol. No. Perspectives on January and Among Adults During the to COVID-191 February in and and during the COVID-19 pandemic health and and Vol. in the COVID‐19 Effects of on December 2021 | British Journal of Vol. No. effects of the on for an emerging January 2022 | & Vol. No. Distress among Dental during the COVID-19 December 2021 | International Journal of Environmental Research and Public Health, Vol. 19, No. physical and social of health during the COVID-19 lockdown: a for of depression, and stress in the population during social isolation to the COVID-19 a cross-sectional study28 April 2021 | BMC Vol. No. and but same mortality of severe disease in March 2021 | BMC Medicine, Vol. No. Factors with and among community October 2021 | and Health, Vol. 17, No. differences in a of COVID-19 patients during the first and pandemic August 2021 | of Sex Vol. 12, No. in December 2021 | Journal of Clinical Medicine, Vol. 10, No. November 2021 | of Coronavirus Anxiety in Women on and Birth One of Coronavirus October 2021 | Journal of and Research, Vol. No. in and among Young Adults During Social to March 2021 | The Journal of Sex Research, Vol. No. of COVID-19 short- and long-term Disparities in and October 2021 | PLOS ONE, Vol. 16, No. analysis of on 2021 | Journal of in Medicine, Vol. No. of and Among COVID-19 by States in Women An September 2021 | and Vol. No. of COVID-19 using Public Gender and COVID-19: a Social Media of 2021 | Journal of Research, Vol. 5, No. for COVID-19 and its impact on in the Research on and Economics, Vol. No. differences in mental health of Canadian during the COVID-19 of and Health, Vol. No. Use and Relationship to Stress, and Perceived During the COVID-19 Pandemic in August 2021 | Frontiers in Public Health, Vol. and Lessons for August 2021 | PLOS ONE, Vol. 16, No. in How women in the United States in of of during the pandemic of March 2021 | Journal of Psychology, Vol. No. of in severe COVID-19 and Vol. No. the gender June 2021 | Journal of Perinatal Medicine, Vol. No. and the Related Factors in for COVID-19 at 2021 | International Journal of Health and Sciences, Vol. No. Gender Disparities and A Vol. No. impact of COVID‐19 on women to A of December | & Vol. No. of the and During the Covid-19 2021 | Frontiers in Psychology, Vol. in a January 2021 | Vol. No. responses to COVID-19 to Abuse & Vol. in and Practice During Social Among Young Adults in the May 2021 | Medicine, Vol. No. SARS-CoV-2 pandemic: A Health, Vol. and and after the pandemic April 2021 | Clinical and Research, Vol. No. on in August | Vol. 13, No. An to COVID-19 February 2022 | Journal of Women and Social Vol. No. in the and Outcomes of With May 2021 | Journal of Medicine, Vol. 16, No. of COVID-19: and May 2021 | Frontiers in Public Health, Vol. in the of February 2022 | Journal of Human Vol. No. and of the COVID-19 pandemic from the of in May 2021 | Journal of Social Work, Vol. No. the Pandemic: December April health disparities in vulnerable populations of psychiatric patients during the COVID-19 Journal of Vol. 11, No. 4The Gender of to in March 2021 | Feminist Economics, Vol. No. in Risk Factors and Mental Health During the of the COVID-19 Pandemic: A of U.S. Women A. E. E. and April 2021 | Journal of Women's Health, Vol. 30, No. and of and in March 2021 | Medicine, Vol. No. impact of COVID-19 on the mental health of and Science & Medicine, Vol. of and with in April 2021 | Vol. 12, No. health and well-being of staff during the coronavirus disease 2019 4 and in an March 2021 | Journal of Vol. of Gender in the and of Coronavirus Disease 2019 An of Health and and March 2021 | Journal of Women's Health, Vol. 30, No. of the COVID-19 pandemic on and Vol. of COVID-19 and of and Public Health, Vol. No. cross-sectional study of the of and with perceptions of to March 2021 | Open, Vol. 11, No. research and social of health: at the of of impact on and of Clinical Medicine, Vol. 17, No. differences in responses to SARS-CoV-2 in patients with January 2021 | Reports, Vol. No. and to COVID-19 in and January 2021 | Policy and Practice, Vol. impact of COVID-19 among and of November | & Health, Vol. 26, No. in case and mortality of coronavirus disease 2019 (COVID-19) among states in the United November | of Medicine, Vol. No. and pandemic risk and fear among September 2021 | Health and Behavioral Medicine, Vol. No. June 2021 | Vol. No. of and with of Coronavirus Related September 2021 | Vol. a January 2021 | Cadernos de Saúde Vol. No. and Among Vol. of Psychological Distress and Factors among During the COVID-19 Pandemic at in March 2021 | Disease and Vol. and on During the COVID-19 Pandemic in of Social Media October 2021 | Journal of Medical Research, Vol. 23, No. and and attitudes, and practices toward COVID-19 among birth of and Health Vol. 10, No. the of in COVID-19 October | Health Vol. No. in the of COVID-19 and political Vol. services in times of in of quality care for pregnant women and their October | Health Care for Women Vol. No. social support in the face of the December | Journal of & Vol. 12, No. with fear and during the COVID-19 pandemic in October | and Health, Vol. 16, No. and of People from by December | Journal of in Health, and Education, Vol. 10, No. is in gender and age for COVID-19 A December | Journal of and Vol. No. of SARS-CoV-2 Among Nursing and in September | Journal of Medicine, Vol. No. role of in the severity of learned from Vol. on gender disparities in the impact of the U.S. COVID-19 Research, Vol. Gender Women's Health and October | Frontiers in Global Women's Health, Vol. and the risk to and women during Journal of Vol. No. With Disparities in COVID-19 Outcomes in an Health Care October | JAMA Network Open, Vol. No. in the time of in August | Vol. 17, No. de la en en por September | Vol. No. de la COVID-19 en la de September | Vol. No. Perspectives to Health Research and Prevention During the COVID-19 | and Health Vol. 24, No. and Disease Disparities in the United in Vol. No. for a to | Global Public Health, Vol. No. and of in September | Vol. 11, No. and What is the Vol. No. we in Covid-19 women and men Vol. in of COVID-19: Insights a Vol. No. will The need to for the research on and the role of and and Vol. Impact and Factors During the of the Coronavirus (COVID-19) Pandemic Among the Population in June | Frontiers in Psychology, Vol. and of and the in SARS-CoV-2 to the in May | International Journal of Sciences, Vol. No. Coronavirus Disease 2019 the of August | Vol. Gender of to in January | Vol. Social of Vol. of of and Digital Vol. this Gausman and Ana and Gender Disparities in the COVID-19 of Women's in April 17,

Journal of Women s Health · editorial or comment · 306 citationsread the source →

The pleasure of art as a matter of fact

You have accessMoreSectionsView PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InRedditEmail Cite this article Nadal Marcos and Skov Martin 2018The pleasure of art as a matter of factProc. R. Soc. B.2852017225220172252http://doi.org/10.1098/rspb.2017.2252SectionYou have accessCommentThe pleasure of art as a matter of fact Marcos Nadal Marcos Nadal http://orcid.org/0000-0002-9341-4688 Department of Psychology, University of the Balearic Islands, Palma de Mallorca 07122, Spain [email protected] Google Scholar Find this author on PubMed Search for more papers by this author and Martin Skov Martin Skov Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Copenhagen 2650, Denmark Center for Decision Neuroscience, Copenhagen Business School, Copenhagen 2000, Denmark Google Scholar Find this author on PubMed Search for more papers by this author Marcos Nadal Marcos Nadal http://orcid.org/0000-0002-9341-4688 Department of Psychology, University of the Balearic Islands, Palma de Mallorca 07122, Spain [email protected] Google Scholar Find this author on PubMed and Martin Skov Martin Skov Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Copenhagen 2650, Denmark Center for Decision Neuroscience, Copenhagen Business School, Copenhagen 2000, Denmark Google Scholar Find this author on PubMed Published:21 March 2018https://doi.org/10.1098/rspb.2017.2252All other forms of perception divide a man, because they are exclusively based either on the sensuous or on the intellectual part of his being; only the perception of the Beautiful makes something whole of him, because both his natures must accord with it.— Schiller, 1793–1795, Letters on the Aesthetic Education of Man, p. 138, Letter 27Can art make us better people? Better members of society? In her recent article, 'Pleasure junkies all around! Why it matters and why "the arts" might be the answer: a biopsychological perspective', Christensen [1] claims that engaging with art can promote healthy choices, choices that balance short-term pleasure goals with long-term general well-being. She suggests that many modern life conveniences, such as social media, computer games or online shopping, have the potential to turn us into 'pleasure junkies' because they maximize short-term pleasures. But art, Christensen argues, is a safe choice and a means to remedy this unhealthy addiction to pleasure. Christensen's argument is grounded on three claims about the sort of pleasure we get from art. First, in contrast to low-level pleasure, which Christensen conceives as 'a mere perceptual stimulation leading to a rewarding sensation (food, sex, etc.)' ([1], p. 2), pleasure from art is presented as a kind of higher-order pleasure that engages 'broader neural networks implied in the attribution of meaning' (p. 2), presumably leading to 'long-term maintenance of healthy bodily function' (p. 2). Second, 'the arts do not induce states of craving without fulfilment—as do activities with reinforcement schedules which are prone to create habits and addictions such as intermittent variable ratio or interval reinforcement schedules (e.g. social media, gambling, football, extreme sports, drugs' (p. 4). Third, 'the arts do not search for a perceptual "Bliss point" […]. They do not just repeat over and over again a sensory stimulus that excites the senses and induces craving for more of a "pleasurable itch" (e.g. sugar, sexualized body displays, certain musical lyrics, tones; i.e. a perceptual "bliss point")' (p. 4).The claim, in a nutshell, is that the pleasure induced by art is different to the pleasure induced by food, sex, sports or drugs, because it is related to the balanced activation of brain systems related to short-term pleasure and long-term wellbeing goals, because it does not induce craving, and because it is not aimed at a perceptual 'bliss point'. This distinct sort of pleasure, according to Christensen, makes it possible for the arts to thwart the pernicious effects that the unhealthy urges and cravings licensed by 'today's mainstream acceptance of pleasure-seeking behaviour' (p. 5) have on individuals' lives and on societies. Such sweeping statements about art, food, sex, sports and society as a whole merit close examination. Christensen's primary claim that the pleasure induced by art is of a special kind, different to the pleasure induced by other activities is not supported by current understanding of what pleasure is. It is, moreover, contradicted by abundant empirical evidence. This evidence shows that pleasures, whatever their source, owe to activity in the same mesocorticolimbic circuit [2] and are encoded as a common neural currency [3]. As Kent Berridge and Morten Kringelbach put it: 'the brain mechanisms involved in fundamental pleasures (food and sexual pleasures) overlap with those for higher-order pleasures (e.g. monetary, artistic, musical, altruistic and transcendent pleasures) […] From sensory pleasures and drugs of abuse […] to monetary, aesthetic and musical delights, all pleasures seem to involve the same hedonic brain systems' ([4], p. 481). Thus, there is no evidence for specific brain regions or neural circuits related to the pleasure from art. Rather, the appreciation of art relies on brain mechanisms that evolved to appraise the value of biologically relevant objects in relation to internal homeostatic states [5]: 'Emotional reactions to music, further, activate the same cortical, subcortical and autonomic circuits, which are considered as the essential survival circuits of biological organisms in general' ([6], p. 6). In sum, the evidence shows that pleasure elicited by music and other art forms is no different in genesis and function to the pleasure induced by food, drugs and sex [7,8]. This is a matter of fact, not opinion. What supports Christensen's argument if not empirical evidence? In our view, her argument for the distinctness of art-induced pleasure seems based upon an oversimplified and devaluing conception of the pleasures of sex, food and sports, and a very narrow notion of art and its function. Christensen presents food, sex and sports as meaningless low-level sources of pleasure, and the arts as privileged vehicles for meaningful experiences. It is the personal and meaningful engagement with art—Christensen suggests—that fosters a balanced activation of brain systems related to short-term pleasure and long-term well-being goals. However, rarely—if ever—are food, sex and sports meaningless rewarding sensations. Contrary to Christensen's definition on page 2 of her article, pleasure—even sensory pleasure—is not simply reward, and never simply a sensation [4]. Indulging in food, sex or sports are meaningful and personally significant experiences that are not a matter of mere physical sensation. The experience of pleasure from food and sex is shaped by context, knowledge, expectations, anticipations, attitudes and beliefs that bring meaning to them [9–11]. Sex can be meaningful because it signifies physical connection with one's loved one, because it is cheating on someone, or deemed a sin. Likewise, eating is not about obtaining low-level pleasure. What we eat, the way we eat, what we believe about what we eat, where and whom we eat with, imbue eating with individual and social meaning, and shape the actual pleasure of eating [12]. On the other hand, encounters with art are not necessarily meaningful [13,14]. Actually, there is nothing intrinsically meaningful about engaging with art. Many laypeople lack the knowledge schemata required to engage meaningfully with abstract, cubist or contemporary art [15,16]. There are plenty of artworks people do not find meaningful or pleasant. Meaning making is not a special feature of art; it is a general feature of our species's cognition [17,18]. We can endow virtually any aspect of reality with meaning: sex, food, sports, a urinal, the shape of a cloud, an averted glance, someone's absence. Christensen's argument also rests on a historically and culturally narrow conception of art and its function. Art is presented as a circumscribed category of activities that elicit a unique sort of pleasant experiences: — The arts are set of activities of a special kind that share certain defining features distinguishing them from other activities: 'the arts push boundaries, surprise, reveal and excite both artist and spectator' ([1], p. 4).— Art encounters are positive, leading to 'pleasurable chills' and pleasurable experiences of understanding: 'The moment of meaning-assignation, also called "mastering" or "understanding" an artwork, is therefore a pleasurable experience' ([1], p. 4).— The pleasure elicited by art is special, because it does not involve craving for intense peaks: 'The arts do not search for a perceptual "bliss point" […] They do not just repeat over and over a sensory stimulus that excites the senses and induces craving for more of a "pleasurable itch"' ([1], p. 4).This characterization of the arts substantially overlaps with the notion of 'fine arts'. The core features of this characterization were instituted in the eighteenth century, after European intellectuals grouped certain activities into a distinct and autonomous collection, labelled 'fine arts'. To make sense of and promote this grouping, it became imperative to identify a common essence setting art apart from other activities [19,20,21]. One of the most popular proposals was that only art could produce a special sort of pleasure, sophisticated and polite [19,21]—a conception stemming not from any understanding of physiology, but from mere speculation. This limited historical and cultural scope renders this conception of the arts unfit for behavioural or neuroscientific research [19]. The category 'the arts' should not be mistaken for a natural kind. It is a historical convention, and has no direct biological correspondence. Moreover, this conception of art that Christensen espouses does not apply to art as practised in non-Western societies [19,22]. It does not even apply to Western art before the eighteenth century or after the nineteenth century [19,20,21]. First, art does not necessarily evoke pleasurable experiences. There are abundant artworks intended to arouse negative emotions [19,23], and to portray physical and moral ugliness [24]. Understanding art is not necessarily a pleasant experience: it can be an angering, disgusting or upsetting one [25]. Second, many artworks actually exploit repetition, bliss points and craving [26]. Repetition is a fundamental design feature of music and other performance arts [27]: In Relation in Space (1976) Marina Abramovic and Ulay ran into each other repeatedly for an hour; Ravel's Bolero is a 17 min-long instance of melodic and rhythmic repetitiveness. Anticipation and craving for bliss points are also essential to music [28]. In fact, the enjoyment of music is linked to intense feelings of anticipation and expectation caused by dopamine activity in the caudate nucleus (also involved in the rewarding aspect of food) [29,30], and peak pleasure states (bliss points) [31], caused by the release of dopamine and opioids in the brain's reward system (also involved in cocaine induced euphoria) [29,30]. Given the available evidence, therefore, there is no reason to believe that the pleasure from art is special or unique [32].In sum, Christensen's claim for the distinctiveness of pleasure from art is contradicted by empirical evidence, and her argument for the beneficial effects of art rests upon disputed foundations. Art's capacity to promote healthier choices and make us better people that can contribute to a better society remains as unconfirmed today as it was when Schiller speculated on art's power to harmonize human's conflicting sensuous and formal impulses. Christensen's argument is problematic even if intended to highlight hypothetical possibilities. Arguments about hypothetical possibilities should still rely on valid premises, and scientific hypotheses should be grounded on evidence, or at least in line with it. Otherwise, they are merely unfounded speculations. Scientific aesthetics is only just finding its footing and its place within cognitive neuroscience [33,34]. If evidence is ignored or rejected because it does not fit preconceived notions about art and its function, scientific aesthetics will become only an arena to promote and legitimize personally appealing notions of art by applying a scientific gloss over them. A proper scientific study of art needs to be grounded on empirical evidence and strong arguments that follow from solid premises [35,36]. Only then can scientific aesthetics provide reliable explanations for artistic and aesthetic behaviour, and thus make a significant contribution to the understanding of our human nature. Data accessibilityThis article has no additional data. Authors' contributionsBoth authors have contributed to conceiving, developing and writing the research presented in this paper, and approved it for publication. Competing interestsWe declare we have no competing interests. FundingThis research was supported by grant PSI2016-77327-P (MINECO/AEI/ERDF, EU).Footnotes© 2018 The Author(s)Published by the Royal Society. All rights reserved. References1Christensen JF. 2017Pleasure junkies all around! Why it matters and why 'the arts' might be the answer: a biopsychological perspective. Proc. R. Soc. B 284, 20162837. (doi:10.1098/rspb.2016.2837) Link, ISI, Google Scholar2Berridge CW, Kringelbach ML. 2013Neuroscience of affect: brain mechanisms of pleasure and displeasure. Curr. Opin. Neurobiol. 23, 294–303. (doi:10.1016/j.conb.2013.01.017) Crossref, PubMed, ISI, Google Scholar3Levy DJ, Glimcher PW. 2012The root of all value: a neural common currency for choice. Curr. Opin. Neurobiol. 22, 1027–1038. (doi:10.1016/j.conb.2012.06.001) Crossref, PubMed, ISI, Google Scholar4Kringelbach ML, Berridge KC. 2009Towards a functional neuroanatomy of pleasure and happiness. Trends Cogn. Sci. 13, 479–487. (doi:10.1016/j.tics.2009.08.006) Crossref, PubMed, ISI, Google Scholar5Brown S, Gao X, Tisdelle L, Eickhoff LM. 2011Naturalizing aesthetics: brain areas for aesthetic appraisal across sensory modalities. Neuroimage 58, 250–258. (doi:10.1016/j.neuroimage.2011.06.012) Crossref, PubMed, ISI, Google Scholar6Reybrouck M, Eerola T. 2017Music and its inductive power: a psychobiological and evolutionary approach to musical emotions. Front. Psychol. 8, 494. (doi:10.3389/fpsyg.2017.00494) Crossref, PubMed, ISI, Google Scholar7Blood AJ, Zatorre RJ. 2001Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc. Natl Acad. Sci. USA 98, 11 818–11 823. (doi:10.1073/pnas.191355898) Crossref, ISI, Google Scholar8Mallik A, Chandra ML, Levitin DJ. 2017Anhedonia to music and mu-opioids: evidence from the administration of naltrexone. Sci. Rep. 7, 41952. (doi:10.1038/srep41952) Crossref, PubMed, ISI, Google Scholar9Barrett LF. 2015How emotions are made: the secret life of the brain. London, UK: Macmillan. Google Scholar10Bloom P. 2010How pleasure works: the new science of why we like what we like. New York, NY: Norton. Google Scholar11Chatterjee A. 2014The aesthetic brain: how we evolved to desire beauty and enjoy art. New York, NY: Oxford University Press. Google Scholar12Spence C. 2017Gastrophysics: the new science of eating. London, UK: Penguin. Google Scholar13Leder H, Belke B, Oeberst A, Augustin D. 2004A model of aesthetic appreciation and aesthetic judgments. Br. J. Psychol. 95, 489–508. (doi:10.1348/0007126042369811) Crossref, PubMed, ISI, Google Scholar14Vessel EA, Rubin N. 2010Beauty and the beholder: highly individual taste for abstract, but not real-world images. J. Vis. 10, 1–14. (doi:10.1167/10.2.18) Crossref, PubMed, ISI, Google Scholar15Minissale G. 2013The psychology of contemporary art. Cambridge, UK: Cambridge University Press. Crossref, Google Scholar16Muth C, Pepperell R, Carbon C-C. 2013Give me Gestalt! Preference for cubist artworks revealing high detectability of objects. Leonardo 46, 488–489. (doi:10.1162/LEON_a_00649) Crossref, ISI, Google Scholar17Deacon TW. 1997The symbolic species: the co-evolution of language and the brain. New York, NY: Norton. Google Scholar18Henshilwood CS, d'Errico F. 2011Homo symbolicus: the dawn of language, imagination and spirituality. Amsterdam, The Netherlands: John Benjamins Publishing Co. Crossref, Google Scholar19Carroll N. 2008Aesthetic experience, art and artists. In Aesthetic experience (eds Shusterman R, Tomlin A), pp. 145–165. New York, NY: Routledge. Google Scholar20Kivy P. 2012What really happened in the eighteenth century: the 'Modern System' re-examined (again). Br. J. Aesthetics 52, 61–74. (doi:10.1093/aesthj/ayr046) Crossref, ISI, Google Scholar21Shiner L. 2001The invention of art: a cultural history. Chicago, IL: University of Chicago Press. Crossref, Google Scholar22Anderson RL. 1989Art in small-scale societies. 2nd edn. Englewood Cliffs, NJ: Prentice Hall. Google Scholar23Silvia PJ. 2009Looking past pleasure: anger, confusion, disgust, pride, surprise, and other unusual aesthetic emotions. Psychol. Aesthetics Creat. Arts 3, 48–51. (doi:10.1037/a0014632) Crossref, ISI, Google Scholar24Eco U. 2007On ugliness. London, UK: Harvill Secker. Google Scholar25Silvia PJ, Brown EM. 2007Anger, disgust, and the negative aesthetic emotions: expanding an appraisal model of aesthetic experience. Psychol. Aesthetics Creat. Arts 1, 100–106. (doi:10.1037/1931-3896.1.2.100) Crossref, Google Scholar26Huron D. 2006Sweet anticipation: music and the psychology of expectation. Cambridge, MA: MIT Press. Crossref, Google Scholar27Fitch W. 2006The biology and evolution of music: a comparative perspective. Cognition 100, 173–215. (doi:10.1016/j.cognition.2005.11.009) Crossref, PubMed, ISI, Google Scholar28Trainor LJ, Zatorre RJ. 2009The neurobiological basis of musical expectations. In The Oxford handbook of music psychology (eds Hallam S, Cross I, Thaut M), pp. 171–183. Oxford, UK: Oxford University Press. Google Scholar29Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. 2011Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat. Neurosci. 14, 257–262. (doi:10.1038/nn.2726) Crossref, PubMed, ISI, Google Scholar30Salimpoor VN, Zatorre RJ. 2013Neural interactions that give rise to musical pleasure. Psychol. Aesthetics Creat. Arts 7, 62–75. (doi:10.1037/a0031819) Crossref, ISI, Google Scholar31Whaley J, Sloboda J, Gabrielsson A. 2009Peak experiences in music. In The Oxford handbook of music psychology (eds Hallam S, Cross I, Thaut M), pp. 452–461. Oxford, UK: Oxford University Press. Google Scholar32Skov M, Nadal M.In press. Art is not special: an assault on the last lines of defense against the naturalization of the human mind. Rev. Neurosci. (doi:10.1515/revneuro-2017-0085) ISI, Google Scholar33Chatterjee A. 2011Neuroaesthetics: a coming of age story. J. Cogn. Neurosci. 23, 53–62. (doi:10.1162/jocn.2010.21457) Crossref, PubMed, ISI, Google Scholar34Pearce MT, Zaidel DW, Vartanian O, Skov M, Leder H, Chatterjee A, Nadal M. 2016Neuroaesthetics: the cognitive neuroscience of aesthetic experience. Perspect. Psychol. Sci. 11, 265–279. (doi:10.1177/1745691615621274) Crossref, PubMed, ISI, Google Scholar35Nadal M, Vartanian O, Skov M. 2017Psychological models of art reception must be empirically grounded. Behav. Brain Sci. 40, 36–37. (doi:10.1017/S0140525X17001790) Crossref, ISI, Google Scholar36Nadal M, Skov M. 2017Top–down and bottom–up: front to back: comment on 'Move me, astonish me… delight my eyes and brain: the Vienna integrated model of top–down and bottom–up processes in Art Perception (VIMAP) and corresponding affective, evaluative, and neurophysiological correlates' by Matthew Pelowski et al. Phys. Life Rev. 21, 148–149. (doi:10.1016/j.plrev.2017.06.013) PubMed, ISI, Google Scholar Previous ArticleNext Article VIEW FULL TEXT DOWNLOAD PDF FiguresRelatedReferencesDetailsCited by Clemente A, Pearce M, Skov M and Nadal M (2021) Evaluative judgment across domains: Liking balance, contour, symmetry and complexity in melodies and visual designs, Brain and Cognition, 10.1016/j.bandc.2021.105729, 151, (105729), Online publication date: 1-Jul-2021. Chuan-Peng H, Huang Y, Eickhoff S, Peng K and Sui J (2020) Seeking the "Beauty Center" in the Brain: A Meta-Analysis of fMRI Studies of Beautiful Human Faces and Visual Art, Cognitive, Affective, & Behavioral Neuroscience, 10.3758/s13415-020-00827-z, 20:6, (1200-1215), Online publication date: 1-Dec-2020. Skov M and Nadal M (2020) A Farewell to Art: Aesthetics as a Topic in Psychology and Neuroscience, Perspectives on Psychological Science, 10.1177/1745691619897963, 15:3, (630-642), Online publication date: 1-May-2020. Kalpokas I (2019) Making the Theory Political A Political Theory of Post-Truth, 10.1007/978-3-319-97713-3_4, (87-121), . Kalpokas I (2019) Affective Encounters of the Algorithmic Kind: Post-Truth and Posthuman Pleasure, Social Media + Society, 10.1177/2056305119845678, 5:2, (205630511984567), Online publication date: 1-Apr-2019. Skov M (2019) Aesthetic Appreciation: The View From Neuroimaging, Empirical Studies of the Arts, 10.1177/0276237419839257, 37:2, Online publication date: H, I and (2020) A for We Aesthetic in Human Neuroscience, A and in A New for Arts, This March Article in 2018 The Author(s)Published by the Royal Society. All rights Citations and are available with

Proceedings of the Royal Society B Biological Sciences · editorial or comment · 24 citationsread the source →

Associations between age and the course of major depressive disorder: a 2-year longitudinal cohort study.

Background: Although there is some evidence that older people might have a poorer course of major depressive disorder (MDD) than younger or middle-aged people, and that age-related course differences might affect the optimisation of MDD treatment, large-scale studies with a broad age range, including consistent course assessments, are needed to properly address this issue. Therefore, we aimed to longitudinally examine whether older age was associated with a poorer naturalistic course trajectory of MDD than that of younger ages and to establish which prognostic-clinical, social, and health-factors could explain this potentially poorer course. Methods: For this longitudinal cohort study, we used baseline and 2-year follow-up data from the Netherlands Study of Depression and Anxiety (NESDA) and the Netherlands Study of Depression in Older Persons (NESDO) cohorts. People aged between 18 and 88 years, with an MDD diagnosis at baseline, and a valid clinical assessment at 2-year follow-up were included. The primary outcome was the 2-year course of MDD, which was assessed by use of four indicators: having a depression diagnosis (MDD or dysthymia) after 2 years, having a chronic symptom course (depressive symptoms present during 80% or more of the 2-year follow-up period), time to remission, and depression severity change. We used multivariate analyses to examine associations between continuous age and these MDD course indicators. We also examined whether prognostic clinical (eg, comorbid anxiety), social (loneliness and social support), and health (body-mass index, pain, and chronic diseases) factors contributed to the differences in the course of MDD between age groups. Findings: Between 2004-2012, baseline and 2-year follow-up data were obtained for 1042 participants from the NESDA and NESDO cohorts, of whom 690 (66%) were women. Older age was significantly associated with a worse 2-year MDD course for all four indicators (MDD diagnosis: odds ratio [OR] 1·08, 95% CI 1·00-1·17; chronic symptom course: OR 1·24, 1·13-1·35; time to remission: hazard ratio [HR] 0·91, 0·87-0·96; and depression severity change: regression coefficient 1·06, p<0·0001; all per 10-year increase). The course of MDD worsened linearly with age, and people aged 70 years or older had the worst outcomes compared with those of the reference group of people aged 18-29 years (MDD diagnosis: OR 2·02, 95% CI 1·18-3·45; chronic symptom course: OR 3·19, 1·74-5·84; time to remission: HR 0·60, 0·44-0·83; and depression severity change: -12·64 [SD 10·85] in those aged 18-29 years and -5·57 [11·14] in those aged 70 years or older). These results were slightly reduced, but remained mostly significant when adjusting for prognostic clinical, social, and health factors. Interpretation: Older age was found to be a consistent and important risk factor for a poorer MDD course, which could not be explained by a range of well established risk factors. Further investigation of potential underlying mechanisms-including the effect of cognitive impairment, for example-is needed to prevent the negative consequences of a long-term MDD burden in older people. Funding: Netherlands Organisation for Health Research and Development, Fonds NutsOhra, Stichting tot Steun VCVGZ, NARSAD The Brain and Behaviour Research Fund, and European Union's 7th Framework Programme.

The lancet. Psychiatry · 114 citationsread the source →

Medical Students' Demographic Characteristics and Their Perceptions of Faculty Role Modeling of Respect for Diversity.

Importance: Faculty role modeling is critical to medical students' professional development to provide culturally adept, patient-centered care. However, little is known about students' perceptions of faculty role modeling of respect for diversity. Objective: To examine whether variation exists in medical students' perceptions of faculty role modeling of respect for diversity by student demographic characteristics. Design, setting, and participants: This cross-sectional study analyzed data from the Association of American Medical Colleges' 2016 and 2017 Medical School Graduation Questionnaire, which was administered to graduating students at 140 accredited allopathic US medical schools. Data were analyzed from January 1 to November 1, 2020. Main outcomes and measures: Students' perceptions of faculty role modeling of respect for diversity by the independent variables sex, race/ethnicity, sexual orientation, and age. Multivariable logistic regression was used to examine the extent to which student-reported perceptions of faculty respect for diversity varied by demographic characteristics, and logistic regression models were sequentially adjusted first for demographic characteristics and then for marital status and financial variables. Results: Of 30 651 students who completed the survey, the final study sample consisted of 28 778 respondents, representing 75.4% of the 38 160 total US medical school graduates in 2016 and 2017. Of the respondents, 14 804 (51.4%) were male participants and 1506 (5.2%) identified as lesbian, gay, or bisexual (LGB); a total of 11 926 respondents (41.4%) were 26 years or younger. A total of 17 159 respondents (59.6%) identified as White, 5958 (20.7%) as Asian, 1469 (5.1%) as Black/African American, 2431 (8.4%) as Hispanic/Latinx, and 87 (0.3%) as American Indian/Alaska Native/Native Hawaiian/Pacific Islander individuals. Overall, 5101 students (17.7%) reported perceiving that faculty showed a lack of respect for diversity. Of those who identified as Black/African American students, 540 (36.8%) reported perceiving a lack of faculty respect for diversity compared with 2468 White students (14.4%), with an OR of perceived lack of respect of 3.24 (95% CI, 2.86-3.66) after adjusting for other demographic characteristics and covariates. American Indian/Alaska Native/Native Hawaiian/Pacific Islander (OR, 1.73; 95% CI, 1.03-2.92), Asian (OR, 1.62; 95% CI, 1.49-1.75), or Hispanic/Latinx (OR, 1.43; 95% CI, 1.26-1.75) students also had greater odds of perceiving a lack of faculty respect for diversity compared with White students. Female students had greater odds compared with male students (OR, 1.17; 95% CI, 1.10-1.25), and students who identified as LGB (OR, 1.96; 95% CI, 1.74-2.22) or unknown sexual orientation (OR, 1.79; 95% CI, 1.29-2.47) had greater odds compared with heterosexual students. Students aged 33 years or older had greater odds of reporting a perceived lack of respect compared with students aged 26 years or younger (OR, 1.81; 95% CI, 1.58-2.08). Conclusions and relevance: In this cross-sectional study, female students, students belonging to racial/ethnic minority groups, and LGB students disproportionately reported perceiving a lack of respect for diversity among faculty, which has important implications for patient care, the learning environment, and the well-being of medical trainees.

JAMA network open · 23 citationsread the source →

Effectiveness of app-based interventions for glucose management, cardiometabolic and mental health, and related risk factors: an umbrella review with meta-analysis.

Background: Non-communicable diseases are the leading cause of death globally. Smartphone apps can offer benefits for individuals, health-care professionals, and governments in the prevention and management of such conditions. We aimed to systematically evaluate the effectiveness of app-based interventions in improving the outcomes of non-communicable diseases and in modifying their metabolic and behavioural risk factors. Methods: For this umbrella review and meta-analysis, we searched eight databases (Embase, Epistemonikos, IEEE Xplore Digital Library, APA PsycInfo via Ovid, PubMed, Scopus, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials) for systematic reviews with meta-analysis published between Jan 1, 2013, and Jan 10, 2024, with no restrictions by geographical location or language. Additional studies were located through citation chaining and searching of reference lists. Eligible studies reviewed randomised controlled trials or controlled studies focused on adults (aged ≥18 years) with or at risk of non-communicable diseases and the use of app-based interventions for managing or improving the outcomes of these diseases and related health and risk factors, both metabolic and behavioural. Two investigators (EK and MFV) used COVIDENCE software to screen abstracts and full texts and to subsequently extract data from eligible studies. In case of missing data, authors of the relevant articles were contacted for unreported data or additional details. Effect sizes were measured as the standardised mean difference (SMD) and were aggregated through meta-analyses. 95% CIs for each review were synthesised using a random-effects model and prediction intervals were based on a t distribution. When more than ten reviews were available, publication bias was assessed visually through the inspection of funnel plots and by Egger's test; if bias was suspected, a trim-and-fill analysis was applied to estimate a revised effect size. The quality of the included reviews was evaluated with the AMSTAR 2 checklist, the certainty of evidence for each outcome was assessed using the GRADE framework and the Ioannidis criteria, and heterogeneity was measured by calculating I2 values. This study was registered with PROSPERO, CRD42023426735. Findings: Of 6951 unique records identified by our searches, 383 underwent full-text review and 78 systematic reviews with meta-analysis, covering 31 outcomes, were included in the study. These reviews covered 496 primary studies and involved a total of 177 373 participants. App-based interventions were found to be effective in lowering diastolic blood pressure (SMD -0·414 [95% CI -0·606 to -0·221], I2=93%), systolic blood pressure (-0·444 [-0·689 to -0·199], I2=96%), glycated haemoglobin (-0·587 [-0·715 to -0·460], I2=91%), fasting blood glucose concentration (-1·189 [-1·605 to -0·774], I2=93%), 2 h postprandial glucose concentration (-1·229 [-1·609 to -0·848], I2=95%), anxiety (-0·215 [-0·407 to -0·023], I2=92%), depression (-0·097 [-0·176 to -0·019], I2=77%), stress (-0·336 [-0·528 to -0·143], I2=87%), bodyweight (-0·427 [-0·594 to -0·260], I2=91%), BMI (-0·265 [-0·522 to -0·007], I2=92%), waist circumference (-0·310 [-0·464 to -0·156], I2=75%), and sedentary time (-0·600 [-1·121 to -0·079], I2=22%). Additionally, apps significantly improve diet quality (0·551 [0·261-0·842], I2=91%), exercise capacity (0·259 [0·119-0·398], I2=17%), moderate-to-vigorous physical activity (0·240 [0·025-0·456], I2=75%), number of steps taken daily (0·489 [0·209-0·770], I2=83%), multiple physical activity outcomes (0·466 [0·243-0·689], I2=90%), mindfulness (0·293 [0·177-0·409], I2=77%), wellbeing (0·186 [0·065-0·307], I2=74%), quality of life (0·227 [0·083-0·371], I2=80%), and medication adherence (0·688 [0·410-0·965], I2=88%) when compared with control groups. However, no significant effect was found on cardiovascular mortality; HDL, LDL, total cholesterol, or triglyceride concentrations; body fat; distress; fruit and vegetable intake; hospitalisation; or smoking abstinence. Of the 78 systematic reviews, only one (1%) was rated as being of high quality, with three (4%) of moderate quality, 17 (22%) of low quality, and 57 (73%) of critically low quality. According to Ioannidis criteria, five outcomes were categorised as having highly suggestive (class II) evidence, with eight outcomes having suggestive evidence (class III), eleven outcomes having weak evidence, and seven outcomes categorised as non-significant. Interpretation: Our analyses provide evidence that app-based interventions support significant improvements in multiple outcomes of and risk factors for non-communicable diseases, including cardiovascular diseases, glucose control, mental health outcomes, physical activity, and quality of life. The integration of app-based interventions into health-care systems should be prioritised to enhance patient care and health outcomes. Funding: None.

The Lancet. Digital healthread the source →

Prevalence and identification of anxiety disorders in pregnancy: the diagnostic accuracy of the two-item Generalised Anxiety Disorder scale (GAD-2).

Objective: To estimate the population prevalence of anxiety disorders during pregnancy and investigate the diagnostic accuracy of the two-item Generalised Anxiety Disorder scale (GAD-2) for a) GAD and b) any anxiety disorder. Design: Cross-sectional survey using a stratified sampling design. Sampling weights were used in the analysis to adjust for the bias introduced by the stratified sampling. Setting: Inner-city maternity service, South London. Participants: 545 pregnant women were interviewed after their first antenatal appointment; 528 provided answers on the GAD-2 questions. Main outcome measures: Diagnosis generated by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (SCID). Results: Population prevalence of anxiety disorders was 17% (95% CI 12% to 21%): 5% (95% CI 3% to 6%) for GAD, 4% (95% CI 2% to 6%) for social phobia, 8% (95% CI 5% to 11%) for specific phobia and 2% (95% CI 1% to 4%) for obsessive-compulsive disorder. Post-traumatic stress disorder (PTSD) prevalence was unclear due to higher levels of reluctance to respond to PTSD interview questions but sensitivity analyses suggest population prevalence maybe up to 4% (95% CI 2% to 6%). Weighted sensitivity of GAD-2 for GAD (cut-off ≥3) was 69%, specificity 91%, positive predictive value 26%, negative predictive value 98% and likelihood ratio 7.35. For any anxiety disorder the weighted sensitivity was 26%, specificity 91%, positive predictive value 36%, negative predictive value 87% and likelihood ratio 2.92. Conclusions: Anxiety disorders are common but GAD-2 generates many false positives and may therefore be unhelpful in maternity services.

BMJ open · 50 citationsread the source →

Prevalence and factors associated with knowledge of and willingness for male circumcision in rural Zimbabwe.

Objective: To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among rural Zimbabweans. Methods: Representative survey of 18-44 year olds in two provinces, as part of an evaluation of the Zimbabwe National Behaviour Change Programme. We conducted univariate, bivariate and multivariate analyses. Linear regression was employed to predict knowledge of MC (composite index) and logistic regression to predict knowledge that MC prevents HIV, willingness (oneself or one's partner) to undergo MC, and willingness to have son circumcised. Results: Two thousand seven hundred and forty-six individuals participated in the survey (87% of eligibles). About two-thirds were women (64%). Twenty per cent of men reported being circumcised, while 17% of women reported having a circumcised partner. Knowledge of MC and its health benefits was low. Attitudes towards MC were relatively positive. If it could prevent HIV, 52% of men reported that they would undergo MC and 58% of women indicated that they would like their partners to be circumcised. Seventy-five per cent of men who reported being HIV positive were willing to undergo MC, against 52% of those who reported HIV negative status. Reported acceptability of neonatal circumcision was high with 58% of men and 60% of women reporting that they would have their sons circumcised if it protected them against HIV. Fear of adverse effects was highlighted as a barrier to MC acceptability. Conclusion: More knowledge about MC's health benefits positively affects people's attitudes towards MC. The relatively high MC acceptability suggests an enabling environment for the scale-up programme.

Tropical medicine & international health : TM & IH · 34 citationsread the source →

Major depressive disorder is associated with cardiovascular risk factors and low Omega-3 Index.

Objective: Cardiovascular disease (CVD) and major depressive disorder (MDD) are frequent worldwide and have a high comorbidity rate. Omega-3 fatty acids have been suggested as disease modulators for both CVD and MDD. Therefore, we studied whether polyunsaturated fatty acids and the Omega-3 Index may represent markers for assessment of the cardiovascular risk in somatically healthy patients suffering from MDD. Method: We conducted a case-control study from July 2004 to December 2007 in 166 adults (86 inpatients with MDD but without CVD from the Department of Psychiatry and Psychotherapy and 80 age- and sex-matched healthy controls from an outpatient clinic of the Division of Preventive Cardiology, Ludwig Maximilian University of Munich, Germany). Information gathered at baseline included MDD diagnosis according to DSM-IV criteria, depression ratings, conventional cardiovascular risk factors, and fatty acid and interleukin-6 determinations. Fatty acid composition was analyzed according to the HS-Omega-3 Index methodology. During the study, patients received no supplementation with omega-3 fatty acids. The main inclusion criteria were the diagnosis of MDD according to DSM-IV and a 17-item Hamilton Depression Rating Scale (HDRS-17) score of at least 17. Treatment response and remission were defined using the HDRS-17. Results: Several conventional risk factors such as high triglyceride (mean, 152 mg/dL vs 100 mg/dL; P < .001) and fasting glucose (mean, 96 mg/dL vs 87 mg/dL; P = .005) values as well as greater waist circumference (mean, 97 cm vs 87 cm; P = .019) and higher body mass index (calculated as kg/m(2); mean, 26 vs 24; P = .011) were more prevalent in MDD patients in comparison with controls. The Omega-3 Index (mean, 3.9% vs 5.1%; P < .001) and individual omega-3 fatty acids were significantly lower in MDD patients. An Omega-3 Index < 4% was associated with high concentrations of the proinflammatory cytokine interleukin-6 (χ(2) = 7.8, P = .02). Conclusions: Conventional cardiovascular risk factors, the Omega-3 Index, and interleukin-6 levels indicated an elevated cardiovascular risk profile in MDD patients currently free of CVD. Our results support the employment of strategies to reduce the cardiovascular risk in still cardiovascularly healthy MDD patients by targeting conventional risk factors and the Omega-3 Index.

The Journal of clinical psychiatry · 69 citationsread the source →

Quality of work life among primary health care nurses in the Jazan region, Saudi Arabia: a cross-sectional study.

Unlabelled: Background: Quality of work life (QWL) is defined as the extent to which an employee is satisfied with personal and working needs through participating in the workplace while achieving the goals of the organization. QWL has been found to influence the commitment and productivity of employees in health care organizations, as well as in other industries. However, reliable information on the QWL of primary health care (PHC) nurses is limited. The purpose of this study was to assess the QWL among PHC nurses in the Jazan region, Saudi Arabia. Methods: A descriptive research design, namely a cross-sectional survey, was used in this study. Data were collected using Brooks' survey of quality of nursing work life and demographic questions. A convenience sample was recruited from 134 PHC centres in Jazan, Saudi Arabia. The Jazan region is located in the southern part of Saudi Arabia. A response rate of 91% (n = 532/585) was achieved (effective response rate = 87%, n = 508). Data analysis consisted of descriptive statistics, t-test and one way-analysis of variance. Total scores and subscores for QWL items and item summary statistics were computed and reported using SPSS version 17 for Windows. Results: Findings suggested that the respondents were dissatisfied with their work life. The major influencing factors were unsuitable working hours, lack of facilities for nurses, inability to balance work with family needs, inadequacy of vacations time for nurses and their families, poor staffing, management and supervision practices, lack of professional development opportunities, and an inappropriate working environment in terms of the level of security, patient care supplies and equipment, and recreation facilities (break-area). Other essential factors include the community's view of nursing and an inadequate salary. More positively, the majority of nurses were satisfied with their co-workers, satisfied to be nurses and had a sense of belonging in their workplaces. Significant differences were found according to gender, age, marital status, dependent children, dependent adults, nationality, nursing tenure, organizational tenure, positional tenure, and payment per month. No significant differences were found according to education level of PHC nurses and location of PHC. Conclusions: These findings can be used by PHC managers and policy makers for developing and appropriately implementing successful plans to improve the QWL. This will help to enhance the home and work environments, improve individual and organization performance and increase the commitment of nurses.

Human resources for health · 63 citationsread the source →

Problematic Internet use: an overview

The “global village”, a metaphor used to describe how the Internet has shortened distances and facilitated the flow of information, has grown to over one billion users 1. Statistics from across the world highlight its reach and penetrance: 90% of South Korean households connect to high-speed, inexpensive broadband 2; Londoners spend an average of 45 days a year online, more than they spend watching TV 3; and the rate of increase in the number of Internet users in Africa and the Middle East exceeded 1,300% between 2000 and 2009 4. For the majority of Internet users, the World Wide Web represents a tremendous wellspring of opportunity that enhances well-being. For others, however, it can lead to a state that appears to meet the DSM definition of a mental disorder, described as a “clinically significant behavioral or psychological syndrome…that is associated with present distress… or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” 5. Scientific understanding of that state has lagged behind media attention 6, in part because of inconsistency in defining the problem 7, disagreement about its very existence 8, and the variable research methodology used in studying it. Still, a body of data by scientists from the East and West (with the East increasingly leading the way) tells a cautionary tale about the Internet's potential to bring about psychological harm. In 1996, the psychologist K. Young became the first to publish a detailed case report of problematic Internet use 9. Her “patient zero” was a non-technologically oriented 43-year-old homemaker with a “content home life and no prior addiction or psychiatric history”, who, within three months of discovering chat rooms, was spending up to 60 hours per week online. She reported feeling excited in front of the computer, and depressed, anxious, and irritable when she would log off. She described having an addiction to the medium “like one would to alcohol”. Within one year of purchasing her home computer, she was ignoring household chores, had quit social activities she used to enjoy, and had become estranged from her two teenage daughters and her husband of 17 years. Based on this and other patients she interviewed, Young proposed the first set of diagnostic criteria for what she termed “Internet addiction”. She modeled them on the DSM-IV definition for substance dependence because of similarities she observed with the states of tolerance (needing more of the substance to achieve the same effect) and withdrawal (psychological and physical discomfort upon reducing or stopping the substance) 9. Others conceptualized problematic Internet use as a behavioral addiction not involving an intoxicant 10, and Young subsequently updated her definition, adapting the DSM-IV criteria for pathological gambling, an impulse control disorder often described as a behavioral addiction, into her Diagnostic Questionnaire 11 (Table 1). The questionnaire, which required at least five of the eight criteria be met for the Internet addiction diagnosis, has not received adequate psychometric testing. Shapira et al 12 proposed five years later a more inclusive diagnostic schema in the general style of the impulse control disorders. They argued that definitions based solely on substance dependence or pathological gambling were too narrow to capture the population of problematic Internet users and could lead to premature conclusions about the new disorder and the patients. They eschewed the “Internet addiction” label for lack of scientific proof for true addiction and favored the less controversial “problematic Internet use”, defining it as: a) maladaptive preoccupation with Internet use, experienced as irresistible use for periods of time longer than intended; b) significant distress or impairment resulting from the behavior; and c) the absence of other Axis I pathology that might explain the behavior, such as mania or hypomania. To date, only two studies have attempted to develop diagnostic criteria empirically by testing them against the diagnosis made on the basis of a systematic psychiatric interview. Ko et al 13 tested a set of criteria in 468 Taiwanese high school students. Starting with 13 candidate criteria, they eliminated those with low diagnostic accuracy, and determined that a cutoff of six out of the nine remaining criteria had the best diagnostic accuracy while maintaining high specificity (97.1%) and acceptable sensitivity (87.5%). The criterion for functional impairment was listed separately as criterion B and was required for the diagnosis (Table 2). In a second study, Ko et al 14 confirmed the diagnostic accuracy of their criteria in an older cohort of 216 Taiwanese college students. However, the relatively small size of both studies and the non-representative nature of the groups studied limit the applicability of the proposed criteria to the general population. Several assessment scales have been proposed to screen for, and help diagnose, problematic Internet use. As a group, these instruments show no consensus on the underlying dimensions that constitute the condition 6,15. In addition to Young's Diagnostic Questionnaire, two are in relatively common use in research and/or clinical settings: Young's Internet Addiction Test 16 and the Chen Internet Addiction Scale 17. Young's Internet Addiction Test 16 consists of 20 “how-often” questions, each rated on a scale of 1 to 5 (1=rarely; 2=occasionally; 3=frequently; 4=often; 5=always.) A score of 80 or above is consistent with problematic use (Table 3). The psychometric properties of the instrument were studied in 86 subjects 18. Six factors were extracted from the questionnaire: salience, excessive use, neglect of work, anticipation, lack of control, and neglect of social life. These factors showed good concurrent validity and internal consistency. Salience explained most of the variance and was also found to be the most reliable as indicated by its Cronbach's alpha. However, the selection bias introduced by online recruitment and the small size of the study limit its value. The Chen Internet Addiction Scale 17 is a self-report instrument composed of 26 items rated on a 4-point Likert scale (adapted in Table 4). It assesses five domains of Internet-related problems: compulsive use, withdrawal, tolerance, interpersonal and health consequences, and time management difficulties. Scores range from 26 to 104. In a study of 454 Taiwanese adolescents who completed the scale and received a structured diagnostic interview, a cutoff of 64 was shown to have high diagnostic accuracy and specificity (88% and 92.6%, respectively) 19. The internal reliability of the scale and subscales in the original study ranged from 0.79 to 0.93 17. Due to the lack of consensus on diagnostic criteria and the dearth of large epidemiological studies, the prevalence of problematic Internet use in the general population has not been established. Overall, prevalence surveys conducted in various countries fall into two main categories, online vs. offline studies, with the former typically yielding higher rates, most likely because of inherent selection bias 20. Only two epidemiological studies exploring the prevalence of problematic Internet use in the general population have been published. One was conducted in the US, the other in Norway 20,21. The US study used random-digit telephone dialing (cellular phone numbers were not included) to interview 2,513 adults taken from all 50 states in a manner proportional to the population in each state 20. More than half of the people reached agreed to be interviewed. Participants’ average age was 48, and 51% fell in the middle class socioeconomic stratum. 68.9% were regular Internet users. The authors’ diagnostic definition, based on published criteria and on similarities with impulse control disorders, substance dependence and obsessive-compulsive disorder, required: a) Internet use that interferes in personal relationships; b) preoccupation with the Internet when offline; c) unsuccessful attempts at quitting or cutting down; and d) staying online longer than intended. This definition yielded a point prevalence of 0.7%. Less stringent definitions yielded higher prevalence rates, and individual features consistent with problematic Internet use were endorsed by as many as 13.7% (respondents who found it hard to stay offline for days in a row). In the second study, Bakken et al 21 mailed Young's Diagnostic Questionnaire to 10,000 inhabitants of Norway, randomly selected from a database of the entire population. 3,399 completed questionnaires were returned (a somewhat lower response rate than the US study). Recipients of the mailed questionnaire also had the option of completing it online. Among respondents, 87% were Internet users. The prevalence of “addicted Internet use” (≥5 questions answered “yes”) was calculated to be 1%, whereas the prevalence of “at risk” Internet use (3–4 questions answered “yes”) was 5.2%. Multivariate analysis showed young age, male gender, higher educational achievement, and financial stress to be positively associated with “problematic Internet use” (defined by the authors to include both “Internet addicts” and “at risk” respondents). Prevalence rates among adolescents have been researched more extensively, perhaps because the so-called “digital natives” grew up incorporating the Internet in many aspects of life and as a result are perceived to be at higher risk. However, even when online-based surveys are excluded, the results can vary widely and are difficult to compare, due to differences in Internet access, recruitment methodology, the exact age bracket studied, and the definitions utilized. Considering only relatively large and offline studies, research from China 22, South Korea 23,24, Greece 25, Norway 26, and Iran 27 has yielded prevalence estimates ranging between 2% and 11%. Problematic Internet use has not been incorporated into large-scale epidemiological studies aimed at estimating the relative prevalence of mental disorders. Still, a review of published studies reveals that the presence of other psychiatric conditions in patients with problematic Internet use is the rule rather than the exception 6. The studies, however, were not designed or statistically powered to detect the nature of the association (cause, effect, or independent). In Bakken's general-population study 21, based on subjects’ self-report, 41.4% of Internet “addicts” reported feelings of depression in the 12-month period prior to the study, compared to 15.8% of non-problematic users. Sleep disturbances, anxious feelings, and alcohol and substance abuse were also more common (38.6% vs. 26.4%, 36.4% vs. 5%, and 13.6% vs. 1.1%, respectively). However, the questions used to assess co-occurring psychological impairment were not based on established criteria for mood, sleep, anxiety, or substance use disorders. Two US case series involved face-to-face interviews of adult patients with problematic Internet use. Black et al 28 assessed 21 subjects with the Diagnostic Interview Schedule and found the lifetime prevalence of mood disorders and major depression to be 33% and 15%, respectively. Further, 38% had a lifetime substance use disorder and 19% had a lifetime diagnosis of anxiety disorder. In a case series that included 20 patients, Shapira et al 29 found a very high (70%) lifetime prevalence for bipolar affective disorder, type I or II, compared with 15% for major depression. Fifty-five percent had a lifetime prevalence of substance abuse, and 45% met criteria for social anxiety disorder. Fifty percent of subjects had a lifetime diagnosis of an impulse control disorder. The authors highlight their observation that patients’ Internet-related symptoms were more impulsive and egosyntonic than compulsive and egodystonic, concluding that problematic Internet use resembles the DSM-IV definition of an impulse control disorder more closely than that of obsessive-compulsive disorder. Our clinical experience supports this conclusion. As a group, surveys conducted among high school and college students show similarly high comorbidity rates with mood and anxiety disorders, but a link between attention-deficit/hyperactivity disorder (ADHD) and problematic Internet use seems more obvious than among adults. One study in 752 South Korean elementary students found that 33% of those with ADHD also met criteria for problematic Internet use 30. Another study in 216 Taiwanese college students showed that 32% subjects with problematic Internet use also had ADHD compared to only 8% of regular Internet users 31. Whether Web-based activities appeal to the short attention span of ADHD sufferers or whether excessive Internet use may cause inattention remains to be elucidated. The clinical evaluation of the patient with problematic Internet use should include a careful assessment of the comorbid conditions frequently present. Those should then be treated according to established treatment guidelines. To the extent that the Internet-related problem may stem from another diagnosis (e.g., a patient with severe social anxiety who starts leading a “virtual” life at the expense of offline interactions), it might improve as the primary condition is addressed. Pharmacotherapeutic and psychotherapeutic interventions specific to problematic Internet use have not yet received adequate testing in large, rigorous studies. Pharmacotherapy often begins with selective serotonin reuptake inhibitors (SSRIs). However, while effective in treating obsessive-compulsive disorder, SSRIs have shown mixed results in impulse control disorders 32,33,34,35–36. In light of the greater similarity between problematic Internet use and impulse control disorders compared to obsessive-compulsive disorder 29, it is unclear whether SSRIs will ultimately prove beneficial, and no double-blind placebo-controlled studies have been published so far. One discontinuation study tested escitalopram, 20 mg/day, in 19 subjects with problematic Internet use 37. During the 10-week open-label phase, subjects showed significant decreases in weekly hours spent online (from a mean of 36.8 hours to 16.5 hours) and improvement in global functioning. At the end of the 10 weeks, subjects were blindly randomized to either continued escitalopram treatment or to placebo. Beyond that, they were followed for 9 weeks. No significant difference was seen between the two groups at the end of the second phase, as gains achieved at week 10 were maintained in both treatment groups. The authors speculate that nine weeks may have not been sufficient for the effect to be lost in the placebo group or for additional gains to be made in the escitalopram group, but do not rule out the possibility that the improvement seen in the open-label phase may have been a placebo response. One case study reported successful treatment with naltrexone 38, a drug that has shown benefit in other impulse control disorders 39,40. The patient was a 31 year old male with compulsive cybersexual behavior who had failed antidepressants, group and individual psychotherapy, Sexual Addicts Anonymous, and pastoral counseling. Naltrexone (150 mg/day), gradually added to a stable dose of sertraline which on its own had been ineffective in treating his problematic Internet use, helped induce a three-year remission. The authors hypothesize that, by blocking the capacity of endogenous opioids to trigger dopamine release in response to reward, naltrexone may block the reinforcing nature of compulsive Internet sexual activity. Another case study reported the successful use of an atypical antipsychotic, quetiapine, 200 mg/day, gradually added to citalopram, in a 23 year old subject with problematic Internet use 41. The improvement was maintained at four-month follow-up. More recently, a study tested methylphenidate in 62 children with ADHD who were Internet video game players 42. Participants’ average age was around 9. After 8 weeks of treatment (average dose 30.5 mg/day), Internet usage decreased significantly and correlated with reduction in ADHD symptoms. The authors cautiously suggest that methylphenidate might be beneficial as a treatment for problematic Internet use, especially when co-occurring with ADHD. Of the psychotherapy approaches used, cognitive behavioral therapy (CBT) has received the most empiric investigation. The largest study enrolled 114 adult subjects and employed CBT interventions including: keeping a daily log of Internet activity, teaching time management skills, and confronting cognitive distortions and rationalizations frequently used by patients to justify continued Internet usage, such as “just a few more minutes won't hurt” 43. Most subjects were able to control their symptoms by the eighth session, and improvement was sustained over a 6-month follow-up. For children and adolescents, family-based interventions that improve communication and teach family monitoring of Internet use can be helpful 44. However, the intensive (and typically very expensive) residential treatment options that have received much media attention have undergone little empiric investigation to warrant a strong recommendation 2,45. The same applies to online treatment websites that encourage the person with problematic Internet use to “click here if you are addicted to the Internet”. For a medium that has so radically changed the way we conduct our lives, the Internet's effects on our psychological health remain understudied. Simply stating that similar fears were raised when the radio, movies and early video games were introduced is not sufficient: the immersive and interactive qualities of the virtual world, and its sheer penetrance, make it potentially more serious. Also deserving of exploration are the more subtle psychological changes that occur in the virtual world, such as online disinhibition and increased risk-taking 46. Those changes are not necessarily evidence of “Internet addiction”, and may not be pathological, but, as important features of the new virtual psychology, should also be studied. As our field continues to debate whether their condition belongs in the next edition of the DSM 47, patients continue to present with symptoms born out of the digital age, and their symptoms are changing as the technology evolves from browsers, to “crackberries”, to “smart phones” that combine texting, talking, video games, and browsing in one device that to many is like a new appendage. Even the “problematic Internet use” designation now seems outdated, which is why some have wisely opted for “pathological use of electronic media”, instead 47. Technology, like media outlets, remains far ahead of scientific investigation. Given the dramatic changes that our society is undergoing as a result of the Internet revolution, it behooves us to try to bridge the gap.

World Psychiatry · 340 citationsread the source →

Life Review in Critical Care: Possibilities at the End of Life

The therapeutic use of life review provides nurses with a framework for clinical interactions. It was a short but memorable clinical encounter, initiated with the eldest of 3 living sons. The men’s mother, an 87-year-old frail, Chinese-born woman, had just been terminally extubated. A palliative care nurse was facilitating the woman’s life review with the sons, who were recounting harrowing tales of their mother’s life in Hong Kong during World War II: how people commonly ate animals off the street and weeds growing in the cracks of buildings to survive. Prompted to share their “gifts of the heart”—what their mother taught them about life and living that would resonate in their hearts—the sons spent the next hour in soft-spoken reflection at the bedside. As time progressed, a healing space was created, echoing the words of Curtis and Eldridge2(pp38–40):Using the palliative care consultation service of Lakeland Regional Medical Center, Lakeland, Florida, as a model, we offer clinical nurses an opportunity to extend practice beyond the physical care of patients at the end of life. When a patient’s goals of care clearly shift from cure to comfort, life review provides an evidence-based approach for interaction with the patient’s family. Using the theory and techniques we describe, practitioners can alleviate suffering, for the concern of nursing is “broader than the organ system that is affected, as we turn our attention to the emotional, physical and spiritual health of the whole patient.”3(p17)In her book Kitchen Table Wisdom: Stories That Heal, 4(ppxxvi–xxvii) Remen speaks of being deeply moved by her patients’ stories, “by the people and the meaning they found in their problems, by the unsuspected strengths, the depths of love and devotion. . . . Everybody is a story. . . . Everyone’s story matters.”Referring to a progressive return of the memories of past experience in search of meaning and in striving for emotional resolution, life review is a formal concept that has its roots in life-span developmental psychology.5 As defined by the theories of Butler5 and Erikson,6 development is shaped by countless factors throughout the entire life span: the historical time in which one lives, the economics and culture, and the positive and negative life circumstances.5–9 In his 1963 article,5(p66) Butler theorized that life review was aLife review has applications in varied situations, such as cultural transmission, anthropological field work, and career planning and vocational guidance.8 However, its therapeutic use provides nurses a framework for clinical interactions. Life review has been described as a recasting of the past in the context of the present10: the chance to reexamine one’s life and solve old problems, the chance to make amends and restore harmony,11 and the chance to “find new meaning in the face of impending death.”12(p120) Widely practiced in gerontology,6,11,12 life review is thought to be a useful method for understanding both self and others.13 In gerontology, multiple and consecutive weekly sessions are used to analyze, evaluate, and synthesize life events.14,15 Investigators16,17 have addressed adaptations of life review with terminally ill patients, situations in which time with patients and patients’ families was often limited because of the severity of the illness. Additionally, we (M.J., P.A.) have had countless single clinical encounters in which the therapeutic use of life review has been used, supporting the counsel of Byock18 to “create a space where healing can happen” and to “use a few moments to go deep—even when time is really short.”When any form of life review is undertaken, a life is examined, and questions such as the following19 are asked: Who am I? How did I do? How did I live my life? Thus, an important difference between reminiscence and review must be addressed. Life review is “not a random sharing of pleasurable past events, but rather a structured process containing a component of self-evaluation.”14(p9) Life review can be used with both patients and patients’ families; the outcomes include increased life satisfaction and accomplishment, promotion of peaceful feelings, and a state of integrity.20 Furthermore, Garland and Garland8 contend that life review has a distinct purpose in end-of-life care by upholding the unique value of each person’s life. These themes are consistent with Erikson’s theories of development6: the final task is ego integrity versus ego despair. Ego integrity6 involves acceptance of the course of one’s life, acceptance of one’s place in history, absence of death-anxiety, and satisfaction with life. In contrast, ego despair echoes in the words of the poet Robert Frost21: “. . . nothing to look backward to with pride, and nothing to look forward to with hope, so now and never any different.”Each health care provider can be inspired by the Institute of Medicine report Approaching Death: Improving Care at the End of Life22:Byock23(p36) builds on this vision, contending that a solely physiological approach with the terminally ill is “two-dimensional, and without the color, tone, or texture of life.” Additionally, Volker and Limerick24 explored the concept of dignified dying. In their interviews with advanced practice nurses in oncology, the theme of “going in peace” emerged, which referred to “the importance of connecting with loved ones; conveying final messages; dying in a quiet, nonchaotic environment; not suffering from physical or existential distress; and meeting spiritual needs.”24(p244)Irrespective of the clinical setting, the grief that is expressed at any bedside represents a “developmental crisis that becomes interwoven with family history.”25(p17) Although Butler’s concept of life review5 traditionally involves a patient and a health care practitioner, life review in critical care usually involves a patient’s family members, who become survivors if the patient dies. Compared with those who do not engage in life review, survivors who purposefully recount the events of their loved one’s life and death maintain a higher level of emotional function, such as moving appropriately through the grieving process and retaining the ability to perform activities of daily living. In support of this approach, many authors8,26–28 have articulated that the physical effects of internal stress are reduced by the outward expression of emotion. According to Pennebaker,27 the continuous inhibition of traumatic memory is a physical stressor that adversely affects the immune system. The death of a loved one is clearly a major life stressor. Despite that loss, survivors who participate in life review have the following desired outcome: they retain or regain hope for the future and a passion for life. The 3 interconnected components of life review are recontextualizing, forgiving, and reclaiming unlived life.29Recontextualizing is using an expanded vision of maturity, referring to the wisdom that comes with age and experience. Recontextualizing is used to reframe self-defined mistakes and failures. First, past negative life events and situations must be reexamined or reframed in such a way that they can be perceived as positive. A person must be willing to view the past differently, even when reliving unpleasant or painful experiences. In contrast to viewing oneself as the “victim” of past negative events and experiences, recontextualizing offers the realization that one is often in control of life experiences and has the opportunity to change memories based on perception of the experiences. Recontextualizing allows a reflection on the past, thus repairing relationships and events. Changing the perception changes the memory, from one of failure to one of success.5,8,10,29 Recontextualizing involves the “search for the deeper, sometimes more elusive, patterns that may be operating beneath the surface of everyday events.”29(p117)Present during the life review of a man who was dying were the man’s wife of 59 years, 2 adult daughters, and 1 granddaughter. Between numerous tears, the younger daughter reluctantly and slowly spoke of childhood memories: when her father was always adamant that she fulfill her academic duties. Deeply resentful as a child and adolescent, she was able to trace her current value of responsibility, as well as her national stature in her field, to her father’s expectations when she was a child. Without this purposeful revisiting of past events, the daughter’s memory might have focused on that resentment. Remen26(p29) remarks:Offering forgiveness to another and oneself often has an important result for patients facing the end of life. Anger and resentment, previously concentrated in a negative effort, can now be redirected toward positive thoughts and attitudes.29 Byock30 recounts numerous clinical cases involving forgiveness and cautions about a frequent misconception. Forgiveness is not about absolving someone else’s responsibility. Yet, when a relationship is completed, the story of the fractured relationship is totally reframed: everything that happened before is a prologue to the healing.18 The repair of life review never eliminates the pain, but forgiveness work helps in coming to terms with the painful feelings.29These thoughts are duplicated by Archbishop Desmond Tutu, who won the Nobel Peace Prize in 1984 for his healing work in South Africa after apartheid. Tutu asserts as follows31(pp270–271,279):The following highlights the concept of forgiveness. A 72-year-old man was unresponsive and had been intubated after an extensive myocardial infarction and unknown down-time before resuscitation. His family assembled to spend time with him, but this gathering was no simple feat; the family did not regard their father as a model parent. As a result, the 5 middle-aged adult children were living separate and rather chaotic lives. Some lived in other states, those who lived in the local area rarely talked, and none knew the whereabouts of their mother. Because of the exceptional and harsh nature of the stories (marked by family chaos and alcohol abuse by both parents), it was critical for the facilitators who were listening to maintain a nonjudgmental and therapeutic stance, to build trust and rapport. When talking about their childhood experiences, the adult siblings began to relate the stories that they had heard, as well as those they had experienced. Life review became an opportunity to place their own stories beside the stories of their father’s life. Painful moments, which could not be denied, could at least be placed in the context of the patient’s troubled life. The entire family was willing to reflect on and laugh about the joys that had been a part of their life together, especially holiday memories. More importantly, they found parts of their lives that they could treasure beyond the earlier pain and the current grief. When life support was discontinued, the many years of separation softened as the siblings began to find a sense of forgiveness for their father and each other. The family discovered that their shared stories were allowing them to reconnect, for they had lived through challenging childhoods. Because of the chaotic nature of this family’s life, the reconnection might not be sustainable, but for one moment, the grieving siblings found a sense of grace, appreciation, and gratitude in their shared life review. Reclaiming an unlived life involves reflecting on an opportunity earlier in life that was never used.29 Regret is a common theme in such reflections and is a topic of growing interest to cognitive researchers. Common life regrets involve education (how misgivings about attending school affected other life decisions), career (lack of success or choice of career), romance (long-lost loves and unsuccessful relationships), family (doubts over parenting or estrangements from parents/siblings), and the self (disappointments in abilities, attitudes, and behaviors).32 In expanding on the classic poem of Robert Frost, Beazley33(p9) addresses the concept of The Road Not Taken asSuch reflection transpired during the extensive life review of a dying patient by his adult daughter. Years ago, an irreparable breach had been created between the patient and his sister; the 2 of them took the specific details of the rift to their graves. However, the patient’s daughter had the courage to examine the lost opportunity of a life with her cousins. Deciding to end the division, she contacted her cousins and invited them to join her at her father’s deathbed. One local cousin responded to her invitation. Among many tears and hugs, the cousins pledged to reunite the family, thus reclaiming a lost heritage. Schachter-Shalomi and Miller29(p93) relate the 3 components of life review to the concept of time:Not every critical situation is a terminal one. Yet, life review is an important tool in placing the trauma of critical illness and associated aggressive medical treatment into the broader context of one’s entire life. The following the of an with of and was that a had and a was to be in hope of the from the The patient and her had moved to the after they so none of their 3 children lived in the Because other of support were not the on responded the patient was to The of the patient’s was so her was to reflect on her memories of time together, and the family that they had that this life review would be the of the The was to be because was of a the life review was part of the value of the patient’s life and a context for more and The life review was expanded as the patient’s children as they to questions about meaning and The patient and was to a nursing for but the family positive emotional from the of care unique for dying patients and the patients’ loved because of after may have been a and to by a painful to by and often spiritual In the to and for and of more than of patients who spent at least in a critical care and 3 of and that in the of critical care is and sometimes than dying in other the on adult patients in critical that positive outcomes for end-of-life care addressed and support as well as in this that palliative such as life review and emotional resolution, are part of When life review is in critical multiple and consecutive weekly sessions are not always However, the approach can be for the time of critical As previously life review offers a framework to and alleviate Although many critical care patients do and critical care is a time in a family’s story. experience the emotional trauma of a to the the family regard to emotional resolution, and of nurses of suffering or spiritual of suffering that can and be and through and that patient . . echoes that “the healing nurse for to to the patient an of am in this with that nursing that and be in the and in review was used in the following history, which the wife of a trauma patient with and The was from of state and without their of emotional In the review of her life, the wife had a where I would have been or I would have been if I had not Using this the explored the of the the that would the wife to living. The patient after the wife However, during the critical care she expressed the of the therapeutic review is for any family willing and able to engage in the emotional work of the Because of the nature of critical care life review encounters are However, for nurses who are more with the of life review offers a structured framework for a patient’s must always to the and emotional of critical care patients and the patients’ life review is must be to a patient’s pain and the patient is attention can be to the many factors with life review facilitators be of the family’s or spiritual for life review is in the of the therapeutic Using questions is always thus the of and for the must when not to care not to a thought or the from those new to life review, the in Table 1 might be a useful are to both the positive and the negative of life. can use any to no single way to a life review Although a life review has no a the when the family or to the In situations, life review might be Some patients and patients’ families have no to the never to participate in a life be to both I just talking are or That is a and or practitioners for a more or relationship than a family can or of the therapeutic relationship are beyond the of this but a life review on the understanding of the of such a as in Table be perceived as a nurse must that facilitating a life review involves a sense of and an that place the patient as the of his or her own life an nonjudgmental approach is to this approach can be a even for One with the daughter of a dying The daughter to the family meeting in a backward and a As the life review it was that this had been her father’s for more than she would her she had had his on her and his on her so she would always have his and in her life. The therapeutic relationship must the and to the work of who on the of suffering and 3 of which the is in the suffering of which the helps by listening to stories and the experience into and of one’s own which the is by both the suffering and the to that is the framework of the therapeutic of a life review is with a sense of responsibility. As by the of for nurses of the in the medical must be of and Although it is important for the health care to be about a patient’s of life review often and that do not to be in a family encounters might include on and of situations reflect patient has rather than patient’s is in the state for The therapeutic of life review be in the and the relationship always be must oneself before to Garland and this in Table 3 are for one’s own life As in her the without healing of the of time families for and the of their situations may chaos in critical care such as at the time of because of family more than a single therapeutic is often These are to involve the of the especially an man who was dying in a life The man’s wife and his adult each other. on time with the patient without the of the other. a was supporting the at the patient’s a palliative care nurse was supporting the wife in the The 2 allowing both the wife and the time with the 2 clinical life review could with each grieving family without of the other family review may result in such as with the past, and and despair. In the following the wife of a patient who had just been do not to be . . . my children have each other. . . . I do not to be In the of the wife had expressed so she was but about her to an by the health outcomes such as be because of a family’s but the and appropriately are regrets during life review involve spiritual In to clinical practice that is and facilitators of review activities be of the or spiritual of a patient and the patient’s family. for her work with in that is “the of and is “the that people through stress and challenging found in and our how people relate to each other. as that part of people that is to is both in negative of and for and and in positive and a of between and is often associated with an and on shared and is more and the meaning of life and rather than a of and involves a relationship to the self and to and may or may not involve a relationship with a higher and their families their and with the for people is meaning and purpose even in the of and this with a of are through the previously components of life recontextualizing, and reclaiming the unlived life. and life review are with common themes of forgiveness and and the of and the search for the purpose and meaning of life. the of an man could not be Because a was a life review was and a harrowing was for the the patient’s in World War a of over a the of The a man with with a the use of recontextualizing, the patient was to his emotional to his family. In the the patient’s family forgiveness on of the men’s and the spiritual was life review, patients can and those past life situations that now be or have a distinct opportunity to make a According to is to be at the end of life and to and life Furthermore, has that this we do not the spiritual . . we for the person as a and that in life, are more than is for dying patients in critical care who have lost the ability to fulfill the and of life. listening work offers the chance to a patient’s this the stories of loved for as meaning through care have a opportunity to a to the of final developmental is the of life their continuous we medical and medical and Lakeland Regional Medical

Critical Care Nurse · 16 citationsread the source →

Preventive care for adolescents: few get visits and fewer get services.

Objective: Professional guidelines for adolescents recommend annual preventive visits with screening and anticipatory guidance for health-related behaviors. The objective of this study was to examine receipt of preventive services, including disparities in services received, by using a nationally representative sample of adolescents. Methods: Using data from the 2001-2004 Medical Expenditure Panel Survey (ages 10-17; N = 8464), we examined receipt of preventive care visits and several measures of the content of care, based on caregiver's reports, among adolescents who received a preventive care visit during the past 12 months. Content of care outcomes included physical parameters measurement (height, weight, and blood pressure); receipt of anticipatory guidance (dental care, seat belts, helmets, exercise, healthy eating, and secondhand smoke exposure); and, for 12- to 17-year-olds, whether adolescents had time alone with their provider during their most recent visit, a proxy for confidential services. We conducted logistic regression analyses to test for disparities in the outcomes on the basis of race/ethnicity, income, and insurance status. Results: Thirty-eight percent of adolescents had a preventive care visit in the previous 12 months. Low-income and full-year uninsured status were associated with higher risk for not receiving this visit. Most adolescents had height (87%), weight (89%), and blood pressure (78%) assessed. Rates for height and weight were lower in poor and uninsured adolescents. Anticipatory guidance rates were much lower, ranging from 31% for seat belts, helmets, and secondhand smoke to 49% for healthy eating. Only 10% had all 6 areas addressed. Multivariate analyses yielded few disparities in receipt of anticipatory guidance. Forty percent had time alone with their providers. Hispanic and the lowest-income adolescents were the least likely to have time alone. Conclusions: Few adolescents received a preventive visit; among those who received this visit, provision of recommended anticipatory guidance was very low. Strategies are required to improve delivery of recommended preventive services to adolescents.

Pediatrics · 224 citationsread the source →

Cognitive complaints are associated with depression, fatigue, female sex, and pain catastrophizing in patients with chronic pain.

Objective: To examine the relation between demographic, pain-related, psychosocial, affective, and treatment factors and complaints of cognitive dysfunction among patients with chronic pain. Design: Cross-sectional survey. Setting: A university hospital outpatient multidisciplinary chronic pain program. Participants: Chronic pain patients (N=222; 135 women, 87 men) completed a battery of psychometric questionnaires as part of an initial evaluation on referral to the program. Interventions: Not applicable. Main outcome measures: Cognitive impairment was assessed with items from the Brief Symptom Inventory; measures of depressive symptoms, pain intensity, posttraumatic stress disorder (PTSD), and pain catastrophizing were obtained from the Beck Depression Inventory (negative affect, negative self, somatic/physical function), McGill Pain Questionnaire, Modified Posttraumatic Chronic Pain Test, and Coping Strategies Questionnaire, respectively; and measures of subjective sleep disturbance, fatigue, opiate use, compensation/litigation status, pain location, and relevant demographic data were obtained from an open-ended questionnaire. Results: Correlational analysis indicated that female sex, pain intensity, PTSD symptoms, depressive symptoms, catastrophizing, pain location (neck), and fatigue were all positively related to cognitive complaints. Simultaneous regression analysis showed that all factors combined accounted for 52% of the variance in self-report of cognitive difficulties and that 6 variables had a significant unique contribution to the report of cognitive complaints in the following order of importance: depression-negative affect (beta=.28, P <.05), fatigue (beta=.17, P <.05), depression-somatic/physical function (beta=.16, P <.05), depression-negative self (beta=.14, P =.05), pain catastrophizing (beta=.12, P =.08), and female sex (beta=.12, P <.05). Conclusions: Complaints of cognitive impairment among chronic pain patients appear to be associated with multiple factors, with particular attention to depressive symptoms, fatigue, and catastrophizing. Our results also suggest that women with chronic pain are particularly vulnerable to cognitive dysfunction.

Archives of physical medicine and rehabilitation · 101 citationsread the source →

Development of a brief diabetes distress screening instrument.

Purpose: Previous research has documented that diabetes distress, defined as patient concerns about disease management, support, emotional burden, and access to care, is an important condition distinct from depression. We wanted to develop a brief diabetes distress screen instrument for use in clinical settings. Methods: We assessed 496 community-based patients with type 2 diabetes on the previously validated, 17-item Diabetes Distress Scale (DDS17) and 6 biobehavioral measures: glycated hemoglobin (HbA(1c)); non-high-density-lipoprotein (non-HDL) cholesterol; kilocalories, percentage of calories from fat, and number of fruit and vegetable servings consumed per day; and physical activity as measured by the International Physical Activity Questionnaire. Results: An average item score of > or =3 (moderate distress) discriminated high- from low-distressed subgroups. The 4 DDS17 items with the highest correlations with the DDS17 total (r = .56-.61) were selected. Composites, comprised of 2, 3, and 4 of these items (DDS2, DDS3, DDS4), yielded higher correlations (r=.69-.71). The sensitivity and specificity of the composites were .95 and .85, .93 and .87, and .97 and .86, respectively. The DDS3 had a lower sensitivity and higher percentages of false-negative and false-positive results. All 3 composites significantly discriminated subgroups on HbA(1c), non-HDL cholesterol, and kilocalories consumed per day; none discriminated subgroups on fruit and vegetable servings consumed per day; and only the DDS3 yielded significant results on the International Physical Activity Questionnaire. Because of its psychometric properties and brevity, the DDS2 was selected as a screening instrument. Conclusions: The DDS2 is a 2-item diabetes distress screening instrument asking respondents to rate on a 6-point scale the degree to which the following items caused distress: (1) feeling overwhelmed by the demands of living with diabetes, and (2) feeling that I am often failing with my diabetes regimen. The DDS17 can be administered to those who have positive findings on the DDS2 to define the content of distress and to direct intervention.

Annals of family medicine · 311 citationsread the source →