Case-finding instruments for depression. Two questions are as good as many

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression

BACKGROUND

Whereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed.

PURPOSE

This study tests whether stigma, defined as depression label avoidance, predicted patients' preferences for depression treatment providers, patients' prospective engagement in depression care, and care quality.

METHODS

We conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression.

RESULTS

Relative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care.

CONCLUSIONS

High stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

Depression motivates quit attempts but predicts relapse: differential findings for gender from the International Tobacco Control Study

AIMS

To determine whether signs of current depression predict attempts to quit smoking, and short-term abstinence among those who try, and to test moderating effects of gender and cessation support (pharmacological and behavioural).

DESIGN

Prospective cohort with approximately annual waves. Among smokers at one wave we assessed outcomes at the next wave using mixed-effects logistic regressions.

SETTING

Waves 5-8 of the Four Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, USA, UK and Australia.

PARTICIPANTS

A total of 6811 tobacco smokers who participated in telephone surveys.

MEASUREMENTS

Three-level depression index: (1) neither low positive affect (LPA) nor negative affect (NA) in the last 4 weeks; (2) LPA and/or NA but not diagnosed with depression in the last 12 months; and (3) diagnosed with depression. Outcomes were quit attempts and 1-month abstinence among attempters.

FINDINGS

Depression positively predicted quit attempts, but not after controlling for quitting history and motivational variables. Controlling for all covariates, depression consistently negatively predicted abstinence. Cessation support did not moderate this effect. There was a significant interaction with gender for quit attempts (P = 0.018) and abstinence (P = 0.049) after controlling for demographics, but not after all covariates. Depression did not predict abstinence among men. Among women, depressive symptoms [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.49-0.81] and diagnosis (OR = 0.46, 95% CI = 0.34-0.63) negatively predicted abstinence.

CONCLUSIONS

Smokers with depressive symptoms or diagnosis make more quit attempts than their non-depressed counterparts, which may be explained by higher motivation to quit, but they are also more likely to relapse in the first month. These findings are stronger in women than men.

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care

In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults.The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years.At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis.Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people.

The impact of quitting smoking on depressive symptoms: findings from the International Tobacco Control Four-Country Survey

AIMS

To determine whether abstinence or relapse on a quit attempt in the previous year is associated with current depressive symptoms.

DESIGN

Prospective cohort with approximately annual waves. Mixed-effect logistic regressions tested whether time 2 (T2) quitting status was associated with reporting symptoms at T2, and whether time 1 (T1) symptoms moderated this relationship.

SETTING

Waves 5-8 of the Four-Country International Tobacco Control Study: a quasi-experimental cohort study of smokers from Canada, the United States, the United Kingdom and Australia.

PARTICIPANTS

A total of 6978 smokers who participated in telephone surveys.

MEASUREMENTS

T1 and T2 depressive symptoms in the last 4 weeks were assessed with two screening items from the PRIME-MD questionnaire. Quitting status at T2: (1) no attempt since T1; (2) attempted and relapsed; and (3) attempted and abstinent at T2.

FINDINGS

Compared with no attempt, relapse was associated with reporting T2 symptoms [odds ratio (OR) = 1.46, 95% confidence interval (CI) = 1.33, 1.59]). Associations between T2 quitting status and T2 symptoms were moderated by T1 symptoms. Relapse was associated positively with T2 symptoms for those without T1 symptoms (OR = 1.71, 95% CI = 1.45, 2.03) and those with T1 symptoms (OR = 1.45, 95% CI = 1.23, 1.70). Abstinence was associated positively for those without T1 symptoms (OR = 1.37, 95% CI = 1.10, 1.71) and negatively for those with T1 symptoms (OR = 0.74, 95% CI = 0.59, 0.94). Age moderated these associations significantly. Relapse did not predict T2 symptoms for those aged 18-39 irrespective of T1 symptoms. The negative effect of abstinence on T2 symptoms for those with T1 symptoms was significant only for those aged 18-39 (OR = 0.61, 95% CI = 0.40, 0.94) and 40-55 (OR = 0.58, 95% CI = 0.40, 0.84). The positive effect of abstinence on T2 symptoms for those without T1 symptoms was significant only for those aged more than 55 (OR =1.97, 95% CI = 1.35, 2.87).

CONCLUSIONS

Most people who stop smoking appear to be at no greater risk of developing symptoms of depression than if they had continued smoking. However, people aged more than 55 who stop smoking may be at greater risk of developing symptoms of depression than if they had continued smoking.

A randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care: the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial

BACKGROUND

Computerised cognitive behaviour therapy (cCBT) has been developed as an efficient form of therapy delivery with the potential to enhance access to psychological care. Independent research is needed which examines both the clinical effectiveness and cost-effectiveness of cCBT over the short and longer term.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care against usual GP care alone, for a free-to-use cCBT program (MoodGYM; National Institute for Mental Health Research, Australian National University, Canberra, Australia) and a commercial pay-to-use cCBT program (Beating the Blues(®); Ultrasis, London, UK) for adults with depression, and to determine the acceptability of cCBT and the experiences of users.

DESIGN

A pragmatic, multicentre, three-armed, parallel, randomised controlled trial (RCT) with concurrent economic and qualitative evaluations. Simple randomisation was used. Participants and researchers were not blind to treatment allocation.

SETTING

Primary care in England.

PARTICIPANTS

Adults with depression who scored ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9).

INTERVENTIONS

Participants who were randomised to either of the two intervention groups received cCBT (Beating the Blues or MoodGYM) in addition to usual GP care. Participants who were randomised to the control group were offered usual GP care.

MAIN OUTCOME MEASURES

The primary outcome was depression at 4 months (PHQ-9). Secondary outcomes were depression at 12 and 24 months; measures of mental health and health-related quality of life at 4, 12 and 24 months; treatment preference; and the acceptability of cCBT and experiences of users.

RESULTS

Clinical effectiveness: 210 patients were randomised to Beating the Blues, 242 patients were randomised to MoodGYM and 239 patients were randomised to usual GP care (total 691). There was no difference in the primary outcome (depression measured at 4 months) either between Beating the Blues and usual GP care [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.75 to 1.88] or between MoodGYM and usual GP care (OR 0.98, 95% CI 0.62 to 1.56). There was no overall difference across all time points for either intervention compared with usual GP care in a mixed model (Beating the Blues versus usual GP care, p = 0.96; and MoodGYM versus usual GP care, p = 0.11). However, a small but statistically significant difference between MoodGYM and usual GP care at 12 months was found (OR 0.56, 95% CI 0.34 to 0.93). Free-to-use cCBT (MoodGYM) was not inferior to pay-to-use cCBT (Beating the Blues) (OR 0.91, 90% CI 0.62 to 1.34; p = 0.69). There were no consistent benefits of either intervention when secondary outcomes were examined. There were no serious adverse events thought likely to be related to the trial intervention. Despite the provision of regular technical telephone support, there was low uptake of the cCBT programs. Cost-effectiveness: cost-effectiveness analyses suggest that neither Beating the Blues nor MoodGYM appeared cost-effective compared with usual GP care alone. Qualitative evaluation: participants were often demotivated to access the computer programs, by reason of depression. Some expressed the view that a greater level of therapeutic input would be needed to promote engagement.

CONCLUSIONS

The benefits that have previously been observed in developer-led trials were not found in this large pragmatic RCT. The benefits of cCBT when added to routine primary care were minimal, and uptake of this mode of therapy was relatively low. There remains a clinical and economic need for effective low-intensity psychological treatments for depression with improved patient engagement.

TRIAL REGISTRATION

This trial is registered as ISRCTN91947481.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme.

Factors Associated with Depression Assessed by the Patient Health Questionnaire-2 in Long-Term Cancer Survivors

Background

This cross-sectional study aimed to evaluate the prevalence of depressive disorders and factors associated in long-term cancer survivors.

Methods

A total of 702 long-term cancer survivors over 5-years in remission were recruited in a university-affiliated tertiary hospital in Korea. Self-report using the Patient Health Questionnaire-2 and the Fatigue Severity Scale assessed depression and fatigue, respectively. Demographic characteristics, cancer-related clinical characteristics, comorbidity, health behaviors, and physical symptoms were assessed through the review of medical records or a structured self-administered questionnaire.

Results

We identified 26.1% of patients who had a depressed mood or displayed a loss of interest. The most prevalent primary site of cancer was the stomach (65.2%), followed by lung, breast, colorectal, and thyroid cancer. We also found that 5.7% of subjects experienced double or triple primary cancers. Larger proportion among depressive group (89.1%) complained at least one physical problem than among non-depressive group (53.2%). Physical symptoms including sleep problems, dry mouth, indigestion, pain, decreased appetite, and febrile sense were more frequent in the depressive group than in the non-depressive group. The Fatigue Severity Scale scores were higher in the depressive group than in the non-depressive group (P<0.001). Multiple logistic regression analysis showed that the highest tertile level of fatigue (odds ratio, 7.31; 95% confidence interval, 3.81–14.02) was associated with the increased risk of depression.

Conclusion

These findings suggest that careful concern about depression is necessary in long-term cancer survivors. Fatigue may be a surrogate sign for depression, and warrants further evaluation.

Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma

BACKGROUND

Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head.

METHODS

Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated.

RESULTS

A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.

CONCLUSIONS

Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.

Migraine and its psychiatric comorbidities

Migraine is a highly prevalent and disabling neurological disorder associated with a wide range of psychiatric comorbidities. In this manuscript, we provide an overview of the link between migraine and several comorbid psychiatric disorders, including depression, anxiety and post-traumatic stress disorder. We present data on psychiatric risk factors for migraine chronification. We discuss the evidence, theories and methods, such as brain functional imaging, to explain the pathophysiological links between migraine and psychiatric disorders. Finally, we provide an overview of the treatment considerations for treating migraine with psychiatric comorbidities. In conclusion, a review of the literature demonstrates the wide variety of psychiatric comorbidities with migraine. However, more research is needed to elucidate the neurocircuitry underlying the association between migraine and the comorbid psychiatric conditions and to determine the most effective treatment for migraine with psychiatric comorbidity.

Quality Over Quantity: Integrating Mental Health Assessment Tools into Primary Care Practice

Depression is one of the most common, costly, and debilitating psychiatric disorders in the US. There are also strong associations between depression and physical health outcomes, particularly chronic diseases such as diabetes mellitus. Yet, mental health services are underutilized throughout the US. Recent policy changes have encouraged depression screening in primary care settings. However, there is not much guidance about how depression screeners are administered. There are people suffering from depression who are not getting the treatment they need. It is important to consider whether enough care is being taken when administering depression screeners in primary care settings.

Not identifying with postnatal depression: a qualitative study of women's postnatal symptoms of distress and need for support

INTRODUCTION

Diagnoses and symptoms of postnatal mental health problems are associated with adverse outcomes for women and their families. Current classification and assessment of postnatal mental health problems may not adequately address the range or combination of emotional distress experienced by mothers. This study aims to explore symptoms of mental health problems reported by new mothers and their experiences of being assessed for these.

METHODS

In-depth interviews with 17 women in southeast England with a baby under 1-year old who experienced a postnatal mental health problem. Data were analyzed using inductive thematic analysis.

RESULTS

Women described a lack of identification with the concept of postnatal depression and felt that other forms of emotional distress were not recognized by the healthcare system. Women felt that support seeking for postnatal mental health problems needed to be normalized and that support should be available whether or not women were diagnosed. Assessment needs to be well timed and caringly implemented.

DISCUSSION

Identification and recognition of symptoms and disorders other than postnatal depression need to be improved. Awareness of multiple types of distress needs to be raised both for women experiencing such distress, and for healthcare professionals, to enable them to support women at this time. Different approaches to assessment that include the range of symptoms reported should be piloted.

Identification of depression in women during pregnancy and the early postnatal period using the Whooley questions and the Edinburgh Postnatal Depression Scale: protocol for the Born and Bred in Yorkshire: PeriNatal Depression Diagnostic Accuracy (BaBY PaNDA) study

INTRODUCTION

Perinatal depression is well recognised as a mental health condition but <50% of cases are identified by healthcare professionals in routine clinical practice. The Edinburgh Postnatal Depression Scale (EPDS) is often used to detect symptoms of postnatal depression in maternity and child services. The National Institute for Health and Care Excellence (NICE) recommends 2 'ultra-brief' case-finding questions (the Whooley questions) to aid identification of depression during the perinatal period, but this recommendation was made in the absence of any validation studies in a perinatal population. Limited research exists on the acceptability of these depression case-finding instruments and the cost-effectiveness of routine screening for perinatal depression.

METHODS AND ANALYSIS

The diagnostic accuracy of the Whooley questions and the EPDS will be determined against a reference standard (the Client Interview Schedule-Revised) during pregnancy (around 20 weeks) and the early postnatal period (around 3-4 months post partum) in a sample of 379 women. Further outcome measures will assess a range of psychological comorbidities, health-related quality of life and resource utilisation. Women will be followed up 12 months postnatally. The sensitivity, specificity and predictive values of the Whooley questions and the EPDS will be calculated against the reference standard at 20 weeks pregnancy and 3-4 months post partum. Acceptability of the depression case-finding instruments to women and healthcare professionals will involve in-depth qualitative interviews. An existing decision analytic model will be adapted to determine the cost-effectiveness of routine screening for perinatal depression.

ETHICS AND DISSEMINATION

This study is considered low risk for participants. Robust protocols will deal with cases where risk of depression, self-harm or suicide is identified. The protocol received favourable ethical opinion from the North East-York Research Ethics Committee (reference: 11/NE/0022). The study findings will be published in peer-reviewed journals and presented at relevant conferences.

Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: a systematic review and meta-analysis

BACKGROUND

The longitudinal associations between psychological dysfunction (PD) and asthma exacerbations (AE) have not been adequately addressed. This study aimed to systematically assess the influence of PD on AE, and to determine whether different PD affects AE differentially.

METHODS

Electronic databases (PubMed, Cochrane library, Web of Science, Embase, and Ovid) were searched for prospective cohort studies on the influence of PD on AE in individuals with asthma. Relative risk (RR) and adjusted RR (RRadj) were pooled across studies. Subgroup analyses assessed the effects of different types of PD and the time-dependent response to the duration of PD exposure.

RESULTS

Ten articles that involved 31,432 adults with asthma with follow-up of 6.0-86.4 months were included. PD significantly increased the risk of AE [RRadj =1.06, 95% confidence interval (95%CI): 1.04-1.09, P<0.001], presenting as hospitalizations (RRadj =1.22, 95% CI: 1.12-1.34, P<0.001), unscheduled doctor visits (RR =4.26, 95% CI: 2.52-7.19), and emergency department (ED) visits (RRadj =1.06, 95% CI: 1.01-1.10, P=0.009) because of asthma. Depression significantly increased the risk of AE (RRadj =1.07, 95% CI: 1.04-1.11, P<0.001), presenting as hospitalizations (RRadj =1.26, 95% CI: 1.07-1.49, P=0.007) and ED visits (RRadj =1.06, 95% CI: 1.02-1.11, P=0.007) because of asthma. Anxiety was only associated with an increased risk of AE in pregnant women (RR =1.05, 95% CI: 1.01-1.08), possibly due to the small amount of data available on anxiety. The influence of PD on AE was only significant when the PD exposure time exceeded one year.

CONCLUSIONS

Co-morbid PD adversely affects AE, and there are differential effects of depression and anxiety. Asthmatic subjects with PD may benefit from more attention when establishing a treatment regimen in clinical practice.

Experiences of Informal Caregivers of Older Adults Transitioned From Nursing Homes to the Community Through the Money Follows the Person Demonstration

This study examined experiences of 156 informal caregivers of older adults who transitioned to the community through the Connecticut Money Follows the Person (MFP) Rebalancing Demonstration after prolonged nursing home stays. Caregiver burden, positive aspects of caregiving, depressive symptoms, anxiety, and comparative subjective stress were examined in relation to caregiver demographics and care receiver characteristics with a cross-sectional survey. Caregivers reported low burden, depressive symptoms, and anxiety, and fairly high levels of positive aspects of caregiving and satisfaction with community services. Most caregivers were less stressed compared to the time the care recipient was in, or before they entered, a nursing home. Live-in caregivers experienced more positive aspects of caregiving, but adult children reported higher burden than other caregivers. Unmet service needs also increased caregiver burden. Programs like MFP are a viable option with broadly positive outcomes from a caregiver's perspective. Enthusiasm for increasing access to community care is growing for older adults who otherwise would reside in nursing homes for extended periods. Identifying unmet service needs and needs for targeted functional support could further enhance caregiver experiences and contribute to the successful transition of older adults to the community.

Childhood Maltreatment in the Migraine Patient

OPINION STATEMENT

Maltreatment during childhood increases vulnerability to a host of health disorders, including migraine. Putative mechanisms linking maltreatment and migraine include stress-induced dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, as well as disruption of other stress-mediating homeostatic systems, including those involving endocannabinoids, monoamine neurotransmitters, oxytocin, and inflammation. Prolonged elevation of glucocorticoids alters the neural architecture of the limbic system, resulting in the structural as well as functional changes described in both maltreatment and in migraine. Although treatment trials for migraine have not stratified participants by abuse history, strategies, such as cognitive behavioral therapy, which alter stress responsivity, may be particularly effective in this subgroup. Some therapies involving the endocannabinoid, serotonergic, oxytonergic, and inflammatory systems are under investigation for migraine. Anti-epileptic drugs such as valproate and topiramate, which are FDA approved for migraine treatment, are also known to interfere with epigenetic changes induced by stress. Discerning the role for this mechanism in treatment of maltreated migraineurs may introduce another therapeutic avenue.

Promoting physical therapists' use of research evidence to inform clinical practice: part 3--long term feasibility assessment of the PEAK program

BACKGROUND

Evidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice.

METHODS

Eighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions--the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists' EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review.

RESULTS

Sixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement.

CONCLUSIONS

This study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists' EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists' adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavior change for knowledge translation.

Impact of the Great East Japan Earthquake on feeding methods and newborn growth at 1 month postpartum: results from the Fukushima Health Management Survey

This study examined the effects of three disasters (the Great East Japan Earthquake of March 11, 2011, followed by a tsunami and the Fukushima Daiichi Nuclear Power Plant accident) on feeding methods and growth in infants born after the disasters. Using results from the Fukushima Health Management Survey, Soso District (the affected area where the damaged nuclear power plant is located) and Aizu District (a less-affected area located farthest from the plant) were compared. In this study, newborn and maternal background characteristics were examined, as well as feeding methods, and other factors for newborn growth at the first postpartum examination for 1706 newborns born after the disaster in the affected (n = 836) and less-affected (n = 870) areas. Postpartum examinations took place 1 month after birth. Feeding method trends were examined, and multivariate regression analyses were used to investigate effects on newborn mass gain. There were no significant differences in background characteristics among newborns in these areas. When birth dates were divided into four periods to assess trends, no significant change in the exclusive breastfeeding rate was found, while the exclusive formula-feeding rate was significantly different across time periods in the affected area (p = 0.02). Multivariate analyses revealed no significant independent associations of maternal depression and change in medical facilities (possible disaster effects) with other newborn growth factors in either area. No area differences in newborn growth at the first postpartum examination or in exclusive breastfeeding rates were found during any period. Exclusive formula-feeding rates varied across time periods in the affected, but not in the less-affected area. It is concluded that effective guidance to promote breast-feeding and prevent exclusive use of formula is important for women in post-disaster circumstances.

Depression and Quality of Life in Older Persons: A Review

BACKGROUND

Depression is a prevalent and disabling condition in older persons (≥ 60 years) that increases the risk of mortality and negatively influences quality of life (QOL). The relationship between depression, or depressive symptoms, and QOL has been increasingly addressed by research in recent years, but a review that can contribute to a better understanding of this relationship in older persons is lacking. Against this background, we undertook a literature review to assess the relationship between depression and QOL in older persons.

SUMMARY

Extensive electronic database searches revealed 953 studies. Of these, 74 studies fulfilled our criteria for inclusion, of which 52 were cross-sectional studies and 22 were longitudinal studies. Thirty-five studies were conducted in a clinical setting, while 39 were community-based epidemiological studies. A clear definition of the QOL concept was described in 25 studies, and 24 different assessment instruments were employed to assess QOL. Depressed older persons had poorer global and generic health-related QOL than nondepressed individuals. An increase in depression severity was associated with a poorer global and generic health-related QOL. The associations appeared to be stable over time and independent of how QOL was assessed.

KEY MESSAGES

This review found a significant association between severity of depression and poorer QOL in older persons, and the association was found to be stable over time, regardless which assessment instruments for QOL were applied. The lack of a definition of the multidimensional and multilevel concept QOL was common, and the large variety of QOL instruments in various studies make a direct comparison between the studies difficult.

Work ability among Finnish workers with type 1 diabetes

BACKGROUND

Work ability represents the balance between individual resources, health status and job demands. As far as we are aware, these issues have not been examined in working people with type 1 diabetes (T1D).

AIMS

To examine how work-related and diabetes-related factors are associated with work ability among male and female workers.

METHODS

Questionnaires were mailed to a random sample of 2500 people with T1D from the Medication Reimbursement Register of The Social Insurance Institution of Finland. The associations of the predictors of poor work ability were examined in a logistic regression analysis.

RESULTS

The final sample comprised 767 working people aged 18-64 with T1D; overall response rate 49%. One in every three working men and women with T1D had poor work ability. High job demands and low job control were associated with poor work ability in both genders. Physical work and low worktime control were significantly associated with poor work ability in men but not in women with T1D. A self-reported high value of glycosylated haemoglobin was the only diabetes-related variable associated with poor work ability in both men and women.

CONCLUSIONS

Work-related factors and poor glycaemic control were associated with poor work ability in individuals with T1D. Thus, job control and worktime control should be taken into account in supporting the work ability of workers with T1D.

Validating screening tools for depression in stroke and transient ischemic attack patients

OBJECTIVE

The best screening questionnaires for detecting post-stroke depression have not been identified. We aimed to validate four commonly used depression screening tools in stroke and transient ischemic attack patients.

METHODS

Consecutive stroke and transient ischemic attack patients visiting an outpatient stroke clinic in Calgary, Alberta (Canada) completed a demographic questionnaire and four depression screening tools: Patient Health Questionnaire (PHQ)-9, PHQ-2, Hospital Anxiety and Depression Scale (HADS-D), and Geriatric Depression Scale (GDS-15). Participants then completed the Structured Clinical Interview for DSM-IV (SCID), the gold-standard for diagnosing major depression. The questionnaires were validated against the SCID and sensitivity and specificity were calculated at various cut-points. Optimal cut-points for each questionnaire were determined using receiver-operating curve analyses.

RESULTS

Among 122 participants, 59.5% were diagnosed with stroke and 40.5% with transient ischemic attack. The point prevalence of SCID-diagnosed current major depression was 9.8%. At the optimal cut-points, the sensitivity and specificity for each screening tool were as follows: PHQ-9 (sensitivity: 81.8%, specificity: 97.1%), PHQ-2 (sensitivity: 75.0%, specificity: 96.3%), HADS-D (sensitivity: 63.6%, specificity: 98.1%), and GDS-15 (sensitivity: 45.5%, specificity: 84.8%). Areas under the receiver operating characteristic curves were as follows: PHQ-9 86.6%, PHQ-2 86.7%, HADS-D 85.9%, and GDS-15 66.3%.

CONCLUSIONS

The PHQ-2 and PHQ-9 are both suitable depression screening tools, taking less than 5 minutes to complete. The HADS-D does not appear to have any advantage over the PHQ-based scales, even though it was designed specifically for medically ill populations. The GDS-15 cannot be recommended for general use in a stroke clinic based on this study as it had worse discrimination due to low sensitivity.

Characteristics of users and usage of different types of electronic cigarettes: findings from an online survey

AIMS

Studying users of e-cigarettes is important to help determine whether these devices aid smoking cessation. Obtaining data in representative samples is difficult, but online surveys of users may begin to build a picture. Therefore, this study aimed, through a large online survey, to describe usage and characteristics of users of e-cigarettes.

DESIGN

Cross-sectional internet survey between 2012 and 2014.

SETTING AND PARTICIPANTS

A total of 2807 current e-cigarette users enrolled via e-cigarette and smoking cessation websites, who lived in France (n = 988), the United States (n = 579), Switzerland (n = 310), the United Kingdom (n = 143) and other countries (n = 787).

MEASUREMENTS

Type of e-cigarette used: pre-filled cartridges (n = 71), unmodified refillable tanks (n = 758), modified refillable tanks (n = 392), patterns of use, perceived effects.

FINDINGS

Pre-filled models were perceived to be less effective than unmodified refillable tanks for smoking cessation by former smokers ('definitely helped': 74% vs. 94%, P < 0.001) and by current smokers for smoking reduction ('definitely helped': 37% vs. 78%, P < 0.001). Users modified their e-cigarettes mainly to obtain a better taste ('very true' 60%, 55.5-64.5%). Modified tanks were perceived to make it easier to abstain from smoking than unmodified tanks 95% vs. 89%, P < 0.001); 34% of users of pre-filled cartridges, 60% of users of unmodified tanks and 83% of users of modified tanks were men (P < 0.001).

CONCLUSIONS

Newer-generation e-cigarettes were perceived to be more satisfactory and more effective for refraining from smoking than older models. Women tended to use pre-filled, unmodified models, which were perceived by participants to be the least effective in terms of abstaining from smoking.

Strategies and methods to study female-specific cardiovascular health and disease: a guide for clinical scientists

BACKGROUND

In 2001, the Institute of Medicine's (IOM) report, "Exploring the Biological Contributions to Human Health: Does Sex Matter?" advocated for better understanding of the differences in human diseases between the sexes, with translation of these differences into clinical practice. Sex differences are well documented in the prevalence of cardiovascular (CV) risk factors, the clinical manifestation and incidence of cardiovascular disease (CVD), and the impact of risk factors on outcomes. There are also physiologic and psychosocial factors unique to women that may affect CVD risk, such as issues related to reproduction.

METHODS

The Society for Women's Health Research (SWHR) CV Network compiled an inventory of sex-specific strategies and methods for the study of women and CV health and disease across the lifespan. References for methods and strategy details are provided to gather and evaluate this information. Some items comprise robust measures; others are in development.

RESULTS

To address female-specific CV health and disease in population, physiology, and clinical trial research, data should be collected on reproductive history, psychosocial variables, and other factors that disproportionately affect CVD in women. Variables related to reproductive health include the following: age of menarche, menstrual cycle regularity, hormone levels, oral contraceptive use, pregnancy history/complications, polycystic ovary syndrome (PCOS) components, menopause age, and use and type of menopausal hormone therapy. Other factors that differentially affect women's CV risk include diabetes mellitus, autoimmune inflammatory disease, and autonomic vasomotor control. Sex differences in aging as well as psychosocial variables such as depression and stress should also be considered. Women are frequently not included/enrolled in mixed-sex CVD studies; when they are included, information on these variables is generally not collected. These omissions limit the ability to determine the role of sex-specific contributors to CV health and disease. Lack of sex-specific knowledge contributes to the CVD health disparities that women face.

CONCLUSIONS

The purpose of this review is to encourage investigators to consider ways to increase the usefulness of physiological and psychosocial data obtained from clinical populations, in an effort to improve the understanding of sex differences in clinical CVD research and health-care delivery for women and men.

Morita therapy for depression and anxiety (Morita Trial): study protocol for a pilot randomised controlled trial

BACKGROUND

Morita Therapy, a psychological therapy for common mental health problems, is in sharp contrast to established western psychotherapeutic approaches in teaching that undesired symptoms are natural features of human emotion rather than something to control or eliminate. The approach is widely practiced in Japan, but untested and little known in the UK. A clinical trial of Morita Therapy is required to establish the effectiveness of Morita Therapy for a UK population. However, a number of methodological, procedural and clinical uncertainties associated with such a trial first require addressing.

METHODS/DESIGN

The Morita Trial is a mixed methods study addressing the uncertainties associated with an evaluation of Morita Therapy compared with treatment as usual for depression and anxiety. We will undertake a pilot randomised controlled trial with embedded qualitative study. Sixty participants with major depressive disorder, with or without anxiety disorders, will be recruited predominantly from General Practice record searches and randomised to receive Morita Therapy plus treatment as usual or treatment as usual alone. Morita Therapy will be delivered by accredited psychological therapists. We will collect quantitative data on depressive symptoms, general anxiety, attitudes and quality of life at baseline and four month follow-up to inform future sample size calculations; and rates of recruitment, retention and treatment adherence to assess feasibility. We will undertake qualitative interviews in parallel with the trial, to explore people's views of Morita Therapy. We will conduct separate and integrated analyses on the quantitative and qualitative data.

DISCUSSION

The outcomes of this study will prepare the ground for the design and conduct of a fully-powered evaluation of Morita Therapy plus treatment as usual versus treatment as usual alone, or inform a conclusion that such a trial is not feasible and/or appropriate. We will obtain a more comprehensive understanding of these issues than would be possible from either a quantitative or qualitative approach alone.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17544090 registered on 23 July 2015.

Prevalence of depressive symptoms in pregnant and postnatal HIV-positive women in Ukraine: a cross-sectional survey

BACKGROUND

Perinatal depression among HIV-positive women has negative implications for HIV-related and other maternal and infant outcomes. The aim of this study was to investigate the burden and correlates of perinatal depression among HIV-positive women in Ukraine, a lower middle income country with one of the largest HIV-positive populations in Europe.

METHODS

Cross-sectional surveys nested within the Ukraine European Collaborative Study were conducted of HIV-positive women at delivery and between 1 and 12 months postpartum. Depressive symptoms in the previous month were assessed using a self-report screening tool. Other data collected included demographics, antiretroviral therapy (ART)-related self-efficacy, and perceptions of risks/benefits of interventions to prevent mother-to-child transmission (PMTCT). Characteristics of women with and without a positive depression screening test result were compared using Fisher's exact test and χ2 test for categorical variables.

RESULTS

A quarter (27% (49/180) antenatally and 25% (57/228) postnatally) of participants screened positive for depressive symptoms. Antenatal risk factors were living alone (58% (7/12) vs. 25% (42/167) p = 0.02), being somewhat/terribly bothered by ART side effects (40% (17/43) vs. 23% (30/129) not /only slightly bothered, p = 0.05) and having lower ART-related self-efficacy (43% (12/28) vs. 23% (25/110) with higher self-efficacy, p = 0.05). Postnatally, single mothers were more likely to screen positive (44% (20/45) vs. 21% (18/84) of cohabiting and 19% (19/99) of married women, p < 0.01) as were those unsure of the effectiveness of neonatal prophylaxis (40% (20/45) vs. 18% (28/154) sure of effectiveness, p < 0.01), those worried that neonatal prophylaxis could harm the baby (30% (44/146) vs. 14% (10/73) not worried p < 0.01) and those not confident to ask for help with taking ART (48% (11/23) vs. 27% (10/37) fairly confident and 15 % (4/26) confident that they could do this). Of women who reported wanting help for their depressive symptoms, 82% (37/45) postnatally but only 31% (12/39) antenatally were already accessing peer counselling, treatment adherence programmes, support groups or social services.

CONCLUSIONS

A quarter of women screened positive for depression. Results highlight the need for proactive strategies to identify depressive symptoms, and an unmet need for provision of mental health support in the perinatal period for HIV-positive women in Ukraine.

Work-related diabetes distress among Finnish workers with type 1 diabetes: a national cross-sectional survey

BACKGROUND

Diabetes distress is common among people with type 1 diabetes, but knowledge is scarce regarding the perceived burden of reconciling work with this disease. This cross-sectional study investigated work-related diabetes distress among Finnish workers with type 1 diabetes.

METHODS

A questionnaire was mailed to 2500 randomly sampled 18- to 65-year-old Finns with type 1 diabetes; 49.3 % responded. Work-related diabetes distress was measured by combining worry and exhaustion in reconciling work with diabetes. Self-perceived work-related diabetes distress was evaluated in the context of physical and psychosocial work conditions, job demands, work ability, general stress, diabetes acceptance, glycosylated hemoglobin (HbA1c) level, high blood glucose maintenance at work, and depressive symptoms. The data were analyzed with the use of cross-tabulation, chi-square tests, ANOVA analysis, Spearman correlation coefficients, and structural equation modeling.

RESULTS

Of the respondents, 70 % experienced work-related diabetes distress. Problems with physical work conditions (β = 0.27), work ability (β = -0.21), difficulty in accepting diabetes (β = 0.18), and job demands (β = 0.14) were found to be associated with work-related diabetes distress. This distress was strongly associated with the maintenance of a high blood glucose level at work (β = 0.34). In turn, a high blood glucose level at work was associated with a high HbA1c level (β = 0.29). Work-related diabetes distress and depressive symptoms had a bi-directional association (β = 0.06 and β = 0.14). Difficulty accepting diabetes had three-dimensional associations: work-related diabetes distress (β = 0.18), depressive symptoms (β = 0.13), and high HbA1c level (β = 0.12). There was no notable association between work-related diabetes distress and general stress.

CONCLUSIONS

Work-related diabetes distress is common among workers with type 1 diabetes, and it may influence metabolic control. This stress could be prevented by adapting physical work conditions. People with type 1 diabetes should also be encouraged to pursue their full educational potential, and psychological support should be provided for those with difficulty accepting their diabetes.

Supporting cardiac patient physical activity: a brief health psychological intervention

Background

One of the most important risk factors for coronary artery disease is physical inactivity. Health psychological research demonstrates the importance of planning for behaviour change success. Consequently, a health action process approach (HAPA) model-based design to support the uptake of physical activity was initiated for the first time in an acute cardiac ward.

Methods

For impact evaluation, a control group (CG) and an intervention group (IG) of coronary artery disease patients were compared in a controlled longitudinal study. Baseline assessment included socio-demographic variables, intentions regarding physical activity, and actual physical activity prior to the coronary artery disease event. Follow-up data were collected 2 and 6 months after discharge.

Results

In total, 193 patients participated in this controlled longitudinal study (63 ± 9 years; CG: N = 78; IG: N = 115). The IG reported a higher increase in physical activity (p < 0.05), intentions, and coping planning (p < 0.05), and also in action planning and control (p < 0.01) 2 months after discharge. Both CG and IG increased their physical activity 6 months after discharge to the point of no significant difference (p = 0.664).

Conclusions

A HAPA model-based health psychological intervention on an acute cardiac ward is able to increase patients’ physical activity over the short term. However, integration of follow-up interventions (preferable in cardiac rehabilitation settings) would be necessary to support sustained physical activity.

Depression and Altitude: Cross-Sectional Community-Based Study Among Elderly High-Altitude Residents in the Himalayan Regions

Suicide rates are higher at high altitudes, and some hypothesize that hypoxia is the cause. There may be a significant correlation between rates of depression and altitude, but little data exist outside the United States. The purpose of the present study is to conduct a survey of depression among the elderly highlanders in Asia. We enrolled 114 persons aged 60 years or older (mean, 69.2 ± 6.7 years; women, 58.8%) in Domkhar (altitude, 3800 m), Ladakh, India and 173 ethnic Tibetans (mean, 66.5 ± 6.1 years; women, 61.3%) in Yushu (altitude, 3700 m), Qinghai Province, China. The two-item Patient Health Questionnaire (PHQ-2) and the geriatric depression scale were administered. A psychiatrist interviewed the subjects who had a positive score on the PHQ-2. The results of the interview with the residents conducted by the specialist showed that two cases (1.8%) from Domkhar and four (2.3%) from Qinghai had depression. Despite the high altitude, the probability of depression was low in elderly highlander in Ladakh and Qinghai. Our finding seems to indicate that cultural factors such as religious outlook and social/family relationship inhibit the development of depression.

Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies

BACKGROUND

The Patient Health Questionnaire (PHQ) is the most commonly used measure to screen for depression in primary care but there is still lack of clarity about its accuracy and optimal scoring method.

AIMS

To determine via meta-analysis the diagnostic accuracy of the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 questions to detect major depressive disorder (MDD) among adults.

METHOD

We systematically searched major electronic databases from inception until June 2015. Articles were included that reported the accuracy of PHQ-9 or PHQ-2 questions for diagnosing MDD in primary care defined according to standard classification systems. We carried out a meta-analysis, meta-regression, moderator and sensitivity analysis.

RESULTS

Overall, 26 publications reporting on 40 individual studies were included representing 26 902 people (median 502, s.d.=693.7) including 14 760 unique adults of whom 14.3% had MDD. The methodological quality of the included articles was acceptable. The meta-analytic area under the receiver operating characteristic curve of the PHQ-9-linear and the PHQ-2 was significantly higher than the PHQ-9-algorithm, a difference that was maintained in head-to-head meta-analysis of studies. Our best estimates of sensitivity and specificity were 81.3% (95% CI 71.6-89.3) and 85.3% (95% CI 81.0-89.1), 56.8% (95% CI 41.2-71.8) and 93.3% (95% CI 87.5-97.3) and 89.3% (95% CI 81.5-95.1) and 75.9% (95% CI 70.1-81.3) for the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 respectively. For case finding (ruling in a diagnosis), none of the methods were suitable but for screening (ruling out non-cases), all methods were encouraging with good clinical utility, although the cut-off threshold must be carefully chosen.

CONCLUSIONS

The PHQ can be used as an initial first step assessment in primary care and the PHQ-2 is adequate for this purpose with good acceptability. However, neither the PHQ-2 nor the PHQ-9 can be used to confirm a clinical diagnosis (case finding).

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Intrapersonal, social-cognitive and physical environmental variables related to context-specific sitting time in adults: a one-year follow-up study

Background

Investigating associations between socio-ecological variables and context-specific sitting time in adults can support the development of future interventions. The purpose of the present study was to examine the cross-sectional and longitudinal relationships of intrapersonal, social-cognitive and physical environmental variables with context-specific sitting time (i.e. TV-viewing, computer use, motorized transport, and occupational sitting) in adults.

Methods

In this longitudinal study, data were retrieved from a random sample of Flemish (Belgian) adults. At baseline, 301 adults (age, 43.3 ± 10.6 years) completed a questionnaire on context-specific sitting time and its potential predictors. After a 1-year follow-up period, complete data of 188 adults was available (age, 46.0 ± 10.4 years). Multiple linear regression analyses were performed for both the cross-sectional data at baseline (correlates) and the longitudinal data (predictors).

Results

The cross-sectional and longitudinal analyses revealed different relationships between sitting during TV viewing, computer use, motorized transport and occupation. Generally, change in cross-sectional correlates did not cause change in context-specific sitting time in the longitudinal analyses. Social-cognitive correlates/predictors were most frequently identified, followed by intrapersonal correlates/predictors. Attitude, self-efficacy, (social) norm and modelling were found to be the most consistently related social-cognitive correlates/predictors to context-specific sitting time. Limited evidence was available for relationships between physical environmental variables and context-specific sitting time.

Conclusions

The cross-sectional correlates differed from the longitudinal predictors of context-specific sitting time, highlighting the need for longitudinal research. The present study also underlined the need for family interventions to minimize context-specific sitting time, as both intrapersonal and social-cognitive variables were associated with context-specific sitting time.

Toward a comprehensive care of HIV patients: finding a strategy to detect depression in a Spanish HIV cohort

Depression is a common but frequently undiagnosed feature in individuals with HIV infection. To find a strategy to detect depression in a non-specialized clinical setting, the overall performance of the Hospital Anxiety and Depression Scale (HADS) and the depression identification questions proposed by the European AIDS Clinical Society (EACS) guidelines were assessed in a descriptive cross-sectional study of 113 patients with HIV infection. The clinician asked the two screening questions that were proposed under the EACS guidelines and requested patients to complete the HADS. A psychiatrist or psychologist administered semi-structured clinical interviews to yield psychiatric diagnoses of depression (gold standard). A receiver operating characteristic (ROC) analysis for the HADS-Depression (HADS-D) subscale indicated that the best sensitivity and specificity were obtained between the cut-off points of 5 and 8, and the ROC curve for the HADS-Total (HADS-T) indicated that the best cut-off points were between 12 and 14. There were no statistically significant differences in the correlations of the EACS (considering positive responses to one [A] or both questions [B]), the HADS-D ≥ 8 or the HADS-T ≥ 12 with the gold standard. The study concludes that both approaches (the two EACS questions and the HADS-D subscale) are appropriate depression-screening methods in HIV population. We believe that using the EACS-B and the HADS-D subscale in a two-step approach allows for rapid, assumable and accurate clinical diagnosis in non-psychiatric hospital settings.

Treatment Optimization in Multiple Sclerosis

The treatment of multiple sclerosis has finally become possible with the advent of the current disease-modifying therapies (DMTs) that have had a significant impact on those living with this disease. Though demonstrating clear efficacy on a number of short-term outcome measures, unfortunately, these agents are not “cures” and many patients with multiple sclerosis continue to experience disease activity in spite of treatment. Clinicians are becoming more comfortable initiating therapy with DMTs, but it is now important to focus attention on monitoring the results of the chosen therapy and deciding whether or not a patient is responding well to treatment. At present, however, clinicians lack criteria for defining optimal versus suboptimal responses to DMTs as well as evidence-based guidelines on how to improve treatment outcomes. Using a recently published model as a framework, The Canadian Multiple Sclerosis Working Group developed practical recommendations on how neurologists can assess the status of patients on DMTs and decide when it may be necessary to modify treatment in order to optimize outcomes. The Canadian Multiple Sclerosis Working Group's recommendations are based on monitoring relapses, neurological progression and MRI activity. Other possible causes of suboptimal treatment responses or treatment failure are also considered.

An Exploratory Analysis of Work Engagement, Satisfaction, and Depression in Psychiatry Residents

OBJECTIVES

This exploratory study aims to measure work engagement levels in psychiatry residents at three psychiatry residency programs using the Utrecht Work Engagement Scale (UWES). In addition, the study investigates the relationship between total engagement and its subscales, resident satisfaction, and a depression screen.

METHODS

Recruitment of 53/79 residents from three psychiatry residency programs in Illinois was completed. The residents were administered a questionnaire consisting of the UWES, the Primary Care Evaluation of Mental Disorders (Prime-MD) depression screen, and a residency satisfaction scale. Statistical analysis using independent samples t test and a one-way analysis of variance was used to assess differences on engagement total score and subscales and satisfaction scale. A logistic regression was used with the engagement subscales and the satisfaction scale as predictors of belonging to the depressed or non-depressed group.

RESULTS

Psychiatry residents scored in the high range for total engagement and all its subscales except for vigor which was in the moderate range. Residents who screened positive for depression reported lower total engagement than those who were negative on the depression screen. Vigor was the only significant predictor (p = .004) of being in the depressed group after logistic regression. Total engagement and the subscale of dedication significantly predicted overall residency satisfaction (β = .473, p = .016).

CONCLUSIONS

Higher total UWES-15 and its subscales of vigor and dedication are correlated with a lower rate of screening positive for depression and higher residency satisfaction. This exploratory study lends support for further study of this psychological construct in medical training programs, but replication is needed.

Perinatal depression and screening among Aboriginal Australians in the Kimberley

PROBLEM

Adhoc culturally questionable perinatal mental-health screening among Aboriginal women in the Kimberley.

BACKGROUND

Mental-health issues, substance abuse and suicide attempts are high among young Aboriginal women in Australia. There is no evidence that the Edinburgh Postnatal Depression Scale (EPDS) is effective or culturally safe. Screening practices are complicated by limited understanding of the complex cultural interface between Western and Aboriginal beliefs and notions about health and mental-health.

QUESTION

What is the current context of perinatal mental-health screening practices among Aboriginal women in the Kimberley and what might be considered a culturally safe approach?

METHODS

A review of the literature and exploration of current screening practices preceded community participatory action research (CPAR) of perinatal mental-health screening.

RESULTS

More than 100 Kimberley women and 72 health practitioners contributed to this joint strategic body of work. Recommendations for practice include one single culturally appropriate Kimberley version of the EPDS.

Burned Out at the Bedside: Patient Perceptions of Physician Burnout in an Internal Medicine Resident Continuity Clinic

BACKGROUND

Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.

OBJECTIVE

To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.

DESIGN

Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.

PARTICIPANTS

Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N = 244).

MAIN MEASURES

Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients' perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.

KEY RESULTS

Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B = 0.28, SE = 0.17, p < 0.001) and enablement (B = 0.11, SE = 0.11, p = 0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.

CONCLUSIONS

Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.

Identification of women at risk of depression in pregnancy: using women's accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice

Antenatal mental health assessment is increasingly common in high-income countries. Despite lacking evidence on validation or acceptability, the Whooley questions (modified PHQ-2) and Arroll 'help' question are used in the UK at booking (the first formal antenatal appointment) to identify possible cases of depression. This study investigated validation of the questions and women's views on assessment. Women (n = 191) booking at an inner-city hospital completed the Whooley and Arroll questions as part of their routine clinical care then completed a research questionnaire containing the Edinburgh postnatal depression scale (EPDS). A purposive subsample (n = 22) were subsequently interviewed. The Whooley questions 'missed' half the possible cases identified using the EPDS (EPDS threshold ≥ 10: sensitivity 45.7 %, specificity 92.1 %; ≥ 13: sensitivity 47.8 %, specificity 86.1 %), worsening to nine in ten when adopting the Arroll item (EPDS ≥ 10: sensitivity 9.1 %, specificity 98.2 %; ≥ 13: sensitivity 9.5 %, specificity 97.1 %). Women's accounts indicated that under-disclosure relates to the context of assessment and perceived relevance of depression to maternity services. Depression symptoms are under-identified in current local practice. While validated tools are needed that can be readily applied in routine maternity care, psychometric properties will be influenced by the context of disclosure when implemented in practice.

Tablet computers for implementing NICE antenatal mental health guidelines: protocol of a feasibility study

INTRODUCTION

Depression is one of the most common mental health disorders that may affect women during pregnancy. The prompt identification of this disorder, and the provision of treatment, may help to reduce the likelihood of post-partum depression, prevent severe forms of the disease, and reduce its intergenerational impact. Despite women's repeated encounters with health services throughout their antenatal care, depression often goes undiagnosed. This is one area where mobile health could prove useful. We will assess the feasibility of using tablets to incorporate depression screening into antenatal pathways. We will also assess if survey layout could affect the quality of the data collected through these devices.

METHODS AND ANALYSIS

We will test the feasibility of using iPad Airs for the administration of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to pregnant women attending antenatal clinics in England. We will assess the impact of survey layout on the quality of the responses given to these screening scales using a parallel, randomised controlled study design. We will calculate the positive predictive value, the negative predictive value and the false omission rate of the Whooley questions in comparison with the EPDS. We will calculate differences in data equivalence, time needed to complete the surveys, break-off rates, data completeness and requests for help between the 2 experimental groups: using all questions in one screen and navigation by vertical scrolling, or a single question per screen and navigation by multiple pages.

ETHICS AND DISSEMINATION

This study has been approved by the National Research Ethics Service Committee South East Coast--Surrey. Our findings will be disseminated through academic peer-reviewed publications, conferences and discussion with peers.

The advance care planning PREPARE study among older Veterans with serious and chronic illness: study protocol for a randomized controlled trial

Background

Advance care planning (ACP) is a process whereby patients prepare for medical decision-making. The traditional objective of ACP has focused on the completion of advance directives. We have developed a new paradigm of ACP focused on preparing patients and their loved ones for communication and informed medical decision-making. To operationalize this new paradigm of ACP, we created an interactive, patient-centered website called PREPARE (www.prepareforyourcare.org) designed for diverse older adults.

Methods/Design

This randomized controlled trial with blinded outcome assessment is designed to determine the efficacy of PREPARE to engage older Veterans in the ACP process. Veterans who are ≥ 60 years of age, have ≥ two medical conditions, and have seen a primary care physician ≥ two times in the last year are being randomized to one of two study arms. The PREPARE study arm reviews the PREPARE website and an easy-to-read advance directive. The control arm only reviews the advance directive. The primary outcome is documentation of an advance directive and ACP discussions. Other clinically important outcomes using validated surveys include ACP behavior change process measures (knowledge, contemplation, self-efficacy, and readiness) and a full range of ACP action measures (identifying a surrogate, identifying values and goals, choosing leeway or flexibility for the surrogate, communicating with clinicians and surrogates, and documenting one’s wishes). We will also assess satisfaction with decision-making and Veteran activation within primary care visits by direct audio recording. To examine the outcomes at 1 week, 3 months, and 6 months between the two study arms, we will use mixed effects linear, Poisson, or negative binomial regression and mixed effects logistic regression.

Discussion

This study will determine whether PREPARE increases advance directive completion rates and engagement with the ACP process. If PREPARE is efficacious, it could prove to be an easy and effective intervention to help older adults engage in the ACP process within or outside of the medical environment. PREPARE may also help older adults communicate their medical wishes and goals to their loved ones and clinicians, improve medical decision-making, and ensure their wishes are honored over the life course.

Trial registration

ClinicalTrials.gov NCT01550731. Registered on 8 December 2011. 

Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians

INTRODUCTION

Burnout is a syndrome of depersonalization, emotional exhaustion and sense of low personal accomplishment. Emergency physicians (EPs) experience the highest levels of burnout among all physicians. Burnout is associated with greater rates of self-reported suboptimal care among surgeons and internists. The association between burnout and suboptimal care among EPs is unknown. The objective of the study was to evaluate burnout rates among attending and resident EPs and examine their relationship with self-reported patient care practices.

METHODS

In this cross-sectional study burnout was measured at two university-based emergency medicine residency programs with the Maslach Burnout Inventory. We also measured depression, quality of life (QOL) and career satisfaction using validated questionnaires. Six items assessed suboptimal care and the frequency with which they were performed.

RESULTS

We included 77 out of 155 (49.7%) responses. The EP burnout rate was 57.1%, with no difference between attending and resident physicians. Residents were more likely to screen positive for depression (47.8% vs 18.5%, p=0.012) and report lower QOL scores (6.7 vs 7.4 out of 10, p=0.036) than attendings. Attendings and residents reported similar rates of career satisfaction (85.2% vs 87.0%, p=0.744). Burnout was associated with a positive screen for depression (38.6% vs 12.1%, p=0.011) and lower career satisfaction (77.3% vs 97.0%, p=0.02). EPs with high burnout were significantly more likely to report performing all six acts of suboptimal care.

CONCLUSION

A majority of EPs demonstrated high burnout. EP burnout was significantly associated with higher frequencies of self-reported suboptimal care. Future efforts to determine if provider burnout is associated with negative changes in actual patient care are necessary.

Diagnostic accuracy of the Whooley questions for the identification of depression: a diagnostic meta-analysis

OBJECTIVES

To determine the diagnostic accuracy of the Whooley questions in the identification of depression; and, to examine the effect of an additional 'help' question.

DESIGN

Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists, and forward citation searches.

INCLUSION CRITERIA

Studies were included that provided sufficient data to calculate the diagnostic accuracy of the Whooley questions against a gold standard diagnosis of major depression.

DATA EXTRACTION

Descriptive information, methodological quality criteria, and 2 × 2 contingency tables were extracted.

RESULTS

Ten studies met inclusion criteria. Pooled sensitivity was 0.95 (95% CI 0.88 to 0.97) and pooled specificity was 0.65 (95% CI 0.56 to 0.74). Heterogeneity was low (I(2)=24.1%). Primary care subgroup analysis gave broadly similar results. Four of the ten studies provided information on the effect of an additional help question. The addition of this question did not consistently improve specificity while retaining high sensitivity as reported in the original validation study.

CONCLUSIONS

The two-item Whooley questions have high sensitivity and modest specificity in the detection of depression. The current evidence for the use of an additional help question is not consistent and there is, as yet, insufficient data to recommend its use for screening or case finding.

TRIAL REGISTRATION NUMBER

CRD42014009695.

Accuracy of proactive case finding for mental disorders by community informants in Nepal

BACKGROUND

Accurate detection of persons in need of mental healthcare is crucial to reduce the treatment gap between psychiatric burden and service use in low- and middle-income (LAMI) countries.

AIMS

To evaluate the accuracy of a community-based proactive case-finding strategy (Community Informant Detection Tool, CIDT), involving pictorial vignettes, designed to initiate pathways for mental health treatment in primary care settings.

METHOD

Community informants using the CIDT identified screen positive (n = 110) and negative persons (n = 85). Participants were then administered the Composite International Diagnostic Interview (CIDI).

RESULTS

The CIDT has a positive predictive value of 0.64 (0.68 for adults only) and a negative predictive value of 0.93 (0.91 for adults only).

CONCLUSIONS

The CIDT has promising detection properties for psychiatric caseness. Further research should investigate its potential to increase demand for, and access to, mental health services.

A comparison of multiple patient reported outcome measures in identifying major depressive disorder in people with multiple sclerosis

BACKGROUND

Depression is one of the most prominent and debilitating symptoms in individuals with multiple sclerosis (MS), yet there is currently no consensus on the best instruments for depression screening in MS. More head to head comparisons of available screening instruments are needed to advise MS researchers and clinicians.

METHODS

A cross-sectional comparison of the effectiveness of screening for MDD using multiple patient reported outcome (PRO) screeners against a modified SCID telephone interview was completed in 164 individuals with MS. Stratum goals were set for depression levels to ensure participation by people with borderline and higher levels of depression. Criterion standard was a modified SCID MDD module. PRO measures included the PHQ-9, BDI-FS, PROMIS depression, Neuro-QOL depression, M-PHQ-2, PHQ-2, and CESD.

RESULTS

48 (29%) individuals met the modified SCID criteria for MDD. The sensitivity of the PRO measures ranged from 60% to 100% while specificity ranged from 46% to 86%. The ROC area for the PRO measures ranged from 0.79 to 0.83. Revised (higher) cutoff scores were suggested by the ROC analyses for most self-reported screeners.

LIMITATIONS

Enrollment was stopped early because of difficulties with recruitment. Several SCID recording could not be reviewed and diagnosis confirmed.

CONCLUSIONS

CESD-10 and PHQ9 had the best diagnostic performance using optimal cutoffs, but no one PRO measure stood out as significantly better than any other. Even when revised cutoff scores were used, none of the self-reported screeners identified people with MDD with adequate accuracy. More accurate self-reported screeners would facilitate diagnosing of MDD for both research and clinical purposes.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014

OBJECTIVE

To evaluate the prevalence of burnout and satisfaction with work-life balance in physicians and US workers in 2014 relative to 2011.

PATIENTS AND METHODS

From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools.

RESULTS

Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n=3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16; P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75; P<.001).

CONCLUSION

Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout.