No physical health without mental health: lessons unlearned?

Risk of not being in employment, education or training (NEET) in late adolescence is signalled by school readiness measures at 4-5 years

BACKGROUND

Not being in employment, education, or training (NEET) is associated with poor health (physical and mental) and social exclusion. We investigated whether England's statutory school readiness measure conducted at 4-5 years provides a risk signal for NEET in late adolescence.

METHODS

We identified 8,118 individuals with school readiness measures at 4-5 years and NEET records at 16-17 years using Connected Bradford, a bank of linked routinely collected datasets. Children were categorised as 'school ready' if they reached a 'Good Level of Development' on the Early Years Foundation Stage Profile. We used probit regression and structural equation modelling to investigate the relationship between school readiness and NEET status and whether it primarily relates to academic attainment.

RESULTS

School readiness was significantly associated with NEET status. A larger proportion of young people who were not school ready were later NEET (11%) compared to those who were school ready (4%). Most of this effect was attributable to shared relationships with academic attainment, but there was also a direct effect. Measures of deprivation and Special Educational Needs were also strong predictors of NEET status.

CONCLUSIONS

NEET risk factors occur early in life. School readiness measures could be used as early indicators of risk, with interventions targeted to prevent the long-term physical and mental health problems associated with NEET, especially in disadvantaged areas. Primary schools are therefore well placed to be public health partners in early intervention strategies.

The effect of physical fitness on psychological health: evidence from Chinese university students

BACKGROUND

Despite frequent discussions on the link between physical and mental health, the specific impact of physical fitness on mental well-being is yet to be fully established.

METHOD

This study, carried out between January 2022 and August 2023, involved 4,484 Chinese University students from eight universities located in various regions of China. It aimed to examine the association between physical fitness on psychological well-being. Descriptive statistics, t-tests, and logistic regression were used to analyze the association between physical fitness indicators (e.g., Body Mass Index (BMI), vital capacity, and endurance running) and mental health, assessed using Symptom Checklist-90 (SCL-90). All procedures were ethically approved, and participants consented to take part in.

RESULTS

Our analysis revealed that BMI, vital capacity, and endurance running scores significantly influence mental health indicators. Specifically, a 1-point increase in BMI increases the likelihood of an abnormal psychological state by 10.9%, while a similar increase in vital capacity and endurance running decreases the risk by 2.1% and 4.1%, respectively. In contrast, reaction time, lower limb explosiveness, flexibility, and muscle strength showed no significant effects on psychological states (p > 0.05).

CONCLUSION

Improvements in BMI, vital capacity, and endurance running capabilities are associated with better mental health outcomes, highlighting their potential importance in enhancing overall well-being.

The mental health impacts of human-ecosystem-animal relationships: A systematic scoping review of Eco-, Planetary, and One Health approaches

The threats to human and animal health, biodiversity conservation, and our living planet's future are ever-present and increasingly more severe due to climate change and environmental degradation. There is an emerging discourse exploring the mental health dimensions contained within these changes. To better understand and respond to these impacts requires novel and creative methodological approaches built on conceptual frameworks that integrate perspectives from the social and natural sciences. Three of the most influential interdisciplinary frameworks at the human-animal-ecosystem interface include: One Health, EcoHealth, and Planetary Health. These frameworks report mental health as an integral component within overall health-related outcomes. However, a comprehensive synthesis of the state of the literature that examines how mental health is explored within these approaches does not currently exist. A systematic scoping review was therefore conducted to obtain clear understandings of patterns, gaps, and broad themes, and to highlight future research needs and considerations. Standardized PRISMA guidelines, including explicitly defined inclusion/exclusion criteria and dual screening/extractions, were used. 13 papers were included: seven using the One Health Framework, with Planetary and EcoHealth each represented by three. Trends observed include a predominate focus on companion animals as interventions, "sense of place" used as a component of mental well-being, and non-physical health-related measurements of animal well-being as an outcome within One Health research. The lack in retrieved studies also highlight the dearth in literature on mental health as a pillar of these three well established frameworks. Compiling what is known in the evidence-base as a launching point for scientific engagement, this review describes guidance for investigators on how to conduct mental health research within these framework parameters so that future studies can elucidate mechanisms underpinning the intersections between the biosphere and human mental-health and data-driven interventions and policy recommendations that simultaneously address mental health and global change can be proposed and enacted.

Usage of unguided, guided, and blended care for depression offered in routine clinical care: Lessons learned

Introduction

Internet-delivered psychotherapy is often considered to be a promising way to extend mental healthcare services around the world. Research findings that have emerged over the past two decades have strengthened this claim. However, very little is known about the usage of internet-delivered psychotherapy in real-life circumstances.

Methods

The current study explored the real-life usage of depressiehulp.be, a publicly available online platform for depression that offers pure self-help, online guided self-help, and blended treatment for depression in Flanders, Belgium, using data collected from 2656 participants between May 2018 and May 2022.

Results

Both duration of engagement with the online platform and number of exercises completed increased with increasing levels of therapist guidance. Findings also showed a particular pattern of engagement for each of the online treatments. Overall, participants completed most exercises during the first days of treatment. However, participants using pure online self-help showed the fastest decrease of engagement over time, with most dropping out after completing a few exercises, and more than half of all participants who enrolled in the self-help programme did not even begin the programme. In both guided and blended treatment, participants tended to show higher levels of engagement with the online platform. In each treatment modality, a relatively small but notable group of participants showed high levels of engagement. There was no relationship between severity of depression and duration of engagement.

Conclusions

The current study demonstrates the importance of therapist support in online interventions and offers additional insights into how, and to what extent, online platforms are used. Future research should explore clinical impact and policy implications.

Self-efficacy in health among university students: the role of social support and place

OBJECTIVE

The aim of this study was to better understand the role of students' living arrangements (on campus, off campus, with and without their parents) on their health self-efficacy.

PARTICIPANTS

A sample of undergraduate students (n = 216) were recruited by using word of mouth and visiting classrooms in a small Atlantic Canadian university.

METHODS

Participants completed a self-report questionnaire measuring health and sleep self-efficacy. Analyses of variance and covariance were used to compare the living arrangements of the students.

RESULTS

Differences between living arrangements were found. Students living on campus had higher health self-efficacy, particularly on the psychological well-being subscale, followed by those living off campus with their parents. Students living off campus without their parents had the lowest scores.

CONCLUSION

This study demonstrated that health self-efficacy varies according to students' living situations, thus illustrating the importance of keeping students' living arrangements in mind when designing health and well-being interventions.

Improving Children's Mental Health Literacy Through the Cocreation of an Intervention and Scale Validation: Protocol for the CHILD-Mental Health Literacy Research Study

BACKGROUND

Children's mental health is a public health priority, with 1 in 5 European children younger than 12 years having a behavioral, developmental, or psychological disorder. Mental health literacy (MHL) is a modifiable determinant of mental health, promoting psychological well-being and reducing mental health problems. Despite its significance, no interventions or scales currently exist for increasing and measuring MHL in this population.

OBJECTIVE

This study has dual objectives: (1) cocreating and evaluating an intervention on children's MHL, and (2) developing and validating a scale that measures children's MHL.

METHODS

Our study focuses on children aged 9-11 years attending primary school classes in various settings, including urban and rural areas, and priority education zones within a French department. Using a participatory research approach, we will conduct workshops involving children, parents, teachers, and 1 artist to cocreate an intervention comprising multiple tools (eg, a pedagogical kit and videos). This intervention will undergo initial evaluation in 4 classes through observations, interviews, and satisfaction questionnaires to assess its viability. Concurrently, the artist will collaborate with children to create the initial version of the CHILD-MHL scale, which will then be administered to 300 children. Psychometric analyses will validate the scale. Subsequently, we will conduct a cluster randomized controlled trial involving a minimum of 20 classes, using the CHILD-MHL scale scores as the primary end point to evaluate the intervention's efficacy. Additional interviews will complement this mixed methods evaluation. Both the intervention and the scale are grounded in the Child-Focused MHL model.

RESULTS

The first tool of the intervention is the pedagogical kit Le Jardin du Dedans, supported by the public organization Psycom Santé Mentale Info and endorsed by UNICEF (United Nations Children's Fund) France. The second tool is a handbook by the Pan American Health Organization and the World Health Organization, which is addressed to teachers to sensitize them to children's mental health problems. The third is a 5-page supplementary leaflet produced by the nongovernmental organization The Ink Link, which teaches children the notion of MHL. Finally, we produced 56 items of the MHL Scale and listed existing education policies for children's mental health.

CONCLUSIONS

After its robust evaluation, the intervention could be extended to several schools in France. The scale will be the first in the world to measure children's MHL. It will be used not only to evaluate interventions but also to provide data for decision makers to include MHL in all educational policies. Both the intervention and the scale could be translated into other languages.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/51096.

The Vermont Family Based Approach in Primary Care Pediatrics: Effects on Children's and Parents' Emotional and Behavioral Problems and Parents' Health-Related Quality of Life

This randomized controlled trial tested the Vermont Family Based Approach (VFBA) in primary care pediatrics. The VFBA is a model of healthcare delivery that shifts the focus from the individual to the family, emphasizes emotional and behavioral health, and uses evidence-based health promotion/prevention along with the treatment of emotional and behavioral problems. Participants were 81 families of 3-15-year-olds. For children, the VFBA was associated with greater reductions than the Control condition on the Child Behavior Checklist Emotionally Reactive, Withdrawn, Sleep Problems, Aggressive Behavior and Total Problems scales. For parents, the VFBA was associated with greater reductions than the Control condition on the Adult Self-Report Anxious/Depressed, Rule-Breaking Behavior, Internalizing Problems and Total Problems scales. The VFBA was also associated with greater improvement than the Control condition in the parents' health-related quality of life, as indicated by all scales of the Medical Outcomes Study Health Survey.

Effects of Physical Activity on Physical and Mental Health of Older Adults Living in Care Settings: A Systematic Review of Meta-Analyses

Previous studies included in meta-analyses have highlighted the effects of physical activity on the physical and psychological health of older adults living in care settings. We conducted a systematic review of meta-analyses, of institutionalized older adults, to evaluate and conduct a narrative synthesis of the results of these meta-analyses. A literature search was conducted in three databases (PubMed, Web of Science, and Cochrane Library) until 22 March 2023. After screening the identified articles with the PRISMA criteria filters, we included 11 meta-analyses in this systematic review. Higgins' (2013) assessment tool of the meta-analyses demonstrates that the studies were of good quality although future meta-analyses need to provide more information on the treatment of missing data. A summary of the results of these meta-analyses shows that physical activity reduces the rate of falls, mobility issues, functional dependence, and depression, and improves health status. Future studies need to focus on new ways to promote and adapt physical activities to increase the participation of older adults in care settings.

Screening visual environment impact factors and the restorative effect of four visual environment components in large-space alternative care facilities

Alternative care facilities (ACFs) based on large-space public buildings were widely used early at the start of the coronavirus disease 2019 (COVID-19) pandemic. However, studies have shown that the indoor spatial environment of ACFs can significantly induce mental health problems among users. Thus, this study hypothesizes that improving the visual environment in the interiors of large-space ACFs may reduce mental health problems among users. To verify this hypothesis, this study used critical analysis to screen the influencing factors and used analytic hierarchy process analysis to determine the weights. Particularly, the analyses were based on ACF research in Wuhan and questionnaire surveys of patients with experience using ACFs. Subsequently, virtual reality experiments were conducted to measure physiological indicators and subjective questionnaire collection based on the orthogonal experimental design of the four screened visual environment components. The results revealed the following related to large-space ACFs: 1) Lifestyle support was the most dominant patient requirement and preference for the visual environment. 2) The visual environment can influence the participants' efficiency of psychological stress relief, emotional regulation, and subjective perception. 3) Different design characteristics of the four visual environment components were causally related to restorative effects. To the best of our knowledge, this is the first study analyzing patients' preferences and psychological needs for the visual environment of large-space ACFs and combining subjective and objective measures to investigate the restorative effects of the visual environment. Improving the quality of the visual environment in large-space ACFs presents an effective intervention for alleviating the psychological problems of admitted patients.

Role of Health Literacy, Social Support, Patient-Physician Relationship, and Health-Related Quality of Life in Predicting Medication Adherence in Cardiovascular Diseases in Oman

Purpose

Cardiovascular diseases (CVDs) remain a global health threat, and medication adherence remains low. Medication adherence is a complex phenomenon and is affected by many factors that require investigation. Oman has limited literature examining medication adherence and influencing factors among patients with CVDs. This study examined the influence of health literacy, social support, the patient-physician relationship, and health-related quality of life on medication adherence among patients with cardiovascular diseases.

Patients and Methods

This cross-sectional study used a correlation design. The study included 360 participants with CVDs. Descriptive statistics, independent t-test, one-way ANOVA, and multiple regression analysis were utilized for data analyses.

Results

Findings revealed that higher social support (B=0.117; p=0.033), good patient-physician relationship (B=0.124; p < 0.01), better mental health (B=0.045; p < 0.01), more bodily pain (B=0.030; p < 0.01), and unemployment (B=1.297; p < 0.01) were predictors of higher adherence. High school education and above predicted lower medication adherence (B= -1.255; p= 0.019), while health literacy was not a significant predictor of medication adherence (B= 0.061; p= 0.289).

Conclusion

To improve medication adherence, healthcare providers and researchers should consider improving patients' social support, mental health, and the patient-physician relationship. In addition, patients' socioeconomic status should always be considered and examined as an influencing factor of medication adherence.

The Arizona Sexual Experiences Scale-the Thai Translation (ASEX-Thai): Reliability and validity in Thai patients with mental disorders

Background: Sexual dysfunction is common among patients with mental disorders but receives less clinical attention, especially in Thailand and other Asian countries. The Arizona Sexual Experiences Scale-the Thai Translation (ASEX-Thai), a self-rated, brief, questionnaire is a potential tool for screening for sexual dysfunction in this population. Our study aimed to assess the reliability and validity of ASEX-Thai in Thai patients with mental disorders.

Methods: We enrolled 202 patients from an outpatient psychiatric department at a tertiary hospital in Bangkok, Thailand. Demographic data, clinical data, and diagnosis of sexual dysfunction were assessed. ASEX-Thai was done, and we analyzed the test’s psychometric properties. 

Results: Most participants were diagnosed with major depressive disorder (48%). There was a positive correlation between the ASEX-Thai and sexual dysfunction diagnosis (r = 0.402, p < 0.001). The KMO coefficient was 0.77 and Barlett’s sphericity test was significant (χ  ² = 409.76, p<0.001). A score of ≥ 17 points of the ASEX-Thai was the most suitable for sexual dysfunction screening (sensitivity 77.23 %, and specificity 58.42 %). For reliability, the Cronbach’s alpha coefficient (0.831) showed good internal consistency.

Conclusions: The ASEX-Thai is a valid and reliable self-rated questionnaire for screening for sexual dysfunction among Thai patients with mental disorders. The test could help clinicians to evaluate this undetected condition and deliver proper interventions.

Associations between MDMA/ecstasy use and physical health in a U.S. population-based survey sample

INTRODUCTION

3,4-Methylenedioxymethamphetamine (MDMA/"ecstasy") is an empathogen that can give rise to increased pleasure and empathy and may effectively treat post-traumatic stress disorder. Although prior research has demonstrated associations between ecstasy use and favorable mental health outcomes, the associations between ecstasy and physical health have largely been unexplored. Thus, the goal of this study was to examine the associations between ecstasy use and physical health in a population-based survey sample.

METHOD

This study utilized data from the National Survey on Drug Use and Health (2005-2018), a yearly survey that collects information on substance use and health outcomes in a nationally representative sample of U.S. adults. We used multinomial, ordered, and logistic regression models to test the associations between lifetime ecstasy use and various markers of physical health (self-reported body mass index, overall health, past year heart condition and/or cancer, past year heart disease, past year hypertension, and past year diabetes), controlling for a range of potential confounders.

RESULTS

Lifetime ecstasy use was associated with significantly lower risk of self-reported overweightness and obesity (adjusted relative risk ratio range: 0.55-0.88) and lower odds of self-reported past year heart condition and/or cancer (adjusted odds ratio (aOR): 0.67), hypertension (aOR: 0.85), and diabetes (aOR: 0.58). Ecstasy use was also associated with significantly higher odds of better self-reported overall health (aOR: 1.18).

CONCLUSION

Ecstasy shares protective associations with various physical health markers. Future longitudinal studies and clinical trials are needed to more rigorously test these associations.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Determinants of Mental Healthcare-Seeking Behavior of Postpartum Women in Ibadan, Nigeria

The mental healthcare-seeking behavior of postpartum mothers has received little attention in Nigeria. Previous studies in the country have focused on determinants of physical health-seeking behavior, choice of maternal healthcare provider, prevalence, and determinants of maternal mental illness, yet, determinants of maternal mental health-seeking behavior among Nigerian women has been understudied. This study, therefore, examined the determinants of mental health-seeking behavior among postpartum women in Ibadan, Nigeria. Maternal mental illness, which was proxied using postpartum depression, was computed using the Edinburgh Postpartum Depression Scale. Data for the study were obtained through a survey method using a 9-page questionnaire. A 3-stage sampling technique was employed. The first stage was a stratified sampling to disaggregate the health facilities offering postnatal and immunization services on the basis of ownership of public and private healthcare providers. In the second stage, seven healthcare facilities comprising three (3) private and four (4) public healthcare were purposively selected based on the number of attendees. The final stage was a random selection of 390 postpartum mothers attending postnatal and immunization clinics across seven healthcare facilities. The prevalence of depression among the mothers was 20.8%. While only 39.5% of the depressed women sought care, 22.3% of the non-sufferers also sought mental healthcare. This revealed that both sufferers and non-sufferers sought mental healthcare. Also, a higher incidence of postpartum depression among the sufferers increased the likelihood of seeking mental healthcare. Age, family history of postpartum depression, and having the desired gender of child were determinants of mental health-seeking behavior. Among the sufferers of postpartum depression who failed to seek care, a low perceived need for mental healthcare, the perception that the depressive symptoms will go on their own, as well as fear of being stigmatized as a "weak mother", were reasons for not seeking mental healthcare. Thus, to promote mental healthcare, the non-cost factors, like availability and accessibility to a mental healthcare facility should be addressed. To achieve this, mental healthcare sensitization programs should be integrated into maternal healthcare at all levels, and mothers attending antenatal clinics should be routinely screened for early symptoms of depression in the postpartum period.

Exploring the Impact of the COVID-19 Pandemic on Male Mental Health Emergencies Attended by Ambulances During the First National "Lockdown" in the East Midlands of the United Kingdom

The novel coronavirus disease 2019 (COVID-19) pandemic and associated mitigation strategies such as “lockdown” are having widespread adverse psychological effects, including increased levels of anxiety and depression. Most research using self-reported data highlights the pandemic’s impact on the psychological well-being of females, whereas data for mental health emergency presentations may reflect the impact on male mental health more accurately. We analyzed records of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national “lockdown.” We computed two binary logistic regression models to (a) compare male mental health emergencies occurring during “lockdown,” 2020 (5,779) with those occurring in the same period in 2019 (N = 4,744) and (b) compare male (N = 5,779) and female (N = 7,695) mental health emergencies occurring during “lockdown.” Comparisons considered the characteristics of mental health emergencies recorded by ambulance clinicians (Primary Impressions), and the socioeconomic characteristics of communities where emergencies use the Index of Multiple Deprivation. We found that during “lockdown,” male emergencies were more likely to involve acute anxiety (odds ratio [OR]: 1.42) and less likely to involve intentional drug overdose (OR: 0.86) or attempted suicide (OR: 0.71) compared with 2019. Compared with females, male emergencies were more likely to involve acute behavioral disturbance (OR: 1.99) and less likely to involve anxiety (OR: 0.67), attempted suicide (OR: 0.83), or intentional drug overdose (OR: 0.76). Compared with 2019, and compared with females, males experiencing mental health emergencies during “lockdown” were more likely to present in areas of high deprivation. Understanding the presentation of male mental health emergencies could inform improved patient care pathways.

Lay Public View of Neuroscience and Science-Based Brain Health Recommendations in Slovenia

Background: Brain health is one of the cornerstones of a long and full life. Active care for brain health and reduction of lifestyle-related risks for brain disorders may be a key strategy in tackling the growing prevalence of mental and neurological illnesses. Public knowledge, perception, and preventive behavior need to be considered in the planning of effective strategies for brain health promotion. Our research is the first effort aimed at assessing Slovenian lay public knowledge, search and use of scientific information about the brain, and care for brain health.

Methods: An online survey was used to gather data for descriptive and associative statistical analyses of a sample of the Slovenian public (n = 2568) in August 2017. Participants with formal brain-related education were excluded, leaving the remaining sample of the lay public (n = 1012). Demographic characteristics and information regarding the perceived importance and knowledge of brain health and engagement in preventive behaviors of participants were collected, and key associative analyses were carried out.

Results: The majority of respondents (89%) considered brain health to be important. Over one-third (39%) considered their knowledge of the brain as sufficient relative to their needs. Most of the respondents identified science-recommended practices to be important for brain health. No recommendation was followed daily by the majority of the respondents, primarily due to declared lack of time (59%), and lack of information (32%). Information was obtained primarily from television (38%), followed by newspapers and magazines (31%), the Internet (31%), and direct conversations (27%). However, the highest-rated, preferred source of information was lectured by experts. One-third of our sample struggled with the trustworthiness of information sources. Female gender and older age were associated with a higher frequency of healthy practices. Personal or familial diagnoses of brain disorders were not associated with a higher frequency of the behavior in favor of brain health, but did affect available time and perceived value of preventive practices.

Conclusions: Our research provides an initial insight into the perceptions, knowledge, and brain health-promoting behavior of the Slovenian lay public. Our findings can inform future strategies for science communication, public education and engagement, and policy-making to improve lifelong active care for brain health.

Reaching the Unreached: Bridging Islam and Science to Treat the Mental Wounds of War

Radical new paradigms are needed to equip non-professionals and leverage community faith-based infrastructure to address the individual and communal wounds of war- and conflict-related trauma. Muslims in war-torn regions like Somalia experience high rates of trauma and posttraumatic stress; yet, lack of providers, potential stigma, and lack of integration with one's faith are substantial barriers to care. In this pre-post feasibility clinical trial (NCT03761732), mosque leaders implemented a brief, group- and mosque-based intervention, Islamic Trauma Healing, targeting trauma-related psychopathology and community reconciliation for trauma survivors (N = 26) in Somaliland, Somalia. Leaders were trained in a brief 2-day training, with supervision provided remotely via WhatsApp. This six-session intervention combines empirically-supported trauma-focused psychotherapy and Islamic principles, focusing on wisdom from the lives of the Prophets and turning to Allah in dua about trauma. There were large, clinically meaningful effects for PTSD (g = 1.91), depression (g = 2.00), somatic symptoms (g = 2.73), and well-being (g = 1.77). Qualitative data from group members highlighted how well the program was aligned with their Islamic faith, built community, and need to expand the program. These results highlight the feasibility of this non-expert, easily up-scalable mental health approach in war-torn Muslim regions and refugee communities. This program has the potential to provide a low-cost, self-sustaining, Islam-based intervention addressing the psychological wounds of war consistent with the IOM's call to develop novel approaches to address unmet clinical needs. ClinicalTrials.gov Identifier: NCT03761732.

Rwanda's Resiliency During the Coronavirus Disease Pandemic

The coronavirus disease (COVID-19) pandemic has illustrated the wide range of preventative measures and responsive strategies of low- and middle-income countries (LMICs). LMICs have implemented lessons learned from previous periods of epidemics and uncertainties. Rwanda's pre-existing decentralized healthcare and mental health system which are in response to the mental health distress from the 1994 genocide, continues to be a formidable system that collaborate and combine efforts to address people's mental health needs. COVID-19 has heightened or exacerbated people's mental health within the country. Rwandans have been exposed to and endured adversities, yet their cultural forms of resilience serve as a mental health protective factor to also overcome COVID-19. Nonetheless, Rwanda has engaged in interventions targeting public safety, social and economic protection that specifically address vulnerable communitie's mental health needs. Lessons from preparedness for the Ebola virus disease (EVD) epidemic has contributed to Rwanda's organization and approach to combating COVID-19. Policies and best practices that were enacted during the EVD outbreak have guided Rwanda's response within the healthcare and mental health system. Coincidentally, this outbreak emerged during the 26th commemoration of the 1994 genocide against the Tutsi. Although for the first-time post genocide, Rwanda was not able to engage in public traditional forms of collective mourning and community healing, evidence of Rwandan's resilient spirit is demonstrated. Community resilience has been defined by Magis [401] as the "existence, development and engagement of community resources by community members to thrive in an environment characterized by change, uncertainty, unpredictability and surprise.". Referring to this definition, community resilience has been an interwoven into the cultural framework that guided Rwandans in past challenges and continues to be evident now. Rwanda's resilience throughout this pandemic remains through ongoing psychoeducation, community awareness of mental health concerns, collective messages of highlighting mental health support, and solidarity. The global community can gain knowledge from Rwanda's learned lessons of their past which has positioned itself to stand on its resilient values in times of uncertainty such as COVID-19 and endeavor to overcome through national cohesion.

Supporting evidence for geropsychiatric nursing as a subspecialty of gerontological advanced practice nursing

Advanced practice nurses (APRNs) make significant contributions to the mental health of older adults. Despite the surge in the number of older adults, the number of APRNs choosing educational preparation for geropsychiatric nursing (GPN) is limited. The purpose of the GAPNA GPN Position Statement is to sustain a new vision for the nursing profession that will improve the care of older adults with psychiatric and mental health disorders. This position paper was written by a diverse group of APRNs with the collective intent to reflect respect, decrease stigma, remove controversy, and uphold a positive, person-centered approach to mental disorders among older adults and their families. The GAPNA GPN Position Statement was written to advance excellence in the GPN subspecialty, provide holistic care for older adults and make recommendations for practice. Blending gerontological and psychiatric nursing results in a subspecialty at the top of the APRN Consensus Model pyramid.

The role of cortisol in ischemic heart disease, ischemic stroke, type 2 diabetes, and cardiovascular disease risk factors: a bi-directional Mendelian randomization study

BACKGROUND

Cortisol, a steroid hormone frequently used as a biomarker of stress, is associated with cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). To clarify whether cortisol causes these outcomes, we assessed the role of cortisol in ischemic heart disease (IHD), ischemic stroke, T2DM, and CVD risk factors using a bi-directional Mendelian randomization (MR) study.

METHODS

Single nucleotide polymorphisms (SNPs) strongly (P < 5 × 10-6) and independently (r2 < 0.001) predicting cortisol were obtained from the CORtisol NETwork (CORNET) consortium (n = 12,597) and two metabolomics genome-wide association studies (GWAS) (n = 7824 and n = 2049). They were applied to GWAS of the primary outcomes (IHD, ischemic stroke and T2DM) and secondary outcomes (adiposity, glycemic traits, blood pressure and lipids) to obtain estimates using inverse variance weighting, with weighted median, MR-Egger, and MR-PRESSO as sensitivity analyses. Conversely, SNPs predicting IHD, ischemic stroke, and T2DM were applied to the cortisol GWAS.

RESULTS

Genetically predicted cortisol (based on 6 SNPs from CORNET; F-statistic = 28.3) was not associated with IHD (odds ratio (OR) 0.98 per 1 unit increase in log-transformed cortisol, 95% confidence interval (CI) 0.93-1.03), ischemic stroke (0.99, 95% CI 0.91-1.08), T2DM (1.00, 95% CI 0.96-1.04), or CVD risk factors. Genetically predicted IHD, ischemic stroke, and T2DM were not associated with cortisol.

CONCLUSIONS

Contrary to observational studies, genetically predicted cortisol was unrelated to IHD, ischemic stroke, T2DM, or CVD risk factors, or vice versa. Our MR results find no evidence that cortisol plays a role in cardiovascular risk, casting doubts on the cortisol-related pathway, although replication is warranted.

The knowledge, attitudes and perceptions of physiotherapists in KwaZulu-Natal, South Africa, towards mental health

Background

Physiotherapists are trained to manage patients with physical needs, but because of limited training at an undergraduate level in mental health, patients may not receive holistic care. This lack of knowledge often can deny people living with a mental illness (PLWMI) the potential benefits of physiotherapy treatment and exercise.

Objectives

Our study conducted in the KwaZulu-Natal province of South Africa aimed to determine the knowledge, attitudes and perceptions of physiotherapists working in the Department of Health (DoH) in KwaZulu-Natal, South Africa, towards mental health, and to determine whether their undergraduate training prepared them to manage PLWMI.

Methods

A mixed-method design was employed. The Attitudes to Psychiatry (ATP-30) questionnaire was distributed to 153 physiotherapists in KwaZulu-Natal. Focus groups were conducted to ascertain whether their undergraduate training prepared them adequately to manage PLWMI.

Results

A total of 124 physiotherapists completed the questionnaires. The mean ATP-30 scores was 103.70 (SD = 11.71). Females had slightly higher ATP-30 scores than males. Physiotherapists indicated in the focus groups that they received limited training about mental health at an undergraduate level.

Conclusion

Physiotherapists working in the KwaZulu-Natal public sector have a positive attitude towards mental health and managing PLWMI. Participants expressed the need for the inclusion of theoretical and practical knowledge about mental health in the undergraduate curriculum and postgraduate courses related to this topic.

Clinical implications

The outcomes of this study show the importance of the inclusion of mental health in the undergraduate physiotherapy programme. Exposure to the theoretical and practical knowledge of mental health during the undergraduate physiotherapy programme will assist qualified physiotherapists better manage PLWMI. Future studies should be conducted in the other provinces and in the private practice setting in South Africa, so as to compare the results.

Willingness of people with Type 2 diabetes to start insulin therapy: Evidence from the South African Tshwane Insulin Project (TIP)

AIMS

To determine factors associated with 'hypothetical willingness' to start insulin among people with Type 2 diabetes (T2DM).

METHODS

A quantitative cross-sectional study with insulin-naïve T2DM patients at 23 primary care facilities in the Tshwane Metropolitan Municipality. Data collected included demographic and clinical data, willingness to start insulin, attitudes and barriers to insulin therapy. Factors associated with unwillingness to start insulin therapy were explored using a multivariable logistic regression model.

RESULTS

Of 468 T2DM study patients (mean age 57.2, SD = 11.3 years), more than half (51.9%) expressed unwillingness to starting insulin therapy. Unwillingness was associated with negative attitudes (OR = 1.32, 95% CI = 1.12-1.55, p = 0.001) and reluctance (OR = 1.41, 95% CI = 1.27-1.57, p < 0.001) rather than age, sex, education or diabetes duration. The strongest reasons for patient unwillingness were injection anxieties, fear of needles, insufficient knowledge of insulin, feeling unable to cope with insulin and concerns about out-of-pocket costs.

CONCLUSIONS

The prospect of insulin therapy disturbs patients' sense of self and their psychological wellbeing. The high prevalence of psychological insulin resistance among these T2DM patients needs to be addressed for effective diabetes management.

Study of the Effects of Recognition of Stress on Symptoms and Regular Hospital Visits: An Analysis from Japanese National Statistics

Stress is a risk factor for numerous lifestyle diseases, including dental diseases. The purpose of the present study was to investigate how sensitivity to psychological stress relates to subjective symptoms and regular hospital visits using information from the large-scale database of national statistics. Anonymized data from 10,584 respondents aged 30–79 of the Japanese 2013 Comprehensive Survey of Living Conditions were analyzed. Respondents were classified by age into a middle-aged group and an elderly group, and a contingency table analysis, rank correlation analysis, and binomial logistic regression analysis were performed. Contingency table analysis confirmed that eight items were related to the presence of a recognition of stress, including the presence of subjective symptoms (p < 0.001), the presence of regular hospital visits (p < 0.001), symptoms of periodontal disease (p < 0.001), and self-rated health (p < 0.001). Responses for symptoms and diseases requiring regular hospital visits were ranked in order for a stress group and a no stress group, and it was found that other than fatigue symptoms being ranked highly in the stress group, there were no particular differences. Logistic regression analysis results showed significant odds ratios for six items including: self-rated health (3.91, 95% CI, 3.23 to 4.73), lifestyle awareness (1.96, 95% CI, 1.68 to 2.28), and symptoms of periodontal disease (1.71, 95% CI 1.19 to 2.48). The present study showed that susceptibility to psychological stress is related to awareness of subjective symptoms and to regular hospital visits due to disease, suggesting that these have direct and indirect mutual effects.

Exploring the Factors Influencing Consumers to Voluntarily Reward Free Health Service Contributors in Online Health Communities: Empirical Study

BACKGROUND

Rewarding health knowledge and health service contributors with money is one possible approach for the sustainable provision of health knowledge and health services in online health communities (OHCs); however, the reasons why consumers voluntarily reward free health knowledge and health service contributors are still underinvestigated.

OBJECTIVE

This study aimed to address the abovementioned gap by exploring the factors influencing consumers' voluntary rewarding behaviors (VRBs) toward contributors of free health services in OHCs.

METHODS

On the basis of prior studies and the cognitive-experiential self-theory (CEST), we incorporated two health service content-related variables (ie, informational support and emotional support) and two interpersonal factors (ie, social norm compliance and social interaction) and built a proposed model. We crawled a dataset from a Chinese OHC for mental health, coded it, extracted nine variables, and tested the model with a negative binomial model.

RESULTS

The data sample included 2148 health-related questions and 12,133 answers. The empirical results indicated that the effects of informational support (β=.168; P<.001), emotional support (β=.463; P<.001), social norm compliance (β=.510; P<.001), and social interaction (β=.281; P<.001) were significant. The moderating effects of social interaction on informational support (β=.032; P=.02) and emotional support (β=-.086; P<.001) were significant. The moderating effect of social interaction on social norm compliance (β=.014; P=.38) was insignificant.

CONCLUSIONS

Informational support, emotional support, social norm compliance, and social interaction positively influence consumers to voluntarily reward free online health service contributors. Social interaction enhances the effect of informational support but weakens the effect of emotional support. This study contributes to the literature on knowledge sharing in OHCs by exploring the factors influencing consumers' VRBs toward free online health service contributors and contributes to the CEST literature by verifying that the effects of experiential and rational systems on individual behaviors can vary while external factors change.

The Mental Health Crisis in America: Recognizing Problems; Working Toward Solutions: Part 1. Defining the Crisis

This column is the first in a series summarizing the 2-day Centennial Conference of the Austen Riggs Center. The conference framed problems in access to care and in the nature of care provided that are part of a mental health crisis in America, and then worked to propose solutions. This column focuses on framing the problems and on beginning to address what it might take to "bend the curve" in mental health outcomes.

Canadian Chronic Disease Indicators, 2019 - Updating the data and taking into account mental health

The 2019 edition of the Canadian Chronic Disease Indicators (CCDI) provides recent estimates of the burden of chronic conditions and measures of general health and associated determinants in Canada. Using data from the CCDI and 2017 Canadian Community Health Survey, we explored the relationship between sociodemographic factors and selfreported mental health. Our findings suggest that sex (males vs females: adjusted odds ratio [aOR] = 1.22); age (65-79 vs 35-49 year age group: aOR = 1.48); education (postsecondary graduate vs less than high school: aOR = 1.68); household income adequacy (highest quintile [Q5] vs lowest [Q1]: aOR = 2.25); and immigrant status (recent immigrants vs nonimmigrants: aOR= 2.29) were significantly associated with higher self-reported mental health.

Quality of life of patients with spinal muscular atrophy: A systematic review

OBJECTIVES

To systematically review the literature of quality of life (QoL) of patients with spinal muscular atrophy (SMA), a rare, autosomal-recessive neuromuscular disease associated with extensive morbidity and elevated mortality.

METHODS

We searched Embase, Web of Science, and PubMed for full-text, English-language articles (published between January 1, 2000 and July 31, 2018) reporting results from studies of QoL of patients with SMA. We excluded review and editorial articles, studies reporting results for samples comprising <5 patients (to allow for meaningful inference), and case reports/qualitative assessments.

RESULTS

Of 824 identified articles, 15 met study criteria. Included publications contained data derived from samples from a total of 11 countries and three continents (Europe, North America, and South America). Estimates of the latent trait, primarily derived using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and the PedsQL 3.0 Neuromuscular Module, indicated impairment in patient QoL, in particular physical functioning. However, both patient self- and caregiver proxy-assessments varied markedly across studies and subgroups. Among adult individuals, the mean self-assessed EuroQol-5D-3L utility has been estimated at 0.16 for a pooled sample of patients with SMA type I, II, and III, and -0.01 for SMA type II. Little is known of the impact of available treatments, including nusinersen, on patient QoL.

CONCLUSIONS

Our review show that QoL is impaired in SMA, mainly due to compromised physical health, but also reveal that little is known of the impact of the disease across different phenotypes and clinical interventions.

Mental and physical health effects of meaningful work and rewarding family responsibilities

Positive feelings about work and family responsibilities benefit psychological well-being, but their physical health effects remain unexplored. The study assessed whether meaningful work and reward from taking care of family benefitted physical health to the same degree as mental health. Participants were 181 Danes aged 49–51. Participants reported on working conditions, providing care to family, depressive symptoms, and perceived stress. Physical health was operationalized as a physiological dysregulation (e.g., hypertension, high levels of blood sugar and cholesterol, high body mass index). A multidimensional index of physiological dysregulation was created using parameters of cardiovascular, metabolic, and immune function. As expected, meaningful work and sense of reward from taking care of family members were associated with better mental health. However, in women, the very same factors were positively associated with higher physiological dysregulation. We conclude that work and family factors promoting psychological well-being may have physical health trade-offs, particularly in women.

Treatment adherence as a mediator of blood pressure control in Chinese older adults with depression

OBJECTIVES

Both depression and hypertension (HTN) are prevalent, costly, and destructive, and frequently coexist among the aging population of China. This study aimed to examine the role that treatment adherence plays in blood pressure control in older adult Chinese with depression.

METHODS

Data for these analyses were taken from a randomized control trial of a collaborative depression care management intervention conducted in rural villages of Zhejiang Province, China with older adults who had comorbid depression and HTN. They included baseline assessments of 2362 subjects ages ≥60 years, whose blood pressure and depression were measured using a calibrated manual sphygmomanometer and the Chinese version of the 17-item Hamilton Depression Rating Scale (HDRS-17), respectively. Treatment adherence was identified by a single question asking whether patients on occasion did not take their medicine.

RESULTS

Uncontrolled HTN was associated with older age (t = 3.10, P<0.01), higher HDRS-17 score (t = 5.76, P<0.01), and higher rates of non-adherence to HTN treatment (χ²  = 21.34, P<0.01). Logistic regression models indicated that adherence accounted for 39.4% of the total effect between depression and HTN. Specifically, those with poor adherence were at 1.417 greater odds of having their HTN uncontrolled compared with those with good adherence.

CONCLUSIONS

Hypertension control in older adults with depression is complicated by nonadherence to treatment. In addition to diagnosing and treating depression in their older adult patients, primary care physicians can optimize blood pressure control by identifying and addressing their patients' adherence to recommendations for HTN management.

Duchenne muscular dystrophy and caregiver burden: a systematic review

AIM

To conduct a systematic literature review of caregiver burden in Duchenne muscular dystrophy (DMD).

METHOD

We searched Embase, Web of Science, and PubMed for full-text articles reporting results from studies of caregiver burden in DMD.

RESULTS

We identified 483 unique publications. Of these, 450 were excluded after title and abstract screening, and 12 after full-text review. A total of 21 articles were included for data synthesis. Results encompassing more than 15 aspects of caregiver burden, investigated through surveys and/or interviews across 15 countries, were identified in the literature. Caregiving in DMD was frequently associated with impaired health-related quality of life, poor sleep quality, reduced family function, depression, pain, stress, sexual dysfunction, and/or lower self-esteem, as well as a considerable impact on work life and productivity.

INTERPRETATION

Providing informal care to a patient with DMD can be associated with a substantial burden. Yet, more research is needed to better understand the clinical implications of caregiving in DMD and the relationship between caregiver burden and the progression of the disease. Our data synthesis should be helpful in informing clinical and social support programmes directed to families caring for a patient with DMD.

WHAT THIS PAPER ADDS

A substantial body of evidence describes caregiver burden in Duchenne muscular dystrophy. Little is known of the family burden beyond caregivers' self-assessments.

Personal Income Before and After Diagnosis of Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is associated with serious morbidity and labor force absenteeism, but little is known of the long-term impact of the disease on personal income.

OBJECTIVES

To assess long-term consequences of MS on personal salary and disposable income.

METHODS

Patients with MS in Sweden were identified in a nationwide, disease-specific register and matched with general population controls. We assessed mean annual personal gross salary and disposable income each year before and after index (i.e., the MS diagnosis date) using data from national registers.

RESULTS

The final sample consisted of 5,472 patients and 54,195 controls (mean age 39 years; 70% females). There was no significant difference in gross salary between patients and controls in any year within the pre-index period. In contrast, on average during follow-up post diagnosis, patients with MS had €5,130 less gross salary per year compared with controls, ranging from a loss of €2,430 the first year to €9,010 after 11 years. Within 10 years after index, 45% of patients had at least one record of zero gross salary, compared with 32% for controls. Mean annual disposable income was comparable between patients and controls across follow-up, with significant differences only at years 9 and 10 post-index.

CONCLUSIONS

We show that many patients with MS in Sweden lose their ability to support for themselves financially but still have a relatively high disposable income because of social transfers. Our findings underscore the detrimental impact of MS on affected patients and the considerable economic burden of disease to society.

Defining and achieving permanency among older youth in foster care

Permanency is a key child welfare system goal for the children they serve. This study addresses three key research questions: (1) How do older youth in foster care define their personal permanency goals? (2) How much progress have these youth made in achieving their personal permanency goals and other aspects of relational permanency, and how does this vary by gender, race, and age? and (3) What transition-related outcomes are associated with relational permanency achievement? Surveys were conducted with 97 youth between the ages of 14 and 20 currently in care. Over three-fourths of participants had an informal/relational permanency goal; however, only 6.7% had achieved their goal. Of eight additional conceptualizations of relational permanency assessed, the one associated with achievement of the highest number of key transition outcomes was Sense of Family Belonging. The transition outcomes with the most associations with permanency achievement were physical health and mental health. Relational permanency is a highly personal part of the transition process for youth in care, warranting personalized supports to ensure individual youths' goals are being addressed in transition planning. Permanency achievement may also provide a foundation for supporting youth in achieving other key transition outcomes.

Community Program Improves Quality of Life and Self-Management in Older Adults with Diabetes Mellitus and Comorbidity

OBJECTIVES

To compare the effect of a 6-month community-based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities.

DESIGN

Multisite, single-blind, parallel, pragmatic, randomized controlled trial.

SETTING

Four communities in Ontario, Canada.

PARTICIPANTS

Community-dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159).

INTERVENTION

Client-driven, customized self-management program with up to 3 in-home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation.

MEASUREMENTS

Quality-of-life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES-D-10), Summary of Diabetes Self-Care Activities (SDSCA), Self-Efficacy for Managing Chronic Disease, and healthcare costs.

RESULTS

Morbidity burden was high (average of eight comorbidities). Intention-to-treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI) = 0.28-5.09, P = .03), SDSCA (mean difference = 3.79, 95% CI = 1.02-6.56, P = .01), and CES-D-10 (mean difference = -1.45, 95% CI = -0.13 to -2.76, P = .03). No group differences were seen in PCS score, anxiety, self-efficacy, or total healthcare costs.

CONCLUSION

Participation in a 6-month community-based intervention improved quality of life and self-management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs.

Prevalence and predictors of depressive symptoms among attendees of a tertiary care dermatology clinic in Muscat, Oman

BACKGROUND

Various studies have suggested that depression is more prevalent among patients with skin disorders than in the general population. Most of the studies addressing this subject involve Euro-American populations.

OBJECTIVES

The present study aimed to estimate the prevalence of depressive symptoms among patients with dermatological disorders and, then, to decipher the clinical-demographic factors associated with depressive symptoms.

METHODS

A cross-sectional analytical study was conducted among a random sample of patients attending a dermatology clinic in Muscat. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. A logistic regression model was used to find the adjusted and unadjusted odds ratios (ORs).

RESULTS

A total of 260 patients participated in this study, with a response rate of 81%. The prevalence of depression symptoms was 24%. According to regression analysis, family history of depression, comorbid medical disorders, and treatment with topicals or isotretinoin were significant predictors of depression (OR = 9.41, 95% confidence interval [CI]: 2.27-39.05, P = 0.002; OR = 2.0, 95% CI: 1.2-3.21, P = 0.05; OR = 2.28, 95% CI: 1.09-4.76, P = 0.028; and OR = 2.78; 95% CI: 1.08-7.19, P = 0.035, respectively).

CONCLUSION

This study indicates that depressive symptoms are common among patients with dermatological disorders in Oman, particularly in those with a family history of depression and medical comorbidities, and those who use a specific dermatological medication. Screening for depression in patients attending dermatology clinics is essential in order to detect and promptly treat patients suffering from depression.

The Potential Role for Group Psychotherapy in the Treatment of Internalized Homophobia in Gay Men

In order to develop a healthy sense of self, gay males must developmentally move beyond feelings of self-hatred concerning their homosexuality and conquer feelings of internalized homophobia. The struggle with internalized homophobia occurs throughout the lifespan and is detrimental to the physical and mental health of gay men. In order to spur the creation of interventions, a literature review was conducted to show how group psychotherapy could be of service in ameliorating the root causes of shame central to internalized homophobia. While the literature focused on the importance to gay men of feeling a sense of belonging within the gay community-a concept similar to group cohesion-as central to creating affective interventions, group psychotherapy has yet to be sufficiently explored quantitatively in the treatment of internalized homophobia.

Modeling multiple health behaviors and general health

Multiple Health Behavior Change assumes health behaviors are related to one another, although research evidence is mixed. More research is needed to understand which behaviors are most closely related and how they collectively predict health. Principle component analysis and structural equation modeling were used to establish a model showing relations between health behaviors, including fruit/vegetable consumption, aerobic and strength exercise, alcohol intake, and smoking, and how these behaviors relate to general physical and mental health functioning in a large, national sample. Although health behaviors were found to coalesce into a health-promoting factor of diet, and exercise, a better overall model fit was found when all behaviors were modeled as separate independent variables. Results suggest that health behaviors relate to one another in complex ways, with perceived health status serving as a mediating variable between specific health behaviors and a factor of physical and mental health. Future research should further investigate how other health behaviors relate to perceptions and overall health, especially among subpopulations.

The burden of generalized anxiety disorder in Canada

INTRODUCTION

Although generalized anxiety disorder (GAD) is common and disabling, there are few Canadian studies on this mental illness. We compared the characteristics, health status, health services use and health care needs of Canadians with GAD to those with depression.

METHODS

Data are from the 2012 Canadian Community Health Survey-Mental Health, which surveyed a nationally representative sample of Canadians aged 15 years and older (n = 23 709; response rate of 68.9%). The respondents we studied had selfreported symptoms compatible with GAD and/or major depressive episode (MDE) in the preceding 12 months (n = 1598). Estimates were weighted to represent the Canadian household population. We performed descriptive and multinomial multivariate logistic regression analyses.

RESULTS

In 2012, an estimated 700 000 (2.5%) Canadians aged 15 years and older reported symptoms compatible with GAD in the previous 12 months. MDE symptoms co-occurred in 50% of these individuals. Those with GAD only reported fair/poor perceived health (29.7%), moderate to severe psychological distress (81.2%) and moderate to severe disability (28.1%) comparable to (or even slightly worse) than those with MDE only (24.7%, 78.8% and 24.8% respectively). Those with comorbid GAD and MDE demonstrated the worst health outcomes; 47.3% of them reported fair/poor perceived health, 94.0% reported moderate to severe psychological distress and 52.4% reported moderate to severe disability. Nearly 50% of those with comorbid GAD and MDE reported that their need for health care was not met or only partially met, compared to about 30% of those with GAD or MDE only.

CONCLUSION

While GAD is associated with levels of distress and disability comparable to (or slightly worse) than those affected by MDE only, the health status of those with comorbid disease is significantly worse than those with GAD or MDE only. Improved diagnosis, screening for comorbidity and management are essential to minimize the impacts of this mental illness.

Multimorbidity and health-related quality of life (HRQoL) in a nationally representative population sample: implications of count versus cluster method for defining multimorbidity on HRQoL

Background

No universally accepted definition of multimorbidity (MM) exists, and implications of different definitions have not been explored. This study examined the performance of the count and cluster definitions of multimorbidity on the sociodemographic profile and health-related quality of life (HRQoL) in a general population.

Methods

Data were derived from the nationally representative 2007 Australian National Survey of Mental Health and Wellbeing (n = 8841). The HRQoL scores were measured using the Assessment of Quality of Life (AQoL-4D) instrument. The simple count (2+ & 3+ conditions) and hierarchical cluster methods were used to define/identify clusters of multimorbidity. Linear regression was used to assess the associations between HRQoL and multimorbidity as defined by the different methods.

Results

The assessment of multimorbidity, which was defined using the count method, resulting in the prevalence of 26% (MM2+) and 10.1% (MM3+). Statistically significant clusters identified through hierarchical cluster analysis included heart or circulatory conditions (CVD)/arthritis (cluster-1, 9%) and major depressive disorder (MDD)/anxiety (cluster-2, 4%). A sensitivity analysis suggested that the stability of the clusters resulted from hierarchical clustering. The sociodemographic profiles were similar between MM2+, MM3+ and cluster-1, but were different from cluster-2. HRQoL was negatively associated with MM2+ (β: −0.18, SE: −0.01, p < 0.001), MM3+ (β: −0.23, SE: −0.02, p < 0.001), cluster-1 (β: −0.10, SE: 0.01, p < 0.001) and cluster-2 (β: −0.36, SE: 0.01, p < 0.001).

Conclusions

Our findings confirm the existence of an inverse relationship between multimorbidity and HRQoL in the Australian population and indicate that the hierarchical clustering approach is validated when the outcome of interest is HRQoL from this head-to-head comparison. Moreover, a simple count fails to identify if there are specific conditions of interest that are driving poorer HRQoL. Researchers should exercise caution when selecting a definition of multimorbidity because it may significantly influence the study outcomes.

Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis

BACKGROUND

The need for effective interventions to improve mental health and emotional well-being at a population level are gaining prominence both in the United Kingdom and globally. Advances in technology and widespread adoption of Internet capable devices have facilitated rapid development of Web-delivered psychological therapies. Interventions designed to manage a range of affective disorders by applying diverse therapeutic approaches are widely available.

OBJECTIVE

The main aim of this review was to evaluate the evidence base of acceptance and commitment therapy (ACT) in a Web-based delivery format.

METHOD

A systematic review of the literature and meta-analysis was conducted. Two electronic databases were searched for Web-delivered interventions utilizing ACT for the management of affective disorders or well-being. Only Randomized Controlled Trials (RCTs) were included.

RESULTS

The search strategy identified 59 articles. Of these, 10 articles met the inclusion criteria specified. The range of conditions and outcome measures that were identified limited the ability to draw firm conclusions about the efficacy of Web-delivered ACT-based intervention for anxiety or well-being.

CONCLUSIONS

ACT in a Web-based delivery format was found to be effective in the management of depression. Rates of adherence to study protocols and completion were high overall suggesting that this therapeutic approach is highly acceptable for patients and the general public.

The Microbiome and Mental Health: Looking Back, Moving Forward with Lessons from Allergic Diseases

Relationships between gastrointestinal viscera and human emotions have been documented by virtually all medical traditions known to date. The focus on this relationship has waxed and waned through the centuries, with noted surges in interest driven by cultural forces. Here we explore some of this history and the emerging trends in experimental and clinical research. In particular, we pay specific attention to how the hygiene hypothesis and emerging research on traditional dietary patterns has helped re-ignite interest in the use of microbes to support mental health. At present, the application of microbes and their structural parts as a means to positively influence mental health is an area filled with promise. However, there are many limitations within this new paradigm shift in neuropsychiatry. Impediments that could block translation of encouraging experimental studies include environmental forces that work toward dysbiosis, perhaps none more important than westernized dietary patterns. On the other hand, it is likely that specific dietary choices may amplify the value of future microbial-based therapeutics. Pre-clinical and clinical research involving microbiota and allergic disorders has predated recent work in psychiatry, an early start that provides valuable lessons. The microbiome is intimately connected to diet, nutrition, and other lifestyle variables; microbial-based psychopharmacology will need to consider this contextual application, otherwise the ceiling of clinical expectations will likely need to be lowered.

Quantifying the burden of caregiving in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a rare pediatric neuromuscular disease associated with progressive muscle degeneration and extensive care needs. Our objective was to estimate the caregiver burden associated with DMD. We made cross-sectional assessments of caregiver health-related quality of life (HRQL) and burden using the EuroQol EQ-5D, a Visual Analogue Scale (VAS), the SF-12 Health Survey, and the Zarit Caregiver Burden Interview (ZBI) administered online. Results were stratified by disease stage (early/late ambulatory/non-ambulatory) and caregivers’ rating of patients’ health and mental status. In total, caregivers to 770 patients participated. Mean EQ-5D utility ranged between 0.85 (95 % CI 0.82–0.88) and 0.77 (0.74–0.80) across ambulatory classes and 0.88 (0.85–0.90) and 0.57 (0.39–0.74) across caregivers’ rating of patients’ health and mental status. Mean VAS score was 0.74 (0.73–0.75), mean SF-12 Mental Health Component Summary score 44 (43–45), and mean ZBI score 29 (28–30). Anxiety and depression, recorded in up to 70 % of caregivers depending on patients’ health and mental status, was significantly associated with annual household cost burden (>$5000 vs. <$1000, odds ratio 1.76, 95 % CI 1.18–2.63) and hours of leisure time devoted to informal care per week (25–50 vs. <25 h 2.01, 1.37–2.94; >50 vs. <25 h 3.35, 2.32–4.83) (p < 0.007). We show that caring for a person with DMD can be associated with a substantial burden and impaired HRQL. Our findings suggest that caregivers to patients with DMD should be screened for depression and emphasize the need for a holistic approach to family mental health in the context of chronic childhood disease.

Impact of universal health coverage on urban-rural inequity in psychiatric service utilisation for patients with first admission for psychosis: a 10-year nationwide population-based study in Taiwan

OBJECTIVE

To examine the disparities in psychiatric service utilisation over a 10-year period for patients with first admission for psychosis in relation to urban-rural residence following the implementation of universal health coverage in Taiwan.

DESIGN

Population-based retrospective cohort study.

SETTING

Taiwan's National Health Insurance Research Database, which has a population coverage rate of over 99% and contains all medical claim records of a nationwide cohort of patients with at least one psychiatric admission between 1996 and 2007.

PARTICIPANTS

69,690 patients aged 15-59 years with first admission between 1998 and 2007 for any psychotic disorder.

MAIN EXPOSURE MEASURE

Patients' urban-rural residence at first admissions.

MAIN OUTCOME MEASURES

Absolute and relative inequality indexes of the following quality indicators after discharge from the first admission: all-cause psychiatric readmission at 2 and 4 years, dropout of psychiatric outpatient service at 30 days, and emergency department (ED) treat-and-release encounter at 30 days.

RESULTS

Between 1998 and 2007, the 4-year readmission rate decreased from 65% to 58%, the 30-day dropout rate decreased from 18% to 15%, and the 30-day ED encounter rate increased from 8% to 10%. Risk of readmission has significantly decreased in rural and urban patients, but at a slower speed for the rural patients (p=0.026). The adjusted HR of readmission in rural versus urban patients has increased from 1.00 (95% CI 0.96 to 1.04) in 1998-2000 to 1.08 (95% CI 1.03 to 1.12) in 2005-2007, indicating a mild widening of the urban-rural gap. Urban-rural differences in 30-day dropout and ED encounter rates have been stationary over time.

CONCLUSIONS

The universal health coverage in Taiwan did not narrow urban-rural inequity of psychiatric service utilisation in patients with psychosis. Therefore, other policy interventions on resource allocation, service delivery and quality of care are needed to improve the outcome of rural-dwelling patients with psychosis.

Recovering function and surviving treatments are primary motivators for health behavior change in patients with head and neck cancer: Qualitative focus group study

Objective:

Against medical advice, head and neck cancer (HNC) patients have been shown to continue to smoke and misuse alcohol post-diagnosis and treatment. This study aimed to better understand the barriers to and facilitators of health behavior change (HBC) in HNC patients.

Method:

We conducted nine focus groups following a standard protocol. Eligible patients were diagnosed less than three years previously with a primary HNC and selected using maximum variability sampling (gender, age, cancer stage, smoking, and alcohol misuse). Thematic analysis was conducted using NVivo 10 software.

Results:

Participants were mostly men (79%), 65 years of age (SD = 10.1), and married/common-law (52%, n = 15). Mean time from diagnosis was 19 months (SD = 12.3, range = 5.0–44.5), and most had advanced cancer (65.5%, n = 19). Participants provided a larger than anticipated definition of health behaviors, encompassing both traditional (smoking, drinking, diet, exercise, UV protection) and HNC-related (e.g., dental hygiene, skin care, speech exercises, using a PEG, gaining weight). The main emerging theme was patient engagement, that is, being proactive in rehabilitation, informed by the medical team, optimistic, flexible, and seeking support when needed. Patients were primarily motivated to stay proactive and engage in positive health behaviors in order to return to normal life and reclaim function, rather than to prevent a cancer recurrence. Barriers to patient engagement included emotional aspects (e.g., anxiety, depression, trauma, demoralization), symptoms (e.g., fatigue, pain), lack of information about HBC, and healthcare providers' authoritarian approach in counseling on HBC. We found some commonalities in barriers and facilitators according to behavior type (i.e., smoking/drinking/UV protection vs. diet/exercise).

Significance of Results:

This study underlines the key challenges in addressing health behaviors in head and neck oncology, including treatment-related functional impairments, symptom burden, and the disease's emotional toll. This delicate context requires health promotion strategies involving close rehabilitative support from a multidisciplinary team attentive to the many struggles of patients both during treatments and in the longer-term recovery period. Health promotion in HNC should be integrated into routine clinical care and target both traditional and HNC-related behaviors, emphasizing emotional and functional rehabilitation as key components.

Brief screening for depression and anxiety in vision and other rehabilitation services

The field of physical and sensory rehabilitation is broad, covering a wide variety of health presentations and intervention processes. There is persuasive evidence that unrecognised and untreated mental health disorders, such as depression and anxiety, can have a major impact on physical health status and rehabilitation outcomes across all areas of practice. It is important to have systems in place for the efficient detection and effective treatment of psychological difficulties. This article considers the role of brief mental health screening measures in case identification, with particular focus on brief mental health screening in vision rehabilitation services. As screening is now regarded as part of evidence-based best practice, the authors also consider issues that affect tool selection and implementation.