"One size does not fit all" - lessons learned from a multiple-methods study of a resident wellness curriculum across sites and specialties

BACKGROUND

There is growing recognition that wellness interventions should occur in context and acknowledge complex contributors to wellbeing, including individual needs, institutional and cultural barriers to wellbeing, as well as systems issues which propagate distress. The authors conducted a multiple-methods study exploring contributors to wellbeing for junior residents in diverse medical environments who participated in a brief resilience and stress-reduction curriculum, the Stress Management and Resiliency Training Program for Residents (SMART-R).

METHODS

Using a waitlist-controlled design, the curriculum was implemented for post-graduate year (PGY)-1 or PGY-2 residents in seven residency programs across three sites. Every three months, residents completed surveys, including the Perceived Stress Scale-10, General Self-Efficacy Questionnaire, a mindfulness scale (CAMSR), and a depression screen (PHQ-2). Residents also answered free-text reflection questions about psychological wellbeing and health behaviors.

RESULTS

The SMART-R intervention was not significantly associated with decreased perceived stress. Linear regression modeling showed that depression was positively correlated with reported stress levels, while male sex and self-efficacy were negatively correlated with stress. Qualitative analysis elucidated differences in these groups: Residents with lower self-efficacy, those with a positive depression screen, and/or female residents were more likely to describe experiencing lack of control over work. Residents with higher self-efficacy described more positive health behaviors. Residents with a positive depression screen were more self-critical, and more likely to describe negative personal life events.

CONCLUSIONS

This curriculum did not significantly modify junior residents' stress. Certain subpopulations experienced greater stress than others (female residents, those with lower self-efficacy, and those with a positive depression screen). Qualitative findings from this study highlight universal stressful experiences early in residency, as well as important differences in experience of the learning environment among subgroups. Tailored wellness interventions that aim to support diverse resident sub-groups may be higher yield than a "one size fits all" approach.

TRIAL REGISTRATION

NCT02621801 , Registration date: December 4, 2015 - Retrospectively registered.

A SMART approach to reducing paroxysmal atrial fibrillation symptoms: Results from a pilot randomized controlled trial

Background

Stress and negative emotions contribute to atrial fibrillation (AF). Mind-body practices decrease stress and negative emotions and may reduce AF episodes and improve quality of life for patients with AF.

Objective

We examined the effects of a multimodal mind-body program, the SMART Program, on AF-related quality of life in patients with paroxysmal AF (PAF).

Methods

In this randomized, waitlist-controlled pilot trial, 18 subjects with PAF participated in an 8-week SMART Program delivered online immediately or 3 months later. Validated measures were completed at baseline and at 3 and 6 months (waitlist group only).

Results

Comparing pre- vs post-program scores among all 18 participants, subjects reported improvement in AF-related quality of life (Cohen’s d = 0.75, P = .005) and depression (d = 0.50, P = .05) but not anxiety (d = 0.35, P = .16). Subjects also reported improvements in AF symptom severity (P = .026), distress (P = .014), positive affect (P = .003), and ability to cope with stress (P = .001). Compared to waitlist control subjects, those in the immediate group reported improvement in positive affect (d = 1.20, P = .021) and coping with stress (d = 1.36, P = .011) after participating in the program.

Conclusion

The SMART Program, delivered virtually, may enhance positive emotions and coping with stress as well as decrease negative emotions and AF symptoms. These results warrant a larger trial to better understand the potential benefits of such programs for patients with PAF.

Qigong for the Prevention, Treatment, and Rehabilitation of COVID-19 Infection in Older Adults

The elderly are at high risk of contracting respiratory infectious diseases, including COVID-19 infection. The recent pandemic has the potential to cause significant physical and mental damage in older adults. Similarly to other mind-body exercises in Traditional Chinese medicine, Qigong features regulation of breath rhythm and pattern, body movement and posture, and meditation. Given these traits, Qigong has the potential to play a role in the prevention, treatment, and rehabilitation of respiratory infections, such as COVID-19. Potential mechanisms of action include stress reduction, emotion regulation, strengthening of respiratory muscles, reduction of inflammation, and enhanced immune function. Three forms of Qigong; abdominal breathing, Ba Duan Jin and Liu Zi Jue, all of which are gentle, smooth, and simple for the elderly to practice, are recommended in this context.

Greater Neurobiological Resilience to Chronic Socioeconomic or Environmental Stressors Associates With Lower Risk for Cardiovascular Disease Events

BACKGROUND

Chronic exposure to socioeconomic or environmental stressors associates with greater stress-related neurobiological activity (ie, higher amygdalar activity [AmygA]) and higher risk of major adverse cardiovascular events (MACE). However, among individuals exposed to such stressors, it is unknown whether neurobiological resilience (NBResilience, defined as lower AmygA despite stress exposure) lowers MACE risk. We tested the hypotheses that NBResilience protects against MACE, and that it does so through decreased bone marrow activity and arterial inflammation.

METHODS

Individuals underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomography; AmygA, bone marrow activity, and arterial inflammation were quantified. Chronic socioeconomic and environmental stressors known to associate with AmygA and MACE (ie, transportation noise exposure, neighborhood median household income, and crime rate) were quantified. Heightened stress exposure was defined as exposure to at least one chronic stressor (ie, the highest tertile of noise exposure or crime or lowest tertile of income). MACE within 5 years of imaging was adjudicated. Relationships were evaluated using linear and Cox regression, Kaplan-Meier survival, and mediation analyses.

RESULTS

Of 254 individuals studied (median age [interquartile range]: 57 years [46-67], 36.7% male), 166 were exposed to at least one chronic stressor. Among stress-exposed individuals, 12 experienced MACE over a median follow-up of 3.75 years. Among this group, higher AmygA (ie, lower resilience) associated with higher bone marrow activity (standardized β [95% CI]: 0.192 [0.030-0.353], P=0.020), arterial inflammation (0.203 [0.055-0.351], P=0.007), and MACE risk (standardized hazard ratio [95% CI]: 1.927 [1.370-2.711], P=0.001). The effect of NBResilience on MACE risk was significantly mediated by lower arterial inflammation (P<0.05).

CONCLUSIONS

Among individuals who are chronically exposed to socioeconomic or environmental stressors, NBResilience (AmygA <1 SD above the mean) associates with a >50% reduction in MACE risk, potentially via reduced arterial inflammation. These data raise the possibility that enhancing NBResilience may decrease the burden of cardiovascular disease.

Systematic review of burnout among healthcare providers in sub-Saharan Africa

BACKGROUND

Burnout is characterized by physical and emotional exhaustion from long-term exposure to emotionally demanding work. Burnout affects interpersonal skills, job performance, career satisfaction, and psychological health. However, little is known about the burden of burnout among healthcare providers in sub-Saharan Africa.

METHODS

Relevant articles were identified through a systematic review of PubMed, Web of Science (Thomson Reuters), and PsycINFO (EBSCO). Studies were selected for inclusion if they examined a quantitative measure of burnout among healthcare providers in sub-Saharan Africa.

RESULTS

A total of 65 articles met our inclusion criteria for this systematic review. Previous studies have examined burnout in sub-Saharan Africa among physicians (N = 12 articles), nurses (N = 26), combined populations of healthcare providers (N = 18), midwives (N = 2), and medical or nursing students (N = 7). The majority of studies assessed burnout using the Maslach Burnout Inventory. The highest levels of burnout were reported among nurses, although all healthcare providers showed high burnout. Burnout among healthcare providers is associated with their work environments, interpersonal and professional conflicts, emotional distress, and low social support.

CONCLUSIONS

Available studies on this topic are limited by several methodological challenges. More rigorously designed epidemiologic studies of burnout among healthcare providers are warranted. Health infrastructure improvements will eventually be essential, though difficult to achieve, in under-resourced settings. Programs aimed at raising awareness and coping with burnout symptoms through stress management and resilience enhancement trainings are also needed.

A mind-body program for pain and stress management in active duty service members and veterans

The Mind-Body Medicine (MBM) program at the Naval Medical Center San Diego, created in collaboration with the Benson-Henry Institute for Mind Body Medicine and the Home Base Program at Massachusetts General Hospital, is a 7-week program designed to facilitate stress management habits into patient treatment plans. The aim of this study is to test the feasibility and acceptability of a mind-body program for service members and veterans. Participants (N = 239) were primarily active duty service members of the U.S. Navy and Marine Corps reporting significant perceived stress (Stress Resiliency (SR) group; n = 124), or meeting criteria for chronic pain (Pain Management (PM) group; n = 115). Participants completed measures at preprogram and post-program assessing for perceived stress, pain, functional impairment, quality of life, and psychological and somatic symptoms. Changes in self-reported psychological symptoms and knowledge and practice of mind-body principles were examined. Participants across groups had significant improvement in most outcomes (perceived stress, response to stressful experience, functional impairment, sleep disturbance, depression, PTSD, and anxiety symptoms; and each quality of life domain aside from social relationships), with p values < .0017 (Bonferroni corrected level of significance). The SR group demonstrated significant improvements in primary outcomes of perceived stress and response to stressful experience, and the PM group demonstrated significant improvement in pain severity, but not perceived stress. Significant change was observed in knowledge and practice of mind-body medicine principles, and high satisfaction was reported. Results suggest that a mind-body program may improve physical and psychological functioning for service members, including those facing significant perceived stress and chronic pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Mobile Videoconference-Based Intervention on Stress Reduction and Resilience Enhancement in Employees: Randomized Controlled Trial

BACKGROUND

Videoconferencing-based treatments have shown great potential in increasing engagement and compliance by decreasing the barriers of time and distance. In general, employees tend to experience a lot of stress, but find it difficult to visit a clinic during office hours.

OBJECTIVE

The purpose of this study was to investigate the effectiveness of a mobile videoconference-based intervention for stress reduction and resilience enhancement in employees.

METHODS

In total, 81 participants were randomly allocated to one of the three conditions: mobile videoconferencing, in-person, and self-care; of these, 72 completed the study. All participants underwent assessment via self-reported questionnaires before, immediately after, and 1 month after the intervention. Intervention lasted for 4 weeks and consisted of elements of cognitive behavioral therapy, positive psychology, and meditation. Changes in clinical variables regarding stress and resilience across time were compared between treatment conditions.

RESULTS

There were significant condition × time effects on variables measuring perceived stress, resilience, emotional labor, and sleep, demonstrating significantly differential effects across time according to treatment condition. Moreover, there were significant effects of condition on perceived stress and occupational stress. There were no significant differences in any variable between the mobile videoconferencing and in-person conditions at 1 month after the intervention.

CONCLUSIONS

Results indicate that both mobile videoconferencing and in-person interventions were comparably effective in decreasing stress and enhancing resilience. Further studies with a larger sample size and a longer follow-up period are warranted to investigate the long-term effect of mobile videoconferencing interventions.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03256682; https://clinicaltrials.gov/ct2/show/NCT03256682 (Archived by WebCite at http://www.webcitation.org/71W77bwnR).

A Qualitative Analysis of Stress and Relaxation Themes Contributing to Burnout in First-Year Psychiatry and Medicine Residents

OBJECTIVE

Qualitative research on trainee well-being can add nuance to the understanding of propagators of burnout, and the role for interventions aimed at supporting well-being. This qualitative study was conducted to identify (i) situations and environments that cause stress for trainees, (ii) stress-reducing activities that trainees utilize, and (iii) whether trainees who report distress (high burnout and depression scores) describe different stressors and relaxation factors than those who do not.

METHODS

The study was conducted with a convenience sample of first-year medicine and psychiatry residents at a large urban teaching hospital. Participants were asked to complete electronic stress and relaxation diaries daily for 1 week. Diary entries were coded for recurrent themes. Participants were screened for burnout and depression. Codes were compared by subgroup based on baseline burnout and depression status to elucidate if specific themes emerged in these subgroups.

RESULTS

Study sample included 51 interns. Sixteen (16/50, 32%) screened positive for burnout and three (3/50, 14%) had a positive depression screen. The most common stressors related to aspects of the learning environment, compounded by feeling under-equipped, overwhelmed, or out of time. The majority of relaxation activities involved social connection, food, other comforts, and occurred outside of the hospital environment.

CONCLUSIONS

This study reveals that interns (regardless of burnout or depression screen) identify stressors that derive primarily from organizational, interpersonal, and cultural experiences of the learning environment; whereas relaxation themes are diversely represented across realms (home, leisure, social, health), though emphasize activities that occur outside of the work place.

Total Lifestyle Coaching: A Pilot Study Evaluating the Effectiveness of a Mind-Body and Nutrition Telephone Coaching Program for Obese Adults at a Community Health Center

BACKGROUND

Stress and obesity are interrelated and common among low-income adults. Mind-body interventions have been shown to reduce psychological distress and have been incorporated into many weight loss interventions. However, few of these programs have incorporated a telephone coaching component.

OBJECTIVE

We designed and piloted a novel weight loss telephone coaching intervention for this population and examined its effectiveness on weight loss and improvements in health behaviors in obese community health center patients.

METHODS

This was a 6-month, single-arm, prospective, pre-post pilot study. The study took place at a community health center near Boston, Massachusetts. Participants were 27 overweight and obese community health center patients. The intervention consisted of one in-person intake with the registered dietitian, trained in mind-body approaches, and approximately 1 phone coaching session every 2 weeks for 6 consecutive months. Anthropometric data consisted of weight, body mass index (BMI), and blood pressure. Questionnaires consisted of the Perceived Stress Scale-10 item, the CIGNA Healthy Eating Survey, Section H: Behavioral Eating, a physical activity questionnaire, and a nutritional habits questionnaire. We used paired samples t tests to assess pre-post changes in weight, BMI, blood pressure, perceived stress, behavioral eating, and physical activity. We also conducted semistructured exit interviews to learn about participants' experiences in this program.

RESULTS

There was a trend toward weight reduction (P < .1, Cohen's d = 0.33) and significant improvements in systolic blood pressure (P = .001, Cohen's d = 0.72), perceived stress (P = .001, Cohen's d = 0.75), and behavioral eating (P = .009, Cohen's d = 0.54). Improvements in weight were sustained 6 months after completion of the intervention.

CONCLUSION

Results suggest that a telephone nutrition health coaching intervention is feasible and may facilitate weight loss in obese community health center patients. Future randomized-controlled studies are warranted to better understand these improvements.

CLINICALTRIALSGOV REGISTRATION

NCT03025217.

Specific Transcriptome Changes Associated with Blood Pressure Reduction in Hypertensive Patients After Relaxation Response Training

OBJECTIVE

Mind-body practices that elicit the relaxation response (RR) have been demonstrated to reduce blood pressure (BP) in essential hypertension (HTN) and may be an adjunct to antihypertensive drug therapy. However, the molecular mechanisms by which the RR reduces BP remain undefined.

DESIGN

Genomic determinants associated with responsiveness to an 8-week RR-based mind-body intervention for lowering HTN in 13 stage 1 hypertensive patients classified as BP responders and 11 as nonresponders were identified.

RESULTS

Transcriptome analysis in peripheral blood mononuclear cells identified 1771 genes regulated by the RR in responders. Biological process- and pathway-based analysis of transcriptome data demonstrated enrichment in the following gene categories: immune regulatory pathways and metabolism (among downregulated genes); glucose metabolism, cardiovascular system development, and circadian rhythm (among upregulated genes). Further in silico estimation of cell abundance from the microarray data showed enrichment of the anti-inflammatory M2 subtype of macrophages in BP responders. Nuclear factor-κB, vascular endothelial growth factor, and insulin were critical molecules emerging from interactive network analysis.

CONCLUSIONS

These findings provide the first insights into the molecular mechanisms that are associated with the beneficial effects of the RR on HTN.

SMART-R: A Prospective Cohort Study of a Resilience Curriculum for Residents by Residents

OBJECTIVE

This study aimed to determine the feasibility of a resident-led resiliency curriculum developed by residents, for residents.

METHODS

The Stress Management and Resiliency Training Program for Residents (SMART-R) is a 6-h group-based curriculum that teaches meditation, behavioral skills, and positive perspective-taking strategies. SMART-R was implemented for all medicine and psychiatry interns at a large US teaching hospital during the first 6 months of internship. Risk and resilience factors for burnout were assessed before and after the curriculum. A wearable health-tracking device was used to assess feasibility of wearables for studying resident health behaviors.

RESULTS

All 73 medicine and 17 psychiatry interns participated in the SMART-R curriculum. Seventy-five of 85 interns (88%) consented to be in the study. Thirty-one of 75 (41%) completed both baseline and post surveys of risk and resilience factors for burnout. Preliminary curriculum feedback was enthusiastic. Twenty-five of 62 (40%) wore the health tracker more than half the time in the first 3 months of the study.

CONCLUSIONS

Implementation of a resident-led resiliency curriculum for internal medicine and psychiatry interns at an academic medical center during the most challenging first months of internship is feasible. Future controlled studies are needed to determine efficacy of SMART-R on risk and resilience factors. Over the first 6 months of internship, we observed an expected increase in burnout, fatigue, and depression, though other key risk and resilience factors were unchanged.

Psychosocial effects of the relaxation response resiliency program (SMART-3RP) in patients with MGUS and smoldering multiple myeloma: A waitlist controlled randomized clinical trial

10051

Background: Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) are asymptomatic clonal precursors to multiple myeloma, a hematological malignancy. Because observation is currently the standard of care, a diagnosis of MGUS or SMM can be associated with stress and worry about progression. We evaluated the efficacy of the evidence-based mind-body intervention, the Stress Management and Resiliency Training: Relaxation Response Resiliency Program (SMART-3RP) in reducing distress and stress reactivity in patients with MGUS and SMM. Methods: In participants diagnosed with intermediate or high risk MGUS or SMM, this randomized, waitlist controlled trial (Oct 2013 – Sep 2016) assessed distress (10-point scale) as the primary outcome and perceived stress (PSS-10), stress reactivity (MOCS-A), and mindfulness (FFMQ) as secondary outcomes and hypothesized mediators of distress reduction. We collected self-report measures at enrollment (T1), 3 months (T2), and 6 months (T3). The immediate treatment arm received the 8-session, 1.5 hour/week SMART-3RP group intervention from T1 to T2 and continued practicing skills from T2 to T3; the waitlist arm received the intervention from T2 to T3. Results: 93 participants (59% women) diagnosed with MGUS (n = 49) or SMM (n = 44) were randomized to immediate treatment (n = 45) or waitlist (n = 48). In an ITT analysis of immediate SMART-3RP vs. waitlist (T1-T2), we found significantly greater improvement in distress (-1.4 vs. -0.3, p = .04) and stress reactivity (0.39 vs. 0.02, p < .001), but not perceived stress (-3.9 vs. -2.2, p = .12) or mindfulness (2.4 vs. -0.1, p = .17). Improvements in stress reactivity were maintained for the immediate treatment group (T2-T3), but only partially for distress. Conclusions: The SMART-3RP, compared to waitlist, reduced distress in participants with intermediate or high-risk MGUS and SMM, with improvements in stress reactivity as a primary mediator of distress reduction. Participants strongly endorsed the intervention’s ability to enhance coping and reduce distress. Clinical trial information: NCT01955395.

A Pilot, Randomized Controlled Study of Tai Chi With Passive and Active Controls in the Treatment of Depressed Chinese Americans

OBJECTIVE

This pilot, randomized clinical trial investigates the effectiveness of tai chi as the primary treatment for Chinese Americans with major depressive disorder (MDD).

METHODS

67 Chinese Americans with DSM-IV MDD and no treatment for depression were recruited between March 2012 and April 2013 and randomized (1:1:1) into a tai chi intervention, an education program, or a waitlisted group for 12 weeks. The primary outcome measure was the 17-item Hamilton Depression Rating Scale (HDRS₁₇); positive response for this outcome was defined as a decrease in total score of 50% or more, and remission was defined as HDRS₁₇ ≤ 7.

RESULTS

Participants (N = 67) were 72% female with a mean age of 54 ± 13 years. No serious adverse events were reported. After the end of the 12-week intervention, response rates were 25%, 21%, and 56%, and remission rates were 10%, 21%, and 50% for the waitlisted, education, and tai chi intervention groups, respectively. The tai chi group showed improved treatment response when compared to both the waitlisted group (odds ratio [OR] = 2.11; 95% CI, 1.01-4.46) and to the education group (OR = 8.90; 95% CI, 1.17-67.70). Tai chi intervention showed significantly improved remission rate over the waitlisted group (OR = 3.01; 95% CI, 1.25-7.10), and a trend of improved remission compared to the education group (OR = 4.40; 95% CI, 0.78-24.17).

CONCLUSIONS

As the primary treatment, tai chi improved treatment outcomes for Chinese Americans with MDD over both passive and active control groups.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01619631.

Risk and Resilience Factors Associated with Resident Burnout

OBJECTIVE

We investigated hypothesized risk and resilience factors and their association with burnout in first year medicine and psychiatry residents at an urban teaching hospital in order to help guide the development of interventions targeted at reducing burnout.

METHODS

We administered the Maslach Burnout Inventory (MBI), Perceived Stress Scale-10, Functional Assessment of Chronic Illness Therapy-Fatigue Scale, Penn State Worry Questionnaire, Patient Health Questionnaire-9 (depression symptoms), Revised Life Orientation Test (optimism), Self-Efficacy Questionnaire, Cognitive and Affective Mindfulness Scale, Interpersonal Reactivity Index Perspective-Taking Scale (empathy), and Measure of Current Status-Part A to first year medicine and psychiatry residents prior to initiation of clinical rotations in June.

RESULTS

The response rate was 91 % (68 of 75 residents). Nineteen respondents (28 %) met criteria for burnout as measured by the MBI. Residents with burnout scored higher on self-report measures assessing perceived stress (Cohen's d = 0.97; p = 0.004), fatigue (d = 0.79; p = 0.018), worry (d = 0.88; p = 0.0009), and depression symptoms (d = 0.84; p = 0.035) and scored lower on questionnaires assessing mindfulness (d = -0.63; p = 0.029) and coping ability (d = -0.79; p = 0.003).

CONCLUSIONS

In a cross-sectional assessment using self-report measures, we found that nearly a third of first year residents prior to starting their internships experience burnout. They exhibit lower levels of mindfulness and coping skills and higher levels of depression symptoms, fatigue, worry, and stress. These preliminary findings should encourage programs to initiate and study curricula that combine mindfulness and self-awareness coping strategies to enhance or protect against burnout as well as cognitive behavioral coaching strategies to offset symptoms of burnout when present.

Mind-body group treatment for women coping with infertility: a pilot study

OBJECTIVES

To evaluate the feasibility of a 10-week mind-body intervention (MBI) for women coping with fertility challenges, examine the impact of an MBI on psychological distress and cortisol levels, and assess adherence to MBI skills 12-months after completion of the intervention.

DESIGN

Prospective open pilot study of 51 women with infertility enrolled in a group MBI. Psychological variables and salivary cortisol levels were obtained pre- and post-intervention; a 12-month follow-up survey assessed MBI skill adherence. Participants completed practice logs throughout the intervention.

RESULTS

Participants attended an average of eight sessions (SD = 2.0), and practiced mind-body techniques which elicited the relaxation response (RR) an average of 5.9 (SD = 0.8) days/week and 20.1 (SD = 9.9) min/day; 80% completed the post-treatment assessment. The intervention resulted in a significant increase in perceived social support and a decrease in depressive symptoms and perceived stress; however, there were no significant changes in cortisol levels. Sixty-eight percent of the participants completed the 12-month follow-up, with 51% reporting continuation of RR-eliciting practice.

CONCLUSION

This group of women with infertility provided with an MBI showed decreased symptoms of depression and stress and increased perceived social support. The protocol was feasible and participants reported a high degree of adherence and maintenance to the skills taught during the intervention. The findings indicate the value of appropriate evaluation against a control group.

Building Resiliency in a Palliative Care Team: A Pilot Study

CONTEXT

Palliative care clinicians (PCCs) are vulnerable to burnout as a result of chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population.

OBJECTIVES

This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians, a program targeted to decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N = 16) at a major academic medical center.

METHODS

A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using nonparametric statistical tests. Effect size was quantified using Cohen's d.

RESULTS

The intervention was feasible; all participants attended at least four of the five sessions, and there was no attrition. After the intervention, participants showed reductions in perceived stress and improvements in perspective taking.

CONCLUSION

Our findings suggest that a novel team-based resiliency intervention based on elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.

A Case Report of Improvement in Crohn's Disease-related Symptoms Following Participation in a Comprehensive Mind-Body Program

Stress is widely believed to play a role in the development and pathogenesis of inflammatory bowel disease (IBD), and several studies of mind-body programs have suggested benefits in this patient population. Here we describe a case report of a young man with a flare in Crohn's disease-related symptoms that improved in response to a comprehensive, multi-modal, mind-body program and the development of a novel IBD treatment center that incorporates mind-body approaches, nutrition, and other modalities to provide more holistic and patient-centered care for individuals with IBD.

Open and Calm--a randomized controlled trial evaluating a public stress reduction program in Denmark

Background

Prolonged psychological stress is a risk factor for illness and constitutes an increasing public health challenge creating a need to develop public interventions specifically targeting stress and promoting mental health. The present randomized controlled trial evaluated health effects of a novel program: Relaxation-Response-based Mental Health Promotion (RR-MHP).

Methods

The multimodal, meditation-based course was publicly entitled “Open and Calm” (OC) because it consistently trained relaxed and receptive (“Open”) attention, and consciously non-intervening (“Calm”) witnessing, in two standardized formats (individual or group) over nine weeks. Seventy-two participants who complained to their general practitioner about reduced daily functioning due to prolonged stress or who responded to an online health survey on stress were randomly assigned to OC formats or treatment as usual, involving e.g., unstandardized consultations with their general practitioner. Outcomes included perceived stress, depressive symptoms, quality of life, sleep disturbances, mental health, salivary cortisol, and visual perception. Control variables comprised a genetic stress-resiliency factor (serotonergic transporter genotype; 5-HTTLPR), demographics, personality, self-reported inattentiveness, and course format.

Results

Intent-to-treat analyses showed significantly larger improvements in OC than in controls on all outcomes. Treatment effects on self-reported outcomes were sustained after 3 months and were not related to age, gender, education, or course format. The dropout rate was only 6 %.

Conclusions

The standardized OC program reduced stress and improved mental health for a period of 3 months. Further testing of the OC program for public mental health promotion and reduction of stress-related illnesses is therefore warranted. A larger implementation is in progress.

Trial registration: ClinicalTrials.gov.: NCT02140307. Registered May 14 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2588-2) contains supplementary material, which is available to authorized users.

Resilient Warrior: A Stress Management Group to Improve Psychological Health in Service Members

BACKGROUND

Many veterans deployed after 9/11/2001 are impacted by subthreshold levels of posttraumatic stress, anxiety, or other psychological health problems that may interfere with successful reintegration. Conventional treatments, including medication and trauma-focused individual psychotherapies, may not be optimally adapted, accepted, or effective to treat these subsyndromal symptoms.

METHODS

We developed "Resilient Warrior," a 4-session, group-based, mind-body stress-management and resilience program targeted to build skills and assessed whether its format was accessible and acceptable, and potentially efficacious, to support resilience among service members.

RESULTS

From April 2014 to October 2014, 15 participants (53.3% women; mean age=36.6 y; SD=6.2) were surveyed for program acceptability and feasibility and completed self-reported psychological health outcomes before and after program participation. The majority (71.4%) of participants reported that the program included the right number of sessions, and all of them reported that it was helpful and relevant and that they would recommend it to others. While changes in self-reported resilience were only marginal, participation was associated with improvements in depressive symptoms, perceived stress, anxiety, and general sense of self efficacy.

CONCLUSION

These pilot data provide preliminary support that "Resilient Warrior," a group-based, stress reduction and resilience program, may improve psychological health in service members even when delivered in community settings. Randomized controlled trials with longer follow-up periods are needed to establish efficacy and effectiveness for this program.

Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization

BACKGROUND

Poor psychological and physical resilience in response to stress drives a great deal of health care utilization. Mind-body interventions can reduce stress and build resiliency. The rationale for this study is therefore to estimate the effect of mind-body interventions on healthcare utilization.

OBJECTIVE

Estimate the effect of mind body training, specifically, the Relaxation Response Resiliency Program (3RP) on healthcare utilization.

DESIGN

Retrospective controlled cohort observational study.

SETTING

Major US Academic Health Network.

SAMPLE

All patients receiving 3RP at the MGH Benson-Henry Institute from 1/12/2006 to 7/1/2014 (n = 4452), controls (n = 13149) followed for a median of 4.2 years (.85-8.4 yrs).

MEASUREMENTS

Utilization as measured by billable encounters/year (be/yr) stratified by encounter type: clinical, imaging, laboratory and procedural, by class of chief complaint: e.g., Cardiovascular, and by site of care delivery, e.g., Emergency Department. Subgroup analysis by propensity score matched pre-intervention utilization rate.

RESULTS

At one year, total utilization for the intervention group decreased by 43% [53.5 to 30.5 be/yr] (p <0.0001). Clinical encounters decreased by 41.9% [40 to 23.2 be/yr], imaging by 50.3% [11.5 to 5.7 be/yr], lab encounters by 43.5% [9.8 to 5.6], and procedures by 21.4% [2.2 to 1.7 be/yr], all p < 0.01. The intervention group's Emergency department (ED) visits decreased from 3.6 to 1.7/year (p<0.0001) and Hospital and Urgent care visits converged with the controls. Subgroup analysis (identically matched initial utilization rates-Intervention group: high utilizing controls) showed the intervention group significantly reduced utilization relative to the control group by: 18.3% across all functional categories, 24.7% across all site categories and 25.3% across all clinical categories.

CONCLUSION

Mind body interventions such as 3RP have the potential to substantially reduce healthcare utilization at relatively low cost and thus can serve as key components in any population health and health care delivery system.

The effectiveness of a brief mind-body intervention for treating depression in community health center patients

Objective:

The objective of this pilot study was to examine the effects of a brief, 6-week, 1.5-hour mind-body intervention for depression (MBID) in patients being treated for depression in 2 community health centers.

Design:

The MBID taught techniques such as meditation that elicit the relaxation response (RR) in combination with additional resiliency-enhancing components. Clinical outcomes of 24 depressed patients were measured pre-MBID, at completion of MBID, and 3 months post-MBID, using the Center for Epidemiological Studies Depression Scale (CES-D 10), Quality of Life Scale (QoL5), SF-12 Health Survey (SF-12), and Health-Promoting Lifestyle Profile-II (HPLP-II).

Results:

Significant post-treatment improvements were shown in depressive symptoms, spiritual growth, mental health, and quality of life, with a median CES-D 10 change from 17.5 (interquartile ratio [IQR] 13.3–22) to 12 (IQR 10–17.5; P<.001); a median HPLP-II Spiritual Growth subscale change from 2.0 (IQR 1.8–2.3) to 2.3 (IQR 2.0–3.0; P=.002) and a median HPLP-II Stress Management sub-scale change from 2.0 (IQR 1.8–2.4) to 2.4 (IQR 2.0–2.9; P=.027); significant improvement in median score on the QoL-5 from 53.3 (IQR 47.5–62.5) at baseline to 63.3 at endpoint (IQR 50–70; P=.008). Three-month follow-up data suggest that the improvement in outcomes were sustained 3 months after the intervention.

Conclusions:

Participation in a 6-week RR-based MBID is associated with an improvement in depression, spiritual growth, and mental health among depressed community health center patients.

Genomic and clinical effects associated with a relaxation response mind-body intervention in patients with irritable bowel syndrome and inflammatory bowel disease

Introduction

Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD) can profoundly affect quality of life and are influenced by stress and resiliency. The impact of mind-body interventions (MBIs) on IBS and IBD patients has not previously been examined.

Methods

Nineteen IBS and 29 IBD patients were enrolled in a 9-week relaxation response based mind-body group intervention (RR-MBI), focusing on elicitation of the RR and cognitive skill building. Symptom questionnaires and inflammatory markers were assessed pre- and post-intervention, and at short-term follow-up. Peripheral blood transcriptome analysis was performed to identify genomic correlates of the RR-MBI.

Results

Pain Catastrophizing Scale scores improved significantly post-intervention for IBD and at short-term follow-up for IBS and IBD. Trait Anxiety scores, IBS Quality of Life, IBS Symptom Severity Index, and IBD Questionnaire scores improved significantly post-intervention and at short-term follow-up for IBS and IBD, respectively. RR-MBI altered expression of more genes in IBD (1059 genes) than in IBS (119 genes). In IBD, reduced expression of RR-MBI response genes was most significantly linked to inflammatory response, cell growth, proliferation, and oxidative stress-related pathways. In IBS, cell cycle regulation and DNA damage related gene sets were significantly upregulated after RR-MBI. Interactive network analysis of RR-affected pathways identified TNF, AKT and NF-κB as top focus molecules in IBS, while in IBD kinases (e.g. MAPK, P38 MAPK), inflammation (e.g. VEGF-C, NF-κB) and cell cycle and proliferation (e.g. UBC, APP) related genes emerged as top focus molecules.

Conclusions

In this uncontrolled pilot study, participation in an RR-MBI was associated with improvements in disease-specific measures, trait anxiety, and pain catastrophizing in IBS and IBD patients. Moreover, observed gene expression changes suggest that NF-κB is a target focus molecule in both IBS and IBD—and that its regulation may contribute to counteracting the harmful effects of stress in both diseases. Larger, controlled studies are needed to confirm this preliminary finding.

Trial Registration

ClinicalTrials.Gov NCT02136745

A healthy aging program for older adults: effects on self-efficacy and morale

CONTEXT

As of 2012, 810 million people worldwide were older than 60 y, accounting for 11% of the population. That number is expected to rise to 2 billion by 2050 or to 22% of the overall population. As a result, a growing need exists to understand the factors that promote mental and physical health in older populations.

OBJECTIVES

The purpose of this study was to develop a healthy aging program for older adults and to measure the changes from baseline to the end of the program in participants' relevant psychosocial outcomes (ie, self-efficacy and morale).

DESIGN

The study's healthy aging mind-body intervention (MBI) was adapted from the Relaxation Response Resiliency Program (3RP) at the Benson-Henry Institute for Mind Body Medicine, which incorporates elements from the fields of stress management, cognitive behavioral therapy, and positive psychology. That program was modified with examples and exercises targeted to an older population and evaluated in the current single-arm pilot study.

SETTING

The program took place at the Massachusetts General Hospital (MGH).

PARTICIPANTS

The 9-wk healthy aging MBI was developed for participants aged 65 y and older. Fifty-one older adults from the surrounding community participated in the study's groups.

INTERVENTION

A new intervention group began the program every 3 mo, with a maximum of 12 individuals per group. For each group, the MBI consisted of weekly 90-min sessions for 9 consecutive wk, directed by a psychologist. The program included sessions that taught participants (1) a variety of methods to elicit the relaxation response (RR), (2) the practice of adaptive coping and cognitions, (3) behaviors necessary to create a healthy lifestyle, and (4) methods of building social support.

OUTCOME MEASURES

The research team chose to focus on 2 psychological variables of interest for aging populations: morale and self-efficacy. The study used 2 questionnaires to measure those outcomes, the Philadelphia Geriatric Center Morale Scale (PGCMS), a multidimensional measure of the psychological state of older people, and the Coping Self-efficacy Scale (CSES), a measure that addresses the multiple dimensions of self-efficacy.

RESULTS

Data from 5 intervention groups were combined for the current analysis. Forty-six participants enrolled and completed questionnaires. Of those participants, 41 attended at least 7 of the 9 sessions. Significant increases in self-efficacy and morale were observed for program completers. After a highly conservative sensitivity analysis, the change for the measure of self-efficacy remained significant, and the change for the measure of morale trended toward significance.

CONCLUSIONS

The study's healthy aging program appears to be a feasible intervention for older adults, with the potential to increase levels of self-efficacy and morale in participants. Further research is warranted to determine its effects on other psychosocial outcomes and health care utilization in aging populations.

Teacher-led relaxation response curriculum in an urban high school: impact on student behavioral health and classroom environment

CONTEXT

Recent data suggest that severe stress during the adolescent period is becoming a problem of epidemic proportions. Elicitation of the relaxation response (RR) has been shown to be effective in treating anxiety, reducing stress, and increasing positive health behaviors.

OBJECTIVE

The research team's objective was to assess the impact of an RR-based curriculum, led by teachers, on the psychological status and health management behaviors of high-school students and to determine whether a train-the-trainer model would be feasible in a high-school setting.

DESIGN

The research team designed a pilot study.

SETTING

The setting was a Horace Mann charter school within Boston's public school system.

PARTICIPANTS

Participants were teachers and students at the charter school.

INTERVENTION

The team taught teachers a curriculum that included (1) relaxation strategies, such as breathing and imagery; (2) psychoeducation regarding mind-body pathways; and (3) positive psychology. Teachers implemented this curriculum with students.

OUTCOME MEASURES

The research team assessed changes in student outcomes (eg, stress, anxiety, and stress management behaviors) using preintervention/postintervention surveys, including the Perceived Stress Scale (PSS), the State-Trait Anxiety Inventory-Form Y (STAI-Y), the stress management subscale of the Health-promoting Lifestyle Profile II (HPLP-II), the Rosenberg Self-Esteem Scale (RSES), the Locus of Control (LOC) questionnaire, and the Life Orientation Test-Revised (LOTR). Classroom observations using the Classroom Assessment Scoring System (CLASS)-Secondary were also completed to assess changes in classroom environment.

RESULTS

Using a Bonferroni correction (P < .007), the study found that students experienced a significant reduction (P < .001) in measures of state-level anxiety on the STAI from pre- to postintervention. The study also found an increase in the use of stress management behaviors at that point. Using a Bonferroni correction (P < .007), the study found that students had significantly less perceived stress (P < .001), less state anxiety (P < .001) and trait anxiety (P < . 001), and increased use of positive stress management behaviors (P < .004) at the follow-up assessment in the fall of the following year. Using a Bonferroni correction (P < .002), the study found a significant increase in overall classroom productivity (eg, increased time spent on activities and instruction from pre- to postintervention).

CONCLUSIONS

This study showed that teachers can lead an RR curriculum with fidelity and suggests that such a curriculum has positive benefits on student emotional and behavioral health and on classroom functioning.

Exploring the effectiveness of a modified comprehensive mind-body intervention for medical and psychologic symptom relief

BACKGROUND

Chronic illnesses are a major current health concern associated with elevated stress and increased health care costs.

OBJECTIVE

The objective of this study was to describe the preliminary effectiveness of a modified, multimodal 8 week mind-body intervention on reducing physical and psychological symptoms in patients with chronic physical, mental and comorbid health issues.

METHODS

Two hundred and twenty six adults enrolled in a mind-body group program and completed pre and post program assessments (63% completer rate), including the Medical Symptoms Checklist (MSCL), Health Promoting Lifestyle Profile (HPLP-II), and Symptom Checklist 90R (SCL-90R).

RESULTS

Significant improvement was found on 9 of 23 medical symptoms (p < .002), all health promoting lifestyle behaviors (p < .001), and all mental health symptoms (p < .001).

CONCLUSIONS

These results indicate that a multimodal mind-body intervention might be useful as a complementary or adjunct therapy for treatment of chronic medical symptoms. Future research is needed to test the intervention using a randomized controlled trial.

Functional genomics in the study of mind-body therapies

BACKGROUND

Mind-body therapies (MBTs) are used throughout the world in treatment, disease prevention, and health promotion. However, the mechanisms by which MBTs exert their positive effects are not well understood. Investigations into MBTs using functional genomics have revolutionized the understanding of MBT mechanisms and their effects on human physiology.

METHODS

We searched the literature for the effects of MBTs on functional genomics determinants using MEDLINE, supplemented by a manual search of additional journals and a reference list review.

RESULTS

We reviewed 15 trials that measured global or targeted transcriptomic, epigenomic, or proteomic changes in peripheral blood. Sample sizes ranged from small pilot studies (n=2) to large trials (n=500). While the reliability of individual genes from trial to trial was often inconsistent, genes related to inflammatory response, particularly those involved in the nuclear factor-kappa B (NF-κB) pathway, were consistently downregulated across most studies.

CONCLUSION

In general, existing trials focusing on gene expression changes brought about by MBTs have revealed intriguing connections to the immune system through the NF-κB cascade, to telomere maintenance, and to apoptotic regulation. However, these findings are limited to a small number of trials and relatively small sample sizes. More rigorous randomized controlled trials of healthy subjects and specific disease states are warranted. Future research should investigate functional genomics areas both upstream and downstream of MBT-related gene expression changes-from epigenomics to proteomics and metabolomics.

The effectiveness of a community-based, mind-body group for symptoms of depression and anxiety

CONTEXT

The prevalence of depression and other mental health conditions is on the rise, with an estimated 350 million people affected. Populations with lower socioeconomic status are at higher risk for mental health problems, including depression and anxiety. Community health centers (CHCs) often have wait lists for individual counseling. Group mind-body interventions (MBIs) that are based on the relaxation response (RR) are plausible options for treating mental health conditions at CHCs.

OBJECTIVE

The study examined the feasibility and effectiveness of an 8-wk MBI developed at the Benson-Henry Institute for Mind Body Medicine (BHI) for treatment of symptoms of depression and anxiety in a community-based population.

DESIGN

The research team designed a retrospective, open-label study of 124 patients with symptoms of depression or anxiety enrolled in an MBI as a group.

SETTING

The setting for the study was 2 CHCs at Massachusetts General Hospital (MGH) in Boston, MA, USA.

PARTICIPANTS

Participants were adult patients at MGH with symptoms of depression and/or anxiety. The program was billed as treatment related to behavioral health and accessible to people with all levels of education.

INTERVENTION

The MBI for depression and/or anxiety in the current study teaches techniques that elicit a relaxation response (RR), in combination with additional resiliencyenhancing components.

OUTCOME MEASURES

To examine effects of the program, self-report clinical measures were administered pre- and postintervention: (1) for depression, the Center for Epidemiologic Studies Depression Scale (CES-D10); (2) for anxiety, the State-Trait Anxiety Inventory-State Subscale (STAI-State); and (3) for perceived stress, the Perceived Stress Scale (PSS-10).

RESULTS

The intervention was associated with a significant decrease in depressive symptoms: 95% CI, -6.0 to -2.6 (P < .001); anxiety--95% CI -12.6 to -2.2 (P = .007); and perceived stress--95% CI -7.6 to -2.0 (P = .001). Approximately 52.4% of the participants completed at least 75% of the 8 sessions, with 5 sessions attended on average.

CONCLUSIONS

Participation in this MBI was associated with an improvement in symptoms of depression and anxiety as well as decreases in perceived stress among CHC patients.

Feasibility and utility of positive psychology exercises for suicidal inpatients

OBJECTIVE

The objective was to assess the feasibility and acceptability of nine positive psychology exercises delivered to patients hospitalized for suicidal thoughts or behaviors, and to secondarily explore the relative impact of the exercises.

METHOD

Participants admitted to a psychiatric unit for suicidal ideation or behavior completed daily positive psychology exercises while hospitalized. Likert-scale ratings of efficacy (optimism, hopelessness, perceived utility) and ease of completion were consolidated and compared across exercises using mixed models accounting for age, missing data and exercise order. Overall effects of exercise on efficacy and ease were also examined using mixed models.

RESULTS

Fifty-two (85.3%) of 61 participants completed at least one exercise, and 189/213 (88.7%) assigned exercises were completed. There were overall effects of exercise on efficacy (χ(2)=19.39; P=.013) but not ease of completion (χ(2)=11.64; P=.17), accounting for age, order and skipped exercises. Effect (Cohen's d) of exercise on both optimism and hopelessness was moderate for the majority of exercises. Exercises related to gratitude and personal strengths ranked highest. Both gratitude exercises had efficacy scores that were significantly (P=.001) greater than the lowest-ranked exercise (forgiveness).

CONCLUSION

In this exploratory project, positive psychology exercises delivered to suicidal inpatients were feasible and associated with short-term gains in clinically relevant outcomes.

A relaxation response training for women undergoing breast biopsy: exploring integrated care

BACKGROUND

Recent changes in clinical guideline recommendations for age of breast cancer screening initiation highlighted the potential psychological ramifications associated with screening. This study examined the feasibility, acceptability, and preliminary efficacy of a brief Relaxation Response training (RRT) to decrease distress among women undergoing breast biopsy.

METHODS

Women scheduled for percutaneous core-needle biopsy were recruited into a single-arm RRT trial, including 3 individual sessions. Psychosocial assessments were completed pre- and postintervention.

RESULTS

Forty women were enrolled between 6/1/10 and 8/31/11. Among enrollees, 75% completed all 3 RRT sessions, and 75% completed the post-assessment. Participants showed significant reductions in acute distress following each RRT session. Qualitative feedback indicated a positive impact of RRT on clinic care experiences.

CONCLUSIONS

RRT is a portable intervention that was feasible to implement, acceptable to patients and associated with significant decreases in acute emotional distress during the period of diagnostic uncertainty related to percutaneous breast biopsy.

The Relaxation Response Resiliency Enhancement Program in the Management of Chronic Refractory Temporomandibular Joint Disorder: Results from a Pilot Study

OBJECTIVES

This is an open-pilot study to evaluate the feasibility, acceptability and efficacy of a pain-specific version of an established mind-body medicine program, the Relaxation Response [RR] Resiliency Program [R₃P], in patients with chronic temporomandibular disorder [TMD].

METHODS

Male and female with at least a six-month history of pain involving the masticatory muscles were sought in the Orofacial Pain Centers of the Massachusetts General Hospital [MGH] or through an advertisement sent to MGH employees from 2008 to 2010. Eligible participants underwent the R₃P intervention [eight group sessions] after standard medical management. Pre- and post-group patients underwent objective measures of impairment [vertical and lateral range of motion with and without pain, temporomandibular joint and muscle pain palpation, and algometer measures] and completed psychosocial measures [Symptom Severity Index, Perceived Stress Scale, the Symptom Checklist-90-Revised and Short Form 36 Health Survey].

RESULTS

Twenty-four subjects [16 females, 90% from MGH Orofacial Pain Centers,10% from among MGH employees], mean age 38 years, met eligibility criteria and participated in the study. The intervention was highly feasible and accepted by patients, as evidenced by a 92% rate of completion. Paired t-test analyses revealed improvement on self-reported pain measures: pain intensity [p<0.02], pain frequency [p<0.002], pain duration [p<0.027], pain tolerability [p<0.009] and on several objective tests.

CONCLUSIONS

The pain specific R₃P is efficacious in reducing objective and subjective symptoms in patients with chronic refractory TMD. The comprehensive intervention, which combines educational information about pain with RR, cognitive behavioral and resiliency-enhancement skills, is accepted by patients and may be more efficacious than other treatments with fewer elements.

Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways

The relaxation response (RR) is the counterpart of the stress response. Millennia-old practices evoking the RR include meditation, yoga and repetitive prayer. Although RR elicitation is an effective therapeutic intervention that counteracts the adverse clinical effects of stress in disorders including hypertension, anxiety, insomnia and aging, the underlying molecular mechanisms that explain these clinical benefits remain undetermined. To assess rapid time-dependent (temporal) genomic changes during one session of RR practice among healthy practitioners with years of RR practice and also in novices before and after 8 weeks of RR training, we measured the transcriptome in peripheral blood prior to, immediately after, and 15 minutes after listening to an RR-eliciting or a health education CD. Both short-term and long-term practitioners evoked significant temporal gene expression changes with greater significance in the latter as compared to novices. RR practice enhanced expression of genes associated with energy metabolism, mitochondrial function, insulin secretion and telomere maintenance, and reduced expression of genes linked to inflammatory response and stress-related pathways. Interactive network analyses of RR-affected pathways identified mitochondrial ATP synthase and insulin (INS) as top upregulated critical molecules (focus hubs) and NF-κB pathway genes as top downregulated focus hubs. Our results for the first time indicate that RR elicitation, particularly after long-term practice, may evoke its downstream health benefits by improving mitochondrial energy production and utilization and thus promoting mitochondrial resiliency through upregulation of ATPase and insulin function. Mitochondrial resiliency might also be promoted by RR-induced downregulation of NF-κB-associated upstream and downstream targets that mitigates stress.

Isolation rearing significantly perturbs brain metabolism in the thalamus and hippocampus

Psychosocial neglect during childhood severely impairs both behavioral and physical health. The isolation rearing model in rodents has been employed by our group and others to study this clinical problem at a basic level. We previously showed that immediate early gene (IEG) expression in the hippocampus and medial prefrontal cortex (mPFC) is decreased in isolation-reared (IR) compared to group-reared (GR) rats. In the current study, we sought to evaluate: (1) whether these changes in IEG expression would be detected by the measurement of brain glucose metabolism using positron emission tomography (PET) with fluorodeoxyglucose (FDG) and (2) whether PET FDG could illuminate other brain regions with different glucose metabolism in IR compared to GR rats. We found that there were significant differences in FDG uptake in the hippocampus that were consistent with our findings for IEG expression (decreased mean FDG uptake in IR rats). In contrast, in the mPFC, the FDG uptake between IR and GR rats did not differ. Finally, we found decreased mean FDG uptake in the thalamus of the IR rats, a region we had not previously examined. The results suggest that PET FDG has the potential to be utilized as a biomarker of molecular changes in the hippocampus. Further, the differences found in thalamic brain FDG uptake suggest that further investigation of this region at the molecular and cellular levels may provide an important insight into the neurobiological basis of the adverse clinical outcomes found in children exposed to psychosocial deprivation.

Relaxation response-based yoga improves functioning in young children with autism: a pilot study

OBJECTIVES

The study objectives were to develop and objectively assess the therapeutic effect of a novel movement-based complementary and alternative medicine approach for children with an autism-spectrum disorder (ASD).

DESIGN

A within-subject analysis comparing pre- to post-treatment scores on two standard measures of childhood behavioral problems was used. SETTINGS AND LOCATION: The intervention and data analysis occurred at a tertiary care, medical school teaching hospital.

SUBJECTS

Twenty-four (24) children aged 3-16 years with a diagnosis of an ASD comprised the study group.

INTERVENTION

The efficacy of an 8-week multimodal yoga, dance, and music therapy program based on the relaxation response (RR) was developed and examined.

OUTCOME MEASURES

The study outcome was measured using The Behavioral Assessment System for Children, Second Edition (BASC-2) and the Aberrant Behavioral Checklist (ABC).

RESULTS

Robust changes were found on the BASC-2, primarily for 5-12-year-old children. Unexpectedly, the post-treatment scores on the Atypicality scale of the BASC-2, which measures some of the core features of autism, changed significantly (p=0.003).

CONCLUSIONS

A movement-based, modified RR program, involving yoga and dance, showed efficacy in treating behavioral and some core features of autism, particularly for latency-age children.

Development of a positive psychology intervention for patients with acute cardiovascular disease

The management of depression and other negative psychological states in cardiac patients has been a focus of multiple treatment trials, though such trials have not led to substantial improvements in cardiac outcomes. In contrast, there has been minimal focus on interventions to increase positive psychological states in cardiac patients, despite the fact that optimism and other positive states have been associated with superior cardiovascular outcomes. Our objective was to develop an 8-week, phone-based positive psychology intervention for patients hospitalized with acute cardiac disease (acute coronary syndrome or decompensated heart failure). Such an intervention would consist of positive psychology exercises adapted for this specific population, and it would need to be feasible for practitioners and patients in real-world settings. By adapting exercises that were previously validated in healthy individuals, we were able to generate a positive psychology telemedicine intervention for cardiac patients that focused on optimism, kindness, and gratitude. In addition, we successfully created a companion treatment manual for subjects to enhance the educational aspects of the intervention and facilitate completion of exercises. Finally, we successfully performed a small pilot trial of this intervention, and found that the positive psychology intervention appeared to be feasible and well-accepted in a cohort of patients with acute cardiac illness. Future studies should further develop this promising intervention and examine its impact on psychological and medical outcomes in this vulnerable population of cardiac patients.

An open study of aripiprazole and escitalopram for psychotic major depressive disorder

OBJECTIVE

This 7-week trial assessed the efficacy and tolerability of aripiprazole combined with escitalopram in the acute treatment of major depressive disorder, with psychotic features (MD-Psy).

METHODS

Sixteen male and female patients with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of MD-Psy were recruited for this study from September 13, 2004 to August 9, 2006. Escitalopram and aripiprazole were flexibly dosed for 7 weeks, with maximum dosages of 20 and 30 mg/d, respectively. The 17-item Hamilton Rating Scale for Depression (HAM-D-17) and Structured Clinical Interview for DSM-IV psychosis module were used to measure depression and psychosis responses. The Barnes Akathisia Scale and the Simpson Angus Scale were used to assess for akathisia and extrapyramidal symptoms.

RESULTS

Thirteen of the 16 subjects completed the study. The MD-Psy response rate (50% or greater drop in HAM-D-17 and no psychosis) (intent-to-treat, last observation carried forward) was 62.5%, and the MD-Psy remission rate (HAM-D-17, <8, and no psychosis) (intent-to-treat, last observation carried forward) was 50.0%. Ten of the 16 subjects developed akathisia; however, 9 of the 10 subjects had resolution or partial resolution of akathisia with dose adjustment or treatment with propranolol.

CONCLUSIONS

The combination of escitalopram and aripiprazole seems to be an effective and safe treatment for MD-Psy.

Pretreatment frontal EEG and changes in suicidal ideation during SSRI treatment in major depressive disorder

OBJECTIVE

We investigated frontal quantitative EEG (QEEG) as predictor of changes in suicidal ideation (SI) during SSRI treatment in major depressive disorder (MDD).

METHOD

Eighty-two subjects meeting DSM-IV criteria for MDD entered an 8-week, prospective, open-label treatment with flexible dose SSRIs and completed at least 4 weeks of treatment. We assessed MDD severity with the 17-item Hamilton Depression Rating Scale (HAM-D-17); change in SI was measured with HAM-D item no. 3. We recorded four-channel EEGs (F7-Fpz, F8-Fpz, A1-Fpz, A2-Fpz) before treatment.

RESULTS

During the first 4 weeks of treatment 9 (11%) subjects experienced worsening SI. Left-right asymmetry of combined theta + alpha power correlated significantly with change in SI from baseline, even when adjusting for changes in depression severity (HAM-D-17) and for the SSRI utilized.

CONCLUSION

Frontal QEEG parameters before treatment may predict worsening SI during SSRI treatment in MDD.

Somatic Symptoms in Outpatients With Major Depressive Disorder Treated With Fluoxetine

Among patients with major depressive disorder (MDD), physical and somatic symptoms are associated with a high degree of disability and healthcare utilization. However, little is known regarding the treatment of these symptoms with standard pharmacotherapy. To measure somatic symptoms of depression, the authors administered The Symptom Questionnaire (Kellner) before and after 8 weeks of open-label treatment with fluoxetine, 20 mg/day, in 170 MDD outpatients (mean age: 40.4 years). Somatic symptom scores decreased significantly after fluoxetine treatment. The degree of reduction in somatic symptoms was significantly and positively correlated with the degree of improvement in depressive symptoms as measured by the 17-item Hamilton Rating Scale for Depression (Ham-D). Somatic symptom scores at baseline did not predict the degree of reduction in Ham-D scores during treatment. However, fluoxetine-remitters had significantly lower somatic symptom scores at end-point than responders who did not remit. Taken together, these findings suggest that developing treatment strategies that successfully target somatic symptoms of depression may further improve the ability to treat depression to remission.

Psychosocial functioning during the treatment of major depressive disorder with fluoxetine

BACKGROUND

Major depressive disorder (MDD) is associated with significant disability, having a profound impact on psychosocial functioning. Therefore, studying the impact of treatment on psychosocial functioning in MDD could help further improve the standard of care.

METHODS

Two hundred twenty-two MDD outpatients were treated openly with 20 mg fluoxetine for 8 weeks. The self-report version of the Social Adjustment Scale was administered at baseline and during the final visit. We then tested for the relationships between (1) self-report version of the Social Adjustment Scale scores at baseline and clinical response, (2) nonresponse, response and remission status and overall psychosocial adjustment at end point, (3) the number/severity of residual depressive symptoms and overall psychosocial adjustment at end point in responders, and (4) the time to onset of response and overall psychosocial adjustment at end point.

RESULTS

An earlier onset of clinical response predicted better overall psychosocial functioning at end point (P = 0.0440). Responders (n = 128) demonstrated better overall psychosocial adjustment at end point than nonresponders (P = 0.0003), while remitters (n = 64) demonstrated better overall psychosocial adjustment at end point than nonremitted responders (P = 0.0031). In fact, a greater number/severity of residual symptoms predicted poorer overall psychosocial adjustment at end point in responders (P = 0.0011). Psychosocial functioning at baseline did not predict response.

CONCLUSIONS

While MDD patients appear equally likely to respond to treatment with fluoxetine, regardless of their level of functioning immediately before treatment, the above results stress the importance of achieving early symptom improvement then followed by full remission of depressive symptoms with respect to restoring psychosocial functioning in MDD.

Treatment-related adverse events and outcome in a clinical trial of fluoxetine for major depressive disorder

Treatment-related adverse events (TRAEs), particularly those that occur early on, may increase the likelihood for premature discontinuation of antidepressants. The purpose of this study was to examine the relationship between TRAEs and outcome in depressed outpatients enrolled in an 8-week, 20 mg, open trial of fluoxetine. A total of 384 patients (54.7% women, mean age 39.9 +/- 10.5 years) were enrolled in the trial. Study visits occurred at baseline and every other week. Somatic complaints were assessed during each study visit. Somatic complaints that, in the opinion of the evaluating physician, were probably related or related to treatment with fluoxetine were entered in the analysis as TRAEs. We then tested whether 1) developing at least one TRAE, 2) developing at least one moderate or severe TRAE, 3) the number of TRAEs reported during the entire trial, or 4) the number of TRAEs reported during each 2-week interval predicted whether patients would respond to fluoxetine, or prematurely discontinue treatment. None of the above scores predicted whether patients responded to or prematurely discontinued the trial. These findings failed to reveal any relationship between side effects and treatment outcome for patients with MDD enrolled in an 8-week, 20 mg, fixed dose, open trial of fluoxetine.

Interaction of soluble guanylate cyclase with YC-1: kinetic and resonance Raman studies

The enzyme-soluble guanylate cyclase (sGC), which converts GTP to cGMP, is a receptor for the signaling agent nitric oxide (NO). YC-1, a synthetic benzylindazole derivative, has been shown to activate sGC in an NO-independent fashion. In the presence of carbon monoxide (CO), which by itself activates sGC approximately 5-fold, YC-1 activates sGC to a level comparable to stimulation by NO alone. We have used kinetic analyses and resonance Raman spectroscopy (RR) to investigate the interaction of YC-1 and CO with guanylate cyclase. In the presence of CO and 200 microM YC-1, the V(max)/K(m GTP) increases 226-fold. While YC-1 does not perturb the RR spectrum of the ferrous form of baculovirus/Sf9 cell expressed sGC, it induces a shift in the Fe-CO stretching frequency for the CO-bound form from 474 to 492 cm(-1). Similarly, YC-1 has no effect on the RR spectrum of ferrous beta1(1-385), the isolated sGC heme-binding domain, but shifts the nu(Fe-CO) of CO-beta1(1-385) from 478 to 491 cm(-1), indicating that YC-1 binds in heme-binding region of sGC. In addition, the CO-bound forms of sGC and beta1(1-385) in the presence of YC-1 lie on the nu(Fe-CO) vs nu(C-O) correlation curve for proximal ligands with imidazole character, which suggests that histidine remains the heme proximal ligand in the presence of YC-1. Interestingly, YC-1 does not shift nu(Fe-CO) for the CO-bound form of H105G(Im), the imidazole-rescued heme ligand mutant of beta1(1-385). The data are consistent with binding of CO and YC-1 to the sGC heme-binding domain leading to conformational changes that give rise to an increase in catalytic turnover and a change in the electrostatic environment of the heme pocket.