The Cultural and Religious Complexities of Amish-Focused Mental Health Conditions Research: Insights from an Exhaustive Narrative Review and Case Study of Counseling Controversies

Mental health conditions research often relies on reductionist cultural assumptions about the population studied and instruments validated from majority populations. In exhaustively reviewing the limited body of Amish mental health conditions research, we find that studies are well-executed by methodological protocols but that findings are inconsistent or limited in generalizability, instrument validity remains contested, and study investigation into Amish cultural and religious dynamics is limited. A case study from a sizeable Amish community in Ohio illustrates how various ideologies-notably old Amish religious theology, the scientific-psychological, and the Evangelical Protestant-have generated population-internal controversies among the Amish over defining and treating mental health conditions, suggesting that mental health conditions research and diagnosis of ethnic religious adherents should better account for internal cultural-religious dynamics. In order to make some assertions about how Amish culture and religion impacts mental health conditions, future research should include pre-study investigations into the targeted population's cultural and religious dynamics, consist of more nuanced case reports from therapists and psychiatrists, and include replication studies at different times and places, with deliberate attention to contextual factors.

Physical health conditions of the Amish and intervening social mechanisms: an exhaustive narrative review

As an ethnic religion, the Amish are of interest to population health researchers due to a distinctive health profile arising from ethnic attributes, including a closed genetic pool and shared culture that shapes lifestyle practices. Amish-focused health research both furthers our knowledge of health conditions by comparing Amish with non-Amish and assists health practitioners in serving this rapidly growing population. Amish health research, now representing approximately a quarter of all Amish-focused publications, is in need of review, to the end of strengthening this knowledge body's coherence, clarifying research directions, and identifying knowledge gaps, lapses, and stagnations. Herein, we synthesize and discuss Amish physical health conditions research, both the population's distinctive health profile and mechanisms shaping this profile. Specifically, we summarize research addressing BMI, physical activity, and body image; diet and supplements; cancer; cardiovascular conditions; communicable diseases; immunity; sleep; genetic disorders; tobacco and alcohol use; periodontal conditions; traumatic injuries; natural treatments for burns; fertility; and sexually transmitted diseases. In reflection, we raise questions about the nature of intervening mechanisms shaping the Amish health profile, the strange omission of several common independent variables commonly used when studying other ethnic groups' health, several recurring methodological complications, and public health policy considerations.

Research Trends in Amish Population Health, a Growing Literature about a Growing Rural Population

The Amish are an endogamous rural population experiencing rapid growth; consequently, they have attracted the attention of population health researchers and service providers. With approximately one quarter of all Amish studies publications now devoted to population health (n=246), the time is ripe to review research trends. Using bibliometric measures, we map the genealogy, influence, and configuration of Amish health publications. Amish population health research has (1) a health culture-focused core with clusters representing social science and health practice, (2) peripheral clusters addressing health conditions-mental, physical, and injury/safety-and (3) several clusters straddling both. We identify fruitful interdisciplinary studies and recommend researchers investigating health culture and conditions seek ways to integrate their research agendas. This article represents a pivot-point for Amish population health research, for it provides a first-ever bibliometric mapping, allowing researchers to more easily locate their work within the literature and identify opportunities for interdisciplinary collaborations.

The Amish health culture and culturally sensitive health services: An exhaustive narrative review

As the Amish population is growing, researcher and practitioner interest in the Amish health culture is also growing. This is largely due to demand from practitioners for population-specific cultural guidance. Once a small area of study, health-themed publications in Amish studies (n = 246) now account for approximately one-fourth of all peer-reviewed publications, and a sizeable percentage address the health culture, i.e. Amish beliefs, practices, attitudes, decision-making processes, financing, and values. In this article, we provide a first-ever exhaustive narrative review of the Amish health culture literature (addressing Amish health conditions elsewhere). Specifically, we address Amish use of modern medicine, complementary & alternative medicine, cultural norms for birthing and intercourse, support and care for the sick and aged, health knowledge, payment for services, barriers to service access, service provider effectiveness, health programming, and ethical conflicts. Our goal is to organize the literature, synthesize findings, identify orienting perspectives, and clarify research questions and directions. Following our synthesis, we reflect on the current state of Amish health culture research, drawing particular attention to strengths and limitations of the oft-used cultural competency paradigm, and recommending more rigorous social scientific theorization of the Amish health culture.

Deprivation and ethnicity impact on diabetes control and use of treatment regimen

AIMS

Deprivation and/or ethnicity impact on care delivery. We have assessed how these factors influence diabetes care in a paediatric clinic.

METHODS

We related access to care [type of insulin treatment regimen-twice daily, multiple daily injections and insulin pump therapy (continuous subcutaneous insulin infusion)], measures of care process (HbA(1c)) and an approximate measure of satisfaction with the service (clinic attendance rate) in 325 (170 male) children and young people with Type 1 diabetes (mean age 10.6 years, mean duration of diabetes of 4.5 years), with indices of deprivation and ethnicity.

RESULTS

Of the 325 children and young people, 2.7% received twice-daily insulin, 48.4% multiple daily injections and 48.9% continuous subcutaneous insulin infusion. Median clinic HbA(1c) was 62 mmol/mol (7.8%) and those receiving the insulin pump therapy had the lowest HbA(1c). Four ethnic groups were represented; White British 81.6%, Asian non-Indian 6.5%, African 8.1% and Asian Indian 3.8%. Mean deprivation score was 21.06. White British and Asian Indian groups were more likely to receive insulin pump therapy (χ(2) = 50.3; P < 0.001). Attendance rates were 94.1% and did not differ across ethnic groups. Deprivation was related to ethnicity and HbA(1c) (R(2) = 0.02; P = 0.02). There was no relationship between clinic attendance and deprivation. Insulin regimen and ethnicity were associated with HbA(1c) (R(2) = 0.096; P < 0.001). Similar findings were obtained when analysis was confined to the White British population.

CONCLUSIONS

These data suggest that deprivation and ethnicity influence diabetes control and how intensive insulin therapy is utilized. A better consideration of the needs of different ethnic groups is required to ensure equitable care delivery in paediatric diabetes.

Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial

BACKGROUND

Trial findings show cognitive behaviour therapy (CBT) and graded exercise therapy (GET) can be effective treatments for chronic fatigue syndrome, but patients' organisations have reported that these treatments can be harmful and favour pacing and specialist health care. We aimed to assess effectiveness and safety of all four treatments.

METHODS

In our parallel-group randomised trial, patients meeting Oxford criteria for chronic fatigue syndrome were recruited from six secondary-care clinics in the UK and randomly allocated by computer-generated sequence to receive specialist medical care (SMC) alone or with adaptive pacing therapy (APT), CBT, or GET. Primary outcomes were fatigue (measured by Chalder fatigue questionnaire score) and physical function (measured by short form-36 subscale score) up to 52 weeks after randomisation, and safety was assessed primarily by recording all serious adverse events, including serious adverse reactions to trial treatments. Primary outcomes were rated by participants, who were necessarily unmasked to treatment assignment; the statistician was masked to treatment assignment for the analysis of primary outcomes. We used longitudinal regression models to compare SMC alone with other treatments, APT with CBT, and APT with GET. The final analysis included all participants for whom we had data for primary outcomes. This trial is registered at http://isrctn.org, number ISRCTN54285094.

FINDINGS

We recruited 641 eligible patients, of whom 160 were assigned to the APT group, 161 to the CBT group, 160 to the GET group, and 160 to the SMC-alone group. Compared with SMC alone, mean fatigue scores at 52 weeks were 3·4 (95% CI 1·8 to 5·0) points lower for CBT (p = 0·0001) and 3·2 (1·7 to 4·8) points lower for GET (p = 0·0003), but did not differ for APT (0·7 [-0·9 to 2·3] points lower; p = 0·38). Compared with SMC alone, mean physical function scores were 7·1 (2·0 to 12·1) points higher for CBT (p = 0·0068) and 9·4 (4·4 to 14·4) points higher for GET (p = 0·0005), but did not differ for APT (3·4 [-1·6 to 8·4] points lower; p=0·18). Compared with APT, CBT and GET were associated with less fatigue (CBT p = 0·0027; GET p = 0·0059) and better physical function (CBT p=0·0002; GET p<0·0001). Subgroup analysis of 427 participants meeting international criteria for chronic fatigue syndrome and 329 participants meeting London criteria for myalgic encephalomyelitis yielded equivalent results. Serious adverse reactions were recorded in two (1%) of 159 participants in the APT group, three (2%) of 161 in the CBT group, two (1%) of 160 in the GET group, and two (1%) of 160 in the SMC-alone group.

INTERPRETATION

CBT and GET can safely be added to SMC to moderately improve outcomes for chronic fatigue syndrome, but APT is not an effective addition.

FUNDING

UK Medical Research Council, Department of Health for England, Scottish Chief Scientist Office, Department for Work and Pensions.

Cessation of attention deficit hyperactivity disorder drugs in the young (CADDY)--a pharmacoepidemiological and qualitative study

OBJECTIVES

To estimate the prevalence of attention deficit hyperactivity disorder (ADHD) pharmacological treatment, and its demographic and clinical details, and to estimate the proportion of patients in the target group who stopped ADHD treatment and investigate possible factors for continuation or cessation of treatment.

DESIGN

A pharmacoepidemiological study using an automated database and a qualititative study using patient interviews. Part 1 was a pharmacoepidemiological study that provided accurate data on use and cessation of ADHD drugs. Part 2 was an in-depth interview study to investigate the reasons, processes and outcomes of treatment cessation.

SETTING

Part 1: primary care using the General Practice Research Database (GPRD). Part 2: secondary and tertiary care paediatric clinics, child and adolescent mental health and adult mental health clinics in London, Nottingham, Dundee and Liverpool.

PARTICIPANTS

Part 1: patients were 15-21 years old during the study period (1 January 2001 and 31 December 2004), had at least one prescription for methylphenidate, dexamfetamine or atomoxetine and had at least 1 year of research-standard data available in the GPRD. Part 2: patients fulfilled Part 1 criteria, had a diagnosis of ADHD as detected by a predefined algorithm and had been treated with methylphenidate, dexamfetamine or atomoxetine for at least 1 year. Child and adolescent psychiatrists, adult psychiatrists and paediatricians involved in the treatment of young people with ADHD were also interviewed as part of the study.

RESULTS

Part 1: prevalence of prescribing averaged across all ages increased eightfold, from 0.26 per 1000 patients in 1999 to 2.07 per 1000 patients in 2006. The increase in prevalence in the younger patients was less evident in the older patients. Prevalence in 15-year-old males receiving a study drug prescription increased from 1.32 per 1000 patients in 1999 to 8.31 per 1000 patients in 2006, whereas the prevalence in 21-year-olds rose from 0 per 1000 patients in 1999 to 0.43 per 1000 patients in 2006. Survival analysis showed that the rate of treatment cessation largely exceeded the estimated rate of persistence of ADHD. The reduction in prescribing was most noticeable between 16 and 17 years of age. Kaplan-Meier analysis showed that approximately 18% of patients restarted treatment if they had stopped treatment after the age of 15. Patients who restarted treatment were more likely to restart within the first year following treatment cessation. Part 2: the Child Health and Illness Profile (CHIP) was chosen as the quality of life questionnaire for the Part 2 study because the CHIP-CE scale has been validated in children with ADHD in the UK. Because of the age range of participants, the adolescent version (CHIP-AE) was administered to patients after interview. Of the 15, a total of nine patients finished the questionnaire. Interviews showed that although some young people felt able to cope after stopping medication, others felt the need to restart to control symptoms. Some patients had difficulty re-engaging with services and clinicians recognised the lack of services for young adults. Patients continuing on treatment considered cessation as an option for the future, but were concerned about the process of stopping and its impact on behaviour.

CONCLUSIONS

Part 1 study demonstrated that the prevalence of prescribing by GPs to patients with ADHD dropped significantly from age 15 to 21. The fall in prescribing was greater than the reported age-related decrease in symptoms, raising the possibility that treatment is prematurely discontinued in some young adults where ADHD symptoms persist. Part 2 of the study identified that some young adults had difficulty in obtaining treatment after discharge from paediatric services. Future work should include randomised placebo-controlled trials into long-term treatment with stimulants, particularly methylphenidate.

Efficacy and complications of adalimumab treatment for medically-refractory Crohn's disease: analysis of nationwide experience in Scotland (2004-2008)

BACKGROUND

Adalimumab is a second generation humanized anti-tumour necrosis factor (TNF) monoclonal antibody with established efficacy in Crohn's disease (CD).

AIMS

To evaluate the efficacy and safety of adalimumab on a nationwide clinical setting.

METHODS

We used the Scottish Society of Gastroenterology network to identify and follow up the clinical outcomes of patients with CD treated with adalimumab over a 4-year period (2004-2008).

RESULTS

A total of 98 patients received adalimumab - 100.5 patient follow-up years were recorded (64.3% females; median age at diagnosis of 20.7 years; 88.8% treated with 80/40 mg induction regimen. Eighty eight (89.8%) had previous infliximab with 29 (32.9%) primary nonresponders; 32 (32.6%) were corticosteroid-dependent; 47 (47.9%) were intolerant/resistant to most immunosuppressive therapies (two or more). In all, 60% of patients were in clinical remission at 1-year follow-up, with 30% and 55% requiring dose escalation to weekly therapy at 1-and 2-year follow-up respectively. Overall, 29 (29.6%) patients developed complications with eight nonfatal serious (8.2%) adverse events and 2 (2.0%) case fatalities (sepsis following perforation and disseminated colorectal cancer, respectively).

CONCLUSIONS

Adalimumab is efficacious in severe and refractory CD in the clinical setting, although there remain significant therapy- and disease-related risks of serious complications.

Efficacy and complications of adalimumab treatment for medically-refractory Crohn's disease: analysis of nationwide experience in Scotland (2004-2008)

BACKGROUND

Adalimumab is a second generation humanized anti-tumour necrosis factor (TNF) monoclonal antibody with established efficacy in Crohn's disease (CD).

AIMS

To evaluate the efficacy and safety of adalimumab on a nationwide clinical setting.

METHODS

We used the Scottish Society of Gastroenterology network to identify and follow up the clinical outcomes of patients with CD treated with adalimumab over a 4-year period (2004-2008).

RESULTS

A total of 98 patients received adalimumab - 100.5 patient follow-up years were recorded (64.3% females; median age at diagnosis of 20.7 years; 88.8% treated with 80/40 mg induction regimen. Eighty eight (89.8%) had previous infliximab with 29 (32.9%) primary nonresponders; 32 (32.6%) were corticosteroid-dependent; 47 (47.9%) were intolerant/resistant to most immunosuppressive therapies (two or more). In all, 60% of patients were in clinical remission at 1-year follow-up, with 30% and 55% requiring dose escalation to weekly therapy at 1-and 2-year follow-up respectively. Overall, 29 (29.6%) patients developed complications with eight nonfatal serious (8.2%) adverse events and 2 (2.0%) case fatalities (sepsis following perforation and disseminated colorectal cancer, respectively).

CONCLUSIONS

Adalimumab is efficacious in severe and refractory CD in the clinical setting, although there remain significant therapy- and disease-related risks of serious complications.

Infrared study of the kinetics and mechanism of adsorption of acrylic polymers on alumina surfaces

In this paper, we studied the kinetics of the adsorption of poly(methyl methacrylate), PMMA, onto native aluminum oxide surfaces by X-ray photoelectron spectroscopy and reflection-absorption infrared spectroscopy, with the intent of tracking the various changes observed in the infrared spectrum of the adsorbed polymer layer as a function of adsorption time. Specifically, we utilized the relative changes in the absorption bands of the carbonyl, carboxylic acid, and carboxylate groups to determine the sequence of events that culminate in the formation of bonds between carboxylate groups on hydrolyzed PMMA and specific sites on the aluminum oxide surface. We have shown that the adsorption process involves the hydrolysis of a fraction of the methoxy groups of the PMMA to generate COOH groups. Unlike previous assumptions, the formation of COOH groups on the PMMA chains does not constitute a sufficient condition for the actual chemisorption of the polymer chains onto the metal oxide surface. To promote bonding, the acid groups must undergo dissociation to form the carboxylate groups, followed subsequently by actual bond formation, that is, active anchoring, on the surface. This process is mediated by the aluminum oxide sites on the surface in the presence of water. Hence, the adsorption process occurs via a two-step mechanism, in which the first step, that is, the hydrolysis step, is a necessary but insufficient condition and the second step, that is, the anchoring step, is largely dependent on the type of interfacial chemistry possible for a particular polymer-metal oxide surface, the polymer conformation, the molecular weight, and the flexibility of the adsorbing molecules.

"A satellite primer on tuberculosis:" a collaboration in distance education

"A Satellite Primer on Tuberculosis" was offered as a distance-based certificate course on tuberculosis (TB) fundamentals to a national audience of over 5,000 individuals. The course was a collaborative effort of a school of public health, a state health department, and the Centers for Disease Control and Prevention. Instruction was provided through print-based self-study modules that were complemented by live, interactive satellite conferences. Course completers, over 70 percent of whom were nurses and employees of public health departments, scored significantly higher on a course posttest than on a pretest, and the vast majority felt the course provided valuable training.

A double-blind comparative study of norfloxacin versus placebo in hospitalised elderly patients with asymptomatic bacteriuria

Patients over the age of 65 years with clear catch specimens of urine containing organisms sensitive to norfloxacin were blindly randomised to receive either norfloxacin in a dose of 400 mg twice daily for 7 days or a placebo for the same period. Urine cultures were repeated immediately prior to treatment, at the end of treatment and at 7 days, 1 month and 3 months after treatment. Physical and mental function were assessed by performing a Crighton Behavioural Rating Scale at the same time intervals. Observations were made on 29 each of subjects on norfloxacin and placebo. The proportions of patients abacteriuric at the end of treatment, 7 days and 3 months post- treatment were 16/24 (66%), 12/24 (50%) and 5/24 (21%) in the norfloxacin group and 10/26 (38%), 8/26 (31%) and 8/25 (32%) in the placebo group. Percentage calculations (and denominators) exclude those patients withdrawn or for whom there were no specimens available at the sampling interval in question. Means and 95% intervals for the Crighton Behaviour Rating Scales initially and at 3 months in subjects on norfloxacin were 18.1 (15.1-20.7) and 19.1 (16.2-21.9) respectively. The same figures for the placebo group were 15.7 (12.6-18.8) and 16.6 (13.7-19.5). It is concluded that a 7 day course of norfloxacin for the treatment of asymptomatic bacteriuria had no effect on the physical and mental function of elderly continuing care patients, and that one explanation for this is that there was a high rate of urinary re-infection.

Pharmacists as HIV/AIDS information resources: survey of Alabama pharmacists

Alabama pharmacists were surveyed by researchers from the University of Alabama at Birmingham's School of Public Health in collaboration with investigators at the Schools of Pharmacy at Auburn University and Stamford University as part of a statewide pharmacists' demonstration project to mobilize pharmacists and pharmacy locations as information resources for HIV/AIDS education and prevention. The objectives of the survey were to: (1) establish a baseline of knowledge and attitudes among Alabama pharmacists about HIV/AIDS; (2) to assess Alabama pharmacists' willingness to assume the role of HIV/AIDS information resources in their communities; and (3) to identify perceived barriers to assuming the role of information resources. The results of the survey were used in the development of an educational intervention program and will be used subsequently to assess the impact of the implementation of the Alabama demonstration project. Findings from this project will serve as a basis for development of a nationwide project as part of a collaborative agreement between the Centers for Disease Control and Prevention's National Partnership Program and the Foundation of Pharmacists and Corporate America for AIDS Education.

Classifying patients with burns for hospital reimbursement: diagnosis-related groups and modifications for severity

This study was designed to evaluate the relative severity and resource consumption of hospitalized patients with burns in a national cross section of hospitals, both with and without burn centers. We investigated to determine whether clinical variables or severity of illness measures not recorded in the Uniform Hospital Discharge Data Set are significant in explaining variation in length of stay, total cost, and mortality for patients with burns. The ability of the six burn diagnosis-related groups (DRGs) to explain variation in patients' length of stay was 20% and their ability to predict total costs was 24%. For the same patient population, the explanatory power of the DRGs improved to 54% for length of stay and 44% for costs when these variables were adjusted by the Severity of Illness Index. We also investigated whether hospitals with burn centers treated a more severely ill population of patients with burns than did hospitals without such centers. Significantly higher levels of severely ill patients with burns (p less than or equal to 0.0001) were found at burn center hospitals. Other patients or treatment variables, combined with a case-mix severity measure, were evaluated for their ability to further increase the explanatory power of DRGs. We also discuss here the use of the study results for reevaluating reimbursement policy.

Unilateral and bilateral ECT: a study of memory disturbance and relief from depression

Fifty-one endogenous and reactive female depressives were given a course of either unilateral non-dominant, unilateral dominant, or bilateral ECT. Visual and verbal memory tests and confusion ratings were administered at frequent intervals during the treatment course. Pre-and post-treatment assessments of depression were made. Comparisons of the therapeutic effect of six and of eight ECTs were studied separately. One month after the last ECT the patients were again assessed on the memory and the depression tests. The results of the memory tests indicate that unilateral non-dominant ECT produced least memory disturbance (particularly of a verbal kind) and also less immediate confusion within 40 minutes of each ECT. This observation applies more to the reactive than the endogenous group. Comparisons of the depression tests reveal that unilateral non-dominant ECT is as effective in relieving depression as bilateral ECT, though progress may be less rapid. The observation holds true only for the reactive depressives. Endogenous depressives benefit more from bilateral ECT. Caution is advised against the administration of unilateral dominant ECT, since this group does not respond to treatment as well as the other two groups. Degree of improvement as a whole does not appear to be related to the degree of confusion experienced. The implications of these findings are discussed.

Low serum pseudocholinesterase levels complicating treatment with phenelzine

Four patients undergoing treatment with phenelzine developed low serum pseudocholinesterase levels. In one of the patients an apnoea of one hour followed modified electric convulsion therapy. In three cases investigations showed that the serum pseudocholinesterase levels returned to normal after withdrawal of phenelzine.