Feasibility, acceptability, and depression outcomes of a randomized controlled trial of Mindful Self-Compassion for Teens (MSC-T) for adolescents with subsyndromal depression

INTRODUCTION

Adolescents are experiencing high rates of depressive symptoms, with negative consequences to their long-term health. Group-based, mindful self-compassion programs show promise in mitigating the development of more significant depression in at-risk adolescents. However, the lack of well-designed, active control conditions has limited the ability to examine the efficacy of such interventions.

METHODS

Fifty-nine adolescents (Mage  = 15.81, 70% female) with subsyndromal depressive symptoms from the Southeastern US were randomized to group-based Mindful Self-Compassion for Teens (N = 30) or a newly developed active control Healthy Lifestyles group (N = 29) during 2018 and 2019. Participants attended 8 weekly "main" sessions followed by 6 monthly continuation sessions. The feasibility and acceptability of participation in both groups were measured using attrition, attendance, credibility, and satisfaction data. Depression scores were collected weekly, and self-compassion scores were collected five times across 36 weeks.

RESULTS

Both groups were equally feasible and acceptable during the 8-week program period; however, monthly continuation sessions were poorly attended in both groups. The risk of developing clinically significant depression was 2.6 times higher in the control group compared with the self-compassion group (p = .037) across 36 weeks. Depression significantly decreased in the self-compassion group, while it significantly increased in the control group. Both groups increased significantly in reports of self-compassion. These findings are on par with results noting the efficacy of cognitive-based interventions for high-risk adolescents; follow-up studies with larger sample sizes should be conducted to confirm these findings.

CONCLUSIONS

Initial examination suggests Mindful Self-Compassion for Teens programming is feasible, acceptable, and efficacious in preventing the development of clinically significant depression in adolescents with subsyndromal depression. Future studies may benefit from refinements to the self-compassion measurement and/or the attention control condition; moreover, larger sample sizes are needed to confirm results.

Integrative medical group visits for patients with chronic pain: results of a pilot single-site hybrid implementation-effectiveness feasibility study

Background

Approximately 20% of adults in the United States experience chronic pain. Integrative Medical Group Visit (IMGV) offers an innovative approach to chronic pain management through training in mindfulness, nutrition, and other mind-body techniques combined with peer support. To date, there are no studies on IMGV implementation, despite its promise as a feasible non-pharmacological intervention for chronic pain management. In this study, we assessed the feasibility of implementing IMGV and assessing its effectiveness for chronic pain.

Methods

Implementation Mapping was used to develop and evaluate implementation strategies for IMGV. Strategies included disseminating educational materials, conducting ongoing training, and conducting educational meetings. IMGV was delivered by three healthcare providers: an allopathic physician, registered yoga teacher, and naturopathic physician. The effectiveness of IMGV on patient health outcomes was assessed through qualitative interviews and a Patient-Reported Outcomes Scale (PROMIS-29). Provider perspectives of acceptability, appropriateness, and feasibility were assessed through periodic reflections (group interviews reflecting on the process of implementation) and field notes. Paired t-tests were used to assess changes between scores at baseline and post intervention. Qualitative data were coded by three experienced qualitative researchers using thematic content analysis.

Results

Of the initial 16 patients enrolled in research, 12 completed at least two sessions of the IMGV. Other than fatigue, there was no statistically significant difference between the pre- and post-scores. Patients reported high satisfaction with IMGV, noting the development of new skills for self-care and the supportive community of peers. Themes from patient interviews and periodic reflections included the feasibility of virtual delivery, patient perspectives on acceptability, provider perspectives of feasibility and acceptability, ease of recruitment, complexity of referral and scheduling process, balancing medical check-in with group engagement, and nursing staff availability.

Conclusions

IMGV was feasible, acceptable, and effective from the perspectives of patients and providers. Although statistically significant differences were not observed for most PROMIS measures, qualitative results suggested that participants experienced increased social support and increased pain coping skills. Providers found implementation strategies effective, except for engaging nurses, due to staff being overwhelmed from the pandemic. Lessons learned from this pilot study can inform future research on implementation of IMGV.

Easing the burden of dementia caregiving: Protocol development for a telephone-delivered mindfulness intervention for rural, African American families

Background

There have been few interventions targeted for rural African American (AA) caregivers of persons with dementia despite their unique cultural, geographic, health-related and socio-economic needs, including relatively less access to-and willingness to engage with-formal supports and resources. One effective intervention, Mindfulness-based stress reduction (MBSR), has been found to be culturally acceptable in AA populations; however, no studies have assessed feasibility, acceptability and impact of an adapted mindfulness intervention targeting rural AA dementia caregivers.

Aims

The purpose of this study is to 1) determine the feasibility and acceptability of a telephone-delivered mindfulness training intervention in decreasing caregiver burden among rural, AA, informal caregiving teams of people with dementia; 2) to explore the effects of the training on caregiver burden and relevant secondary outcomes for both caregiving team members, including emotional regulation, tolerance of uncertainty, emotional and physical health, family conflict within the informal caregiving team, and self-efficacy; and 3) to explore comfort with and willingness to adopt technologies to access mindfulness practices and existing caregiving educational resources.

Methods

Our study utilizes a single-group, uncontrolled design to assess the feasibility and acceptability of telephone-delivered mindfulness training designed to alleviate burden for rural caregivers of AA individuals with moderate to severe dementia. A care partner-the person who provides additional help -is included in the intervention. The primary outcome is feasibility of the telephone-delivered mindfulness intervention as assessed by an 85% retention rate with completion of at least 6 of the intervention sessions. Pre- and post-participation interviews assess acceptability.

Aerobic exercise, mindfulness meditation, and stress-reduction in high-stress, college-based young adults: A pilot study

This pilot study assessed the feasibility and combined effect of aerobic exercise (AE) and mindfulness meditation (MM), compared with MM alone and a control (CON) condition, on stress, anxiety, and depression in high-stress college-based young adults. Thirty-two participants (84.4% F, 20.5 ± 2.7 years, 23.9 ± 5.0 kg/m2) were randomized to a four-week, AE + MM (n = 16), MM (n = 10), or control intervention (n = 6). ANOVA revealed non-significant, but noteworthy group x time interactions (perceived stress: p = 0.09; anxiety/depression: p = 0.07). Both AE + MM and MM seem to be feasible strategies to reduce levels of stress, anxiety and depression in college-based young adults.

Effects of Mindfulness-Based Stress Reduction on Experimental Pain Sensitivity and Cortisol Responses in Women With Early Life Abuse: A Randomized Controlled Trial

OBJECTIVE

Early life abuse (ELAb) initiates pathophysiological cascades resulting in long-term maladaptive stress responsivity, hyperalgesia, and an increased risk of psychopathology. Mindfulness-based stress reduction (MBSR) is effective in modifying psychological and somatic symptoms; thus, we predicted that MBSR would be particularly efficacious for women with ELAb.

METHOD

Medically healthy women (mean age = 31 years) with or without a history of early (≤13 years) physical or sexual abuse provided self-report measures and were tested in the laboratory before and after randomization to standard MBSR (n = 52) or social support (SSG) (n = 60) for 8 weeks. The laboratory procedure involved pain testing using the cold pressor and temporal summation of heat pain (indexing central sensitization) procedures, and exposure to the Trier Social Stress Test. Plasma cortisol in response to the experimental protocol was assessed as area under the curve (AUC).

RESULTS

The interventions differentially impacted pain sensitivity and cortisol AUC for women with ELAb, as MBSR increased the temporal summation of heat pain intensity ratings (p = .024) and reduced cortisol AUC (p = .004). For women without ELAb, MBSR decreased cold pressor tolerance (p = .045) and decreased the temporal summation of heat pain intensity ratings relative to SSG (p = .024). Both MBSR and SSG improved depression symptoms and emotion regulation abilities (p values < .001); however, MBSR was associated with greater benefits in describing emotions (p = .008) and impulse control (p = .017) for women with ELAb.

CONCLUSIONS

Women with ELAb benefited from MBSR-specific improvements in central sensitization, mindfulness skills, and emotion regulation abilities. This is the first study to examine the efficacy of MBSR in modifying affective and somatic symptoms based on ELAb status and provides evidence for considering ELAb in tailoring treatment approaches.Trial Registration: ClinicalTrials.gov Identifier: NCT01995916; https://clinicaltrials.gov/ct2/show/NCT01995916.

Methodology for altering omega-3 EPA+DHA and omega-6 linoleic acid as controlled variables in a dietary trial

BACKGROUND & AIMS

Increasing dietary intake of n-3 EPA+DHA and lowering dietary n-6 LA is under investigation as a therapeutic diet for improving chronic pain syndromes as well as other health outcomes. Herein we describe the diet methodology used to modulate intake of n-3 and n-6 PUFA in a free living migraine headache population and report on nutrient intake, BMI and diet acceptability achieved at week 16 of the intensive diet intervention and week 22 follow-up time-point.

METHODS

A total of 178 participants were randomized and began one of three diet interventions: 1) a high n-3 PUFA, average n-6 PUFA (H3) diet targeting 1500 mg EPA+DHA/day and 7% of energy (en%) from n-6 linoleic acid (LA), 2) a high-n-3 PUFA, low-n-6 PUFA (H3L6) targeting 1500 mg EPA+DHA/day and <1.8 en% n-6 LA or 3) a Control diet with typical American intakes of both EPA+DHA (<150 mg/day) and 7 en% from n-6 LA. Methods used to achieve diet change to week 16 include diet education, diet counseling, supply of specially prepared foods, self-monitoring and access to online diet materials. Only study oils and website materials were provided for the follow-up week 16 to week 22 periods. Diet adherence was assessed by multiple 24 h recalls administered throughout the trial. Diet acceptability was assessed in a subset of participants at 4 time points by questionnaire.

RESULTS

At week 16 H3 and H3L6 diet groups significantly increased median n-3 EPA+DHA intake from 48 mg/2000 kcals at baseline to 1484 mg/2000 kcals (p < 0.0001) and from 44 mg/2000 kcals to 1341 mg/2000 kcals (p < 0.0001), respectively. In the Control group, EPA+DHA intake remained below the typical American intake with baseline median at 60 mg/2000 kcals and 80 mg/2000 kcals (p = 0.6) at week 16. As desired, LA intake was maintained in the H3 and Control group with baseline median of 6.5 en% to 7.1 en% (p = 0.4) at week 16 and from 6.5 en% to 6.8 en% (p = 1.0) at week 16, respectively. In the H3L6 group, n-6 LA decreased from 6.3 en% at baseline to 3.2 en% (p < 0.0001) at week 16. There were no significant changes in BMI or diet acceptability throughout the trial or between diet groups.

CONCLUSIONS

We find this diet method to be acceptable to research participants and successful in altering dietary n-3 EPA+DHA with and without concurrent decreases in n-6 LA. If n-6 LA of less than 3 en% is desired, additional techniques to limit LA may need to be employed.

Feasibility of Implementation Mapping for Integrative Medical Group Visits

Objectives: Implementation science is key to translating complementary and integrative health intervention research into practice as it can increase accessibility and affordability while maximizing patient health outcomes. The authors describe using implementation mapping to (1) identify barriers and facilitators impacting the implementation of an Integrative Medical Group Visit (IMGV) intervention in an outpatient setting with a high burden of patients with chronic pain and (2) select and develop implementation strategies utilizing theory and stakeholder input to address those barriers and facilitators. Design: The authors selected a packaged, evidence-based, integrative pain management intervention, the IMGV, to implement in an outpatient clinic with a high burden of patients with chronic pain. The authors used implementation mapping to identify implementation strategies for IMGV, considering theory and stakeholder input. Stakeholder interviews with clinic staff, faculty, and administrators (n = 15) were guided by the Consolidated Framework for Implementation Research. Results: Based on interview data, the authors identified administrators, physicians, nursing staff, and scheduling staff as key stakeholders involved in implementation. Barriers and facilitators focused on knowledge, buy-in, and operational procedures needed to successfully implement IMGV. The implementation team identified three cognitive influences on behavior that would impact performance: knowledge, outcome expectations, and self-efficacy; and three theoretical change methods: cue to participate, communication, and mobilization. Implementation strategies identified included identifying and preparing champions, participation in ongoing training, developing and distributing educational materials, and organizing clinician implementation team meetings. Conclusions: This study provides an example of the application of implementation mapping to identify theory-driven implementation strategies for IMGV. Implementation mapping is a feasible method that may be useful in providing a guiding structure for implementation teams as they employ implementation frameworks and select implementation strategies for integrative health interventions.

Comparing prospective headache diary and retrospective four-week headache questionnaire over 20 weeks: Secondary data analysis from a randomized controlled trial

BACKGROUND

Headache diaries and recall questionnaires are frequently used to assess headache frequency and severity in clinical and research settings.

METHODS

Using 20 weeks of data from an intervention trial with 182 participants, we evaluated concordance between an electronic headache diary administered on a daily basis and designed to capture the presence and severity of headaches on an hourly basis (the headache diary) and a recall questionnaire, with retrospective estimation of the number of headache days assessed on a monthly basis. We further examined whether the duration or severity of headaches assessed by the electronic diary impacted concordance between these two measures.

RESULTS

Over the course of four 28-day periods, people with migraine participating in a dietary intervention reported an average of 13.7 and 11.1 headache days in the headache diary and recall questionnaire, respectively.

CONCLUSION

Over time, the concordance between headache days reported in these two measures tended to increase; however, the recall questionnaire headache estimates were lower than the diary measures in all four periods. When analysis was restricted to headaches lasting 8 hours or more, the number of headache days was more closely aligned with days reported in the recall questionnaire, indicating that the accuracy of recall estimates is likely to be influenced by headache duration. Restriction of analyses to moderate-to-severe headaches did not change results as much as headache duration. The findings indicate that recall questionnaires administered on a monthly basis may underestimate headache frequency and therefore should not be used interchangeably with headache diaries.Clinical Trials.gov Identifier: NCT02012790.

Trends in Yoga, Tai Chi, and Qigong Use Among US Adults, 2002-2017

OBJECTIVES

To examine the characteristics and temporal trends of yoga, tai chi, and qigong (YTQ) use among US adults.

METHODS

Using the 2002, 2007, 2012, and 2017 National Health Interview Surveys, we examined the prevalence, patterns, and predicting factors of YTQ use by Taylor series linear regression, the Wald F χ² test, and multivariable logistic regression models (n = 116 404).

RESULTS

YTQ use increased from 5.8% in 2002 to 14.5% in 2017 (P ≤ .001). Only 6.6% of YTQ users were referred by their medical doctors, and approximately one third disclosed their use of YTQ to medical professionals. Reasons for using YTQ included (1) YTQ was beneficial, (2) YTQ focused on the whole person, and (3) YTQ was natural. Acute and chronic pain, arthritis, and depression were the top 3 medical conditions for which people used YTQ the most.

CONCLUSIONS

YTQ use is increasing substantially, mainly because of its natural and holistic healing approach toward health and chronic diseases. Future studies aiming to explore how to best integrate YTQ into the current health care system are warranted.

Prevalence, patterns, and predictors of meditation use among U.S. children: Results from the National Health Interview Survey

OBJECTIVES

The purpose of the study is to examine the characteristics of various types of meditation use (i.e., mantra, mindful, and spiritual meditation) among U.S. children.

METHODS

Using 2017 National Health Interview Survey, we examined the prevalence, patterns, and potential predictors of meditation use among U.S. children aged 4 to 17 years. Descriptive statistics, Wald F chi-square test, and multivariable logistic regression were used for data analysis (n = 6925).

RESULTS

Overall meditation use has increased substantially from 1.6% in 2012 to 7.4% in 2017 among children in the US. Children with chronic medical conditions were more likely to use mindful meditation (Adjusted Odds Ratio (AOR) = 1.9-3.6, 95% CI [1.0-7.4]). Regularly taking prescription medication had an inverse relation with mantra meditation use (AOR = 0.4, 95% CI [0.2-0.9]). Children with delayed medical care due to access difficulties were more likely to use spiritual meditation, compared to those who did not (AOR = 1.7, 95% CI [1.1-2.6]).

CONCLUSIONS

Meditation use has rapidly increased among U.S. children within the past few years. Future studies should explore the underlying reasons for this increase and its potential benefits for pediatric meditators.

Literature Review of Research on Chronic Pain and Yoga in Military Populations

Background: Although yoga is increasingly being provided to active duty soldiers and veterans, studies with military populations are limited and effects on chronic pain are largely unknown. We reviewed the existing body of literature and provide recommendations for future research. Methods: We conducted a literature review of electronic databases (PubMed, PsychINFO, Web of Science, Science Citation Index Expanded, Social Sciences Citation Index, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities). The studies were reviewed for characteristics such as mean age of participants, sample size, yoga type, and study design. Only peer-reviewed studies were included in the review. Results: The search yielded only six studies that examined pain as an outcome of yoga for military populations. With one exception, studies were with veteran populations. Only one study was conducted with Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) veterans. One study was a randomized controlled trial (RCT). Four of the five studies remaining used pre/post design, while the last study used a post-only design. Conclusions: Studies on the use of yoga to treat chronic pain in military populations are in their infancy. Methodological weaknesses include small sample sizes, a lack of studies with key groups (active duty, OEF/IEF veterans), and use of single group uncontrolled designs (pre/post; post only) for all but one study. Future research is needed to address these methodological limitations and build on this small body of literature.

A mindful self-compassion videoconference intervention for nationally recruited posttreatment young adult cancer survivors: feasibility, acceptability, and psychosocial outcomes

PURPOSE

Young adult (YA) cancer survivors report substantial distress, social isolation, and body image concerns that can impede successful reintegration into life years after treatment completion. Mindful Self-Compassion (MSC) interventions focus on developing mindfulness and self-compassion for managing distress, hardships, and perceived personal inadequacies. An MSC intervention would be beneficial in supporting YA survivors' management of psychosocial challenges that arise in survivorship; however, a telehealth intervention modality is essential for reaching this geographically dispersed population. We conducted a single-arm feasibility study of an MSC 8-week videoconference intervention for nationally recruited YA survivors (ages 18-29).

METHODS

The MSC intervention was group-based, 90-minute videoconference sessions, held weekly over 8 weeks, with audio-supplemented home practice. Feasibility and acceptability were assessed via attendance rate and an intervention satisfaction scale. Baseline to post-intervention changes in psychosocial outcomes (body image, anxiety, depression, social isolation, posttraumatic growth, resilience, self-compassion, mindfulness) were assessed using paired t tests and Cohen's d effect sizes.

RESULTS

Thirty-four participants were consented and 25 attended a videoconference group. Feasibility was established with 84% attending at least six of the eight sessions, and intervention acceptability was high (M = 4.36, SD = 0.40, score range = 1-5). All psychosocial outcomes, except for resilience, demonstrated significant changes (p < 0.002), with medium to large effect sizes (Cohen's d > 0.5).

CONCLUSION

YA survivors are interested in receiving an MSC videoconference intervention. Feasibility, acceptance, and potential psychosocial benefits of the intervention were demonstrated. Findings can be applied toward the design of an efficacy randomized controlled trial to improve quality of life for YA survivors in transition after cancer treatment.

Safety Issues in the Interaction of Conventional, Complementary, and Alternative Health Care

This article reviews issues of safety in health care, applied particularly to the interface between conventional medicine and complementary and alternative medicine. These issues include errors in treatment and medical management, adverse effects of pharmaceuticals, and defining risk for patients. For complementary and alternative medicine, especially dietary supplements, problems of quality control, licensing, regulation, and misrepresentation are discussed. An important issue is the interface between conventional and complementary therapies, in terms of drug/herb interactions, laboratory diagnosis, and lack of communication between clinicians about patients. Improvements in safety and quality will come from a commitment to better education and understanding between both types of care.

Moving Toward Integrative Care: Rationales, Models, and Steps for Conventional-Care Providers

Integration of conventional and complementary care in the United States is driven by the growing use of complementary therapies by patients, limitations in the effectiveness of conventional care for a variety of chronic conditions, a growing emphasis on patient satisfaction as a legitimate outcome of care, and an awareness on the part of insurers and practitioners that complementary approaches can offer a broad array of options that may significantly enhance healing and promote more active patient participation in health maintenance. Many models of integrative care are possible, ranging from the informed practitioner, to fully integrated group practices, to hospital-based and academic center systems of integration. A variety of barriers and challenges can slow the process of integration, including limited personal financial and temporal resources, negative peer opinion, legislative hindrances, and reimbursement shortfalls. This review describes seven models of integrative health care and offers recommendations to conventional-care providers for moving toward the practice of integrative medicine.

Korean Oriental Medicine in Stroke Care

Korean Oriental medicine (KOM), known as Hanbang in Korea, is the primary health care system for more than 20% of the population in Korea. Often integrated with allopathic Western medicine, it has been used and studied extensively in Korea for a variety of conditions, including stroke and Parkinson’s disease. Although KOM shares its origins with traditional Chinese medicine, its unique cultural contributions include a number of innovations in diagnosis and technique, such as Sasang constitutional medicine, Saam acupuncture, herbal acupuncture, and Korean hand acupuncture. This article reviews the development and use of KOM in Korea, focusing on a major component, Sasang constitutional medicine. It describes a preliminary study of effectiveness of Sasang constitutional medicine in the treatment of stroke and discusses the directions of future research in KOM.

Comparative Benefits and Harms of Antidepressant, Psychological, Complementary, and Exercise Treatments for Major Depression: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians

BACKGROUND

Primary care patients and clinicians may prefer options other than second-generation antidepressants for the treatment of major depressive disorder (MDD). The comparative benefits and harms of antidepressants and alternative treatments are unclear.

PURPOSE

To compare the benefits and harms of second-generation antidepressants and psychological, complementary and alternative medicine (CAM), and exercise treatments as first- and second-step interventions for adults with acute MDD.

DATA SOURCES

English-, German-, and Italian-language studies from multiple electronic databases (January 1990 to September 2015); trial registries and gray-literature databases were used to identify unpublished research.

STUDY SELECTION

Two investigators independently selected comparative randomized trials of at least 6 weeks' duration on health outcomes of adult outpatients; nonrandomized studies were eligible for harms.

DATA EXTRACTION

Reviewers abstracted data on study design, participants, interventions, and outcomes; rated the risk of bias; and graded the strength of evidence. A senior reviewer confirmed data and ratings.

DATA SYNTHESIS

45 trials met inclusion criteria. On the basis of moderate-strength evidence, cognitive behavioral therapy (CBT) and antidepressants led to similar response rates (relative risk [RR], 0.90 [95% CI, 0.76 to 1.07]) and remission rates (RR, 0.98 [CI, 0.73 to 1.32]). In trials, antidepressants had higher risks for adverse events than most other treatment options; no information from nonrandomized studies was available. The evidence was too limited to make firm conclusions about differences in the benefits and harms of antidepressants compared with other treatment options as first-step therapies for acute MDD. For second-step therapies, different switching and augmentation strategies provided similar symptom relief.

LIMITATION

High dropout rates, dosing inequalities, small sample sizes, and poor assessment of adverse events limit confidence in the evidence.

CONCLUSION

Given their similar efficacy, CBT and antidepressants are both viable choices for initial treatment of MDD.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis

STUDY QUESTION

What are the benefits and harms of second generation antidepressants and cognitive behavioral therapies (CBTs) in the initial treatment of a current episode of major depressive disorder in adults?

METHODS

This was a systematic review including qualitative assessment and meta-analyses using random and fixed effects models. Medline, Embase, the Cochrane Library, the Allied and Complementary Medicine Database, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from January 1990 through January 2015. The 11 randomized controlled trials included compared a second generation antidepressant CBT. Ten trials compared antidepressant monotherapy with CBT alone; three compared antidepressant monotherapy with antidepressant plus CBT.

SUMMARY ANSWER AND LIMITATIONS

Meta-analyses found no statistically significant difference in effectiveness between second generation antidepressants and CBT for response (risk ratio 0.91, 0.77 to 1.07), remission (0.98, 0.73 to 1.32), or change in 17 item Hamilton Rating Scale for Depression score (weighted mean difference, -0.38, -2.87 to 2.10). Similarly, no significant differences were found in rates of overall study discontinuation (risk ratio 0.90, 0.49 to 1.65) or discontinuation attributable to lack of efficacy (0.40, 0.05 to 2.91). Although more patients treated with a second generation antidepressant than receiving CBT withdrew from studies because of adverse events, the difference was not statistically significant (risk ratio 3.29, 0.42 to 25.72). No conclusions could be drawn about other outcomes because of lack of evidence. Results should be interpreted cautiously given the low strength of evidence for most outcomes. The scope of this review was limited to trials that enrolled adult patients with major depressive disorder and compared a second generation antidepressant with CBT, and many of the included trials had methodological shortcomings that may limit confidence in some of the findings.

WHAT THIS STUDY ADDS

Second generation antidepressants and CBT have evidence bases of benefits and harms in major depressive disorder. Available evidence suggests no difference in treatment effects of second generation antidepressants and CBT, either alone or in combination, although small numbers may preclude detection of small but clinically meaningful differences. Funding, competing interests, data sharing This project was funded under contract from the Agency for Healthcare Research and Quality by the RTI-UNC Evidence-based Practice Center. Detailed methods and additional information are available in the full report, available at http://effectivehealthcare.ahrq.gov/.

Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: a randomized trial

Omega-3 and n-6 fatty acids are biosynthetic precursors to lipid mediators with antinociceptive and pronociceptive properties. We conducted a randomized, single-blinded, parallel-group clinical trial to assess clinical and biochemical effects of targeted alteration in dietary n-3 and n-6 fatty acids for treatment of chronic headaches. After a 4-week preintervention phase, ambulatory patients with chronic daily headache undergoing usual care were randomized to 1 of 2 intensive, food-based 12-week dietary interventions: a high n-3 plus low n-6 (H3-L6) intervention, or a low n-6 (L6) intervention. Clinical outcomes included the Headache Impact Test (HIT-6, primary clinical outcome), Headache Days per month, and Headache Hours per day. Biochemical outcomes included the erythrocyte n-6 in highly unsaturated fatty acids (HUFA) score (primary biochemical outcome) and bioactive n-3 and n-6 derivatives. Fifty-six of 67 patients completed the intervention. Both groups achieved targeted intakes of n-3 and n-6 fatty acids. In intention-to-treat analysis, the H3-L6 intervention produced significantly greater improvement in the HIT-6 score (-7.5 vs -2.1; P<0.001) and the number of Headache Days per month (-8.8 vs -4.0; P=0.02), compared to the L6 group. The H3-L6 intervention also produced significantly greater reductions in Headache Hours per day (-4.6 vs -1.2; P=0.01) and the n-6 in HUFA score (-21.0 vs -4.0%; P<0.001), and greater increases in antinociceptive n-3 pathway markers 18-hydroxy-eicosapentaenoic acid (+118.4 vs +61.1%; P<0.001) and 17-hydroxy-docosahexaenoic acid (+170.2 vs +27.2; P<0.001). A dietary intervention increasing n-3 and reducing n-6 fatty acids reduced headache pain, altered antinociceptive lipid mediators, and improved quality-of-life in this population.

Generalization of deferred imitation in 6-, 9-, and 12-month-old infants using visual and auditory contexts

This study investigated the generalization of deferred imitation in 6-, 9-, and 12-month-old infants across auditory and visual contexts. The task involved testing for the imitation of demonstrated actions on an animal puppet 24h later. There were two independent variables defined by the background music and room of the infant's home on the test day relative to the music and room present on the demonstration day. 6-month-olds generalized imitation only when the music and room on the test day were identical to their learning environment 24h earlier. 9-month-olds were able to generalize deferred imitation across a change in music but not a change in room. 12-month-olds were able to defer imitation across both a change in the room with the same music as well as a change in both the room and music. These results reveal that the similarity between the contextual conditions of encoding and retrieval across multiple contexts determine whether infants generalize and, furthermore, the necessity of such a similarity decreases with age.

Odor as a contextual cue in memory reactivation in young infants

Three-month-old infants were trained to move a mobile in the presence of a coconut or cherry odor (context). Six days later, a reactivation session took place. Infants were randomly assigned to 4 groups (same odor during training and reactivation, different odor during training and reactivation, no odor present during reactivation, no reactivation). A retention test was conducted 24h later in the presence of the training odor and mobile. Retention was seen only in the group of infants trained and reactivated with the same odor. This indicates that olfactory contextual cues function in a similar manner to visual and auditory contextual cues in that a novel context, or the absence of the context in which the memory was formed, are ineffective as reminders once the original memory has been forgotten.

The role of mindfulness in positive reappraisal

Mindfulness meditation is increasingly well known for therapeutic efficacy in a variety of illnesses and conditions, but its mechanism of action is still under debate in scientific circles. In this paper, we propose a hypothetical causal model that argues for the role of mindfulness in positive reappraisal coping. Positive reappraisal is a critical component of meaning-based coping that enables individuals to adapt successfully to stressful life events. Mindfulness, as a metacognitive form of awareness, involves the process of decentering, a shifting of cognitive sets that enables alternate appraisals of life events. We review the concept of positive reappraisal in transactional stress and coping theory, then describe research and traditional literature related to mindfulness and positive reappraisal, and detail the central role of mindfulness in the reappraisal process. With this understanding, we present a causal model explicating the proposed mechanism. The discussion has implications for clinical practice, suggesting how mindfulness-based integrative medicine interventions can be designed to support adaptive coping processes.

Envisioning a Future Contemplative Science of Mindfulness: Fruitful Methods and New Content for the Next Wave of Research

Mindfulness is an ancient spiritual practice as well as a unique behavioral technique involving the cultivation of non-judgmental, non-reactive, metacognitive awareness of present-moment experience. Given the growing interest in mindfulness across numerous academic and clinical disciplines, an agenda is needed to guide the next wave of research. Here, we suggest four areas that, in our view, are important for a future contemplative science of mindfulness: performance-based measures of mindfulness, scientific evaluation of Buddhist claims, neurophenomenology of mindfulness, and measuring changes in mindfulness-induced gene expression. By exploring these domains, the wisdom of the meditative traditions may be complemented by leading-edge empirical research methodologies.

Preparing complementary and alternative practitioners to teach learners in conventional health professions

Federal funding is supporting complementary and alternative medicine (CAM) educational programming in health-professions schools in the United States. CAM practitioners from a wide range of disciplines are now being invited to participate as instructors or content experts in this effort. The challenge is to promote effective and consistent teaching methods around appropriate content. This article describes the development of a series of 4 workshops intended to enhance the teaching skills of 9 complementary medicine practitioners participating in an educational project at the University of North Carolina. Key issues addressed in the workshops included the interface between CAM and conventional medicine, a better understanding of the nature of conventional medical practice, styles and strategies in teaching complementary medicine, and building skills in accessing information from databases.

Alternative therapies and empowerment of older women

There has been a striking increase in Americans' awareness and use of alternative therapies over the last decade. Women, in particular, have been drawn to explore these unconventional health practices, which include herbal medicine, acupuncture, homeopathy, manual therapies, energy healing, and mind-body therapies. From a feminist perspective, the rise in alternative therapies' use in the United States represents a shift in cultural concepts of health from an out-moded patriarchical model which disempowers older women, to a more feminine, holistic model which can reempower older women. Throughout history, older women have developed, applied, and taught the principles and practices of what are now considered alternative healing modalities, in their roles as mothers, expert herbalists, midwives, wise women, and shaman. By becoming familiar with these therapies, older women can increase their control over their health, enhance prevention and self-care, and enjoy a health-care pathway that leads to wholeness in body, mind, and spirit.

Homeopathic and psychiatric perspectives on grief

OBJECTIVE

This review describes the homeopathic analysis of grief and common remedies corresponding to this reaction. Homeopathic descriptions of grief are compared with contemporary psychiatric criteria.

DATA SOURCES

Each homeopathic rubric (i.e., symptom) is identified on the basis of a computerized repertory search, grouped according to body systems, and compared with a current set of operational criteria derived from the psychiatric literature. The major homeopathic remedies for grief are identified.

STUDY SELECTION

One hundred four rubrics for grief were found, incorporating mental and physical symptoms as well as physical disease.

DATA SYNTHESIS

Homeopathic phenomenology of grief was closely matched with its current psychiatric definition. A close correspondence was seen between psychiatry and homeopathy, even though each has a differing heritage and temporal origin. The correspondence of a later descriptive system (i.e., psychiatry) to an earlier, independently derived system (i.e., homeopathy) confers validation to both systems' description of the grief response.

CONCLUSION

The similarities and differences between homeopathic and psychiatric descriptions of grief have been noted. Similar forms of grief response are recognized by both systems, though homeopathy provides a more extensive list of physical sequelae following bereavement. Controlled trials of homeopathy in grief states are recommended.

Meeting of minds in psychiatry and homeopathy: an example in social phobia

Communication between homeopaths and the biomedical community can be enhanced by an interpretation of the homeopathic repertory in light of current medical diagnostic terminology. This report reviews the current, conventional symptom formulation for social phobia, the third most common psychiatric diagnosis in the US community. Eighty-three rubrics in the homeopathic materia medica corresponding to symptoms of social phobia were identified and then used in a computerized repertorizing program to identify potential homeopathic remedies for social phobia. Although Kent's Repertory describes many symptoms of social phobia, the terminology should be updated, and there is a surprising lack of information about some key rubrics. Clinical judgment is always needed to interpret the significance of symptoms that could be caused by more than one pathogenic mechanism. Although many of the remedies traditionally thought to be useful in treating patients with social phobia do indeed appear in the computerized Repertory search, additional remedies emerged, including both polycrests and small remedies, which may have a place in treating this disorder.

Short versions of the Timed Manual Performance Test. Development, reliability, and validity

The Timed Manual Performance test is gaining wider use as a measure of functional status in research and clinical settings. It is a rather lengthy 27-item test, however, requiring the use of a large cumbersome panel of doors. The authors, therefore, studied 1,286 community-dwelling elderly subjects recruited through their primary care provider to: 1) reduce the number of items in the Timed Manual Performance (TMP) test and 2) assess the reliability and validity of the shorter versions of the TMP compared with the 27-item TMP. Using principal components analysis, we identified two shorter measures, TMP (Doors) consisting of five board tasks and TMP (Table) consisting of six table tasks. Timed Manual Performance (Doors) and TMP (Table) involve less equipment than the original TMP and have higher rates of completion. Furthermore, not only are these tests reliable (alpha = 0.79 and 0.82 for TMP [Doors] and TMP [Table], respectively), they appear to be better measures of manual performance compared with the 27-item TMP.

The effect of mode of delivery on the risk of intraventricular hemorrhage in nondiscordant twin gestations under 1500 g

The effect of birth order, presentation, and mode of delivery on neonatal outcome in nondiscordant twin gestations under 1500 g was investigated. All neonates had echoencephalograms performed by the fourth day of life to diagnose the presence and severity of intraventricular hemorrhage. One hundred fifty-six sets of twins were included in the study, of which 59 were in a vertex/vertex presentation, 59 in vertex/nonvertex presentation, and 38 with twin A in a nonvertex presentation. Second twins were characterized by a higher incidence of respiratory distress syndrome (RDS): 66 versus 54% (P less than .05), and severe grades of intraventricular hemorrhage: 30 versus 19% (P less than .01). For vertex/vertex twins, cesarean delivery did not result in improved outcome. Rather, the incidence of RDS was significantly increased in neonates from this group delivered by cesarean birth: 67 versus 46% (P less than .01). Among twins in which at least one of the fetuses was in a nonvertex presentation, those born via cesarean delivery demonstrated a lower incidence of both severe grades of intraventricular hemorrhage and mortality. However, after multivariate analysis to correct for differences in birth weight between the groups, no advantage for cesarean delivery could be demonstrated. Therefore, differences in birth weight, rather than in mode of delivery, accounted for the differences in the neonatal outcome of nonvertex-presenting twins.