Delayed sleep phase syndrome is related to seasonal affective disorder

Background

Both delayed sleep phase syndrome (DSPS) and seasonal affective disorder (SAD) may manifest similar delayed circadian phase problems. However, the relationships and co-morbidity between the two conditions have not been fully studied. The authors examined the comorbidity between DSPS and SAD.

Methods

We recruited a case series of 327 DSPS and 331 controls with normal sleep, roughly matched for age, gender, and ancestry. Both DSPS and controls completed extensive questionnaires about sleep, the morningness-eveningness trait, depression, mania, seasonality of symptoms, etc.

Results

The prevalences of SAD and subsyndromal SAD (S-SAD) were higher in DSPS compared to controls (χ² = 12.65, p = 0.002). DSPS were 3.3 times more likely to report SAD (odds ratio, 3.34; 95% CI, 1.41-7.93) compared to controls as defined by the Seasonal Pattern Assessment Questionnaire (SPAQ). Correspondingly, DSPS showed significantly higher seasonality scores compared to controls in mood, appetite, and energy level subscores and the global seasonality score (t = 3.12, t = 0.002; t = 2.04, p = 0.041; t = 2.64, p = 0.008; and t = 2.15, p = 0.032, respectively). Weight fluctuation during seasons and winter-summer sleep length differences were also significantly higher in DSPS than controls (t = 5.16, p < 0.001 and t = 2.64, p = 0.009, respectively). SAD and S-SAD reported significantly higher eveningness, higher depression self-ratings, and more previous mania symptoms compared to non-seasonal subjects regardless of whether they were DSPS or controls.

Conclusions

These cases suggested that DSPS is partially comorbid with SAD. These data support the hypothesis that DSPS and SAD may share a pathophysiological mechanism causing delayed circadian phase.     

Factors that affect HIV testing and counseling services among heterosexuals in Canada and the United Kingdom: an integrated review

Objective

To examine factors that affect the utilization of HIV testing and counseling (HTC) services among heterosexual populations in Canada and the UK.

Methods

We conducted an integrated review of published and unpublished literature (1996–September 2010) using Scopus, OVID-EMBASE, CSA illumina, CINHAL, PROQuest, Web of Science, and Google.

Results

Twenty-seven studies met the inclusion criteria. We identified and categorized the key factors into three broad categories depending on their source. Personal-related factors included socio-demographic characteristics, risk perception, illness, HIV-related stigma, level of HIV and testing knowledge, and culture. Provider-related factors included provider-recommended HIV testing, provision of culturally and linguistically appropriate services, and doctor–patient relationship. System-related factors included integrating HIV testing with other health care services, anonymity of testing services, suitability of testing venues, technical aspects of HIV testing, and funding for immigrant health services.

Conclusion

The findings from our review indicate that HTC behaviors of heterosexuals in the Canada and the UK are likely influenced by several unchangeable (socio-demographic characteristics) and amenable factors. There is need to step-up research to confirm whether these associations are causal using stronger research designs.

Practical implication

We have made several recommendations that could be used to improve existing services in Canada.     

The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder,and nondepressed controls

Background

Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression.

Methods

Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder.

Results

Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment.

Limitations

Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based.

Conclusions

Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.     

Treatment adherence in bipolar I and schizoaffective disorder,bipolar type

Background

Poor adherence rates in Bipolar Disorder type I (BDI) and Schizoaffective Disorder, bipolar type (SAD) may be high This study was aimed at comparing the clinical correlates of adherence to treatment and the course of illness in BDI and SAD patients.

Methods

75 SAD and 150 BDI DSM-IV outpatients were included. Adherence was assessed on the basis of patients’ and care-givers’ reports and serum levels, when available. Socio-demographic, clinical and treatment variables were collected and compared between diagnostic subsamples and then between goodly and poorly adherent patients. Multiple logistic regressions were performed, controlling for diagnostic subsample differences, to identify correlates of adherence in BDI and SAD groups.

Results

Poor adherence was highly prevalent both in BDI (32%) and in SAD patients (44%), with no significant differences between diagnostic categories. Presence of psychotic symptoms (p=0.029), higher number of manic relapses (p<0.001), comorbidity with personality disorders (p=0.002), and lithium therapy (p=0.003) were associated with poor adherence to treatment. Diagnostic subgroup analyses showed different predictive models, with the BDI poorly adherent subsample being more likely to include comorbid personality and manic recurrences and the SAD poorly adherent subsample being less clinically predictable.

Limitations

The cross-sectional nature of the study limits de capacity to ascertain the direction of the relationship between certain variables.

Conclusions

Rates of poor adherence to oral treatments are similar in SAD and BDI. BDI patients with comorbid personality and substance use disorders are likely to be poorly adherent. Treatment adherence may be more difficult to predict in SAD patients.     

Validation of a patient-centered culturally sensitive health care provider inventory using a national sample of adult patients

Objective

The Tucker-Culturally Sensitive Health Care Provider Inventory – Patient Form (T-CSHCPI-PF) is an inventory for culturally diverse patients to evaluate provider cultural sensitivity in the health care process. The T-CSHCPI-PF is novel in that it assesses provider cultural sensitivity as defined by culturally diverse patients. The purpose of the present study was to determine the factor structure and internal consistency reliability of the T-CSHCPI-PF.

Method

A sample of 1648 adult patients was recruited by staff at 67 health care sites across the United States. These patients anonymously completed the T-CSHCPI-PF, a demographic data questionnaire, and a patient satisfaction questionnaire.

Results

Confirmatory factor analyses of the TCSHCPI-PF revealed that it has three factors with high internal consistency and validity.

Conclusion

It is concluded that the T-CSHCPI-PF is a psychometrically strong and useful inventory for assessing the cultural sensitivity of health care providers.

Practical implications

The T-CSHCPI-PF may be a useful inventory for obtaining patients’ feedback on their providers’ cultural sensitivity and for assessing the effectiveness of trainings to promote patient-centered cultural sensitivity among providers.     

Applying qualitative methods in developing a culturally tailored workbook for black patients with hypertension

Objective

To apply qualitative research methods in developing a culturally tailored, educational workbook for hypertensive black patients.

Methods

The workbook was developed using formative qualitative data from 60 black primary care patients with hypertension. Participants were interviewed using qualitative methods and data were analyzed through sequential steps of open coding, axial coding, and selective coding. From these analyses, themes describing patients’ cultural beliefs about hypertension were derived and used to develop the workbook.

Results

The workbook, “Living With Hypertension: Taking Control” is a 37-page illustrated workbook with 11 chapters based on patients’ perceptions of hypertension. These chapters focus on strengthening participants’ ability to take control and manage hypertension and on providing knowledge and health behavior techniques.

Conclusion

Qualitative research methods were used to inform the development of a culturally tailored educational workbook.

Practice implications

The workbook developed in this study may offer a practical and effective means of educating patients about blood pressure control in primary care settings.     

Cross-cultural adaptation and validation of the health literacy assessment tool METER in the Portuguese adult population

Objective

We aimed to culturally adapt and validate METER in the Portuguese population, and to define cut-off values for adequate health literacy.

Methods

We used the standard procedure for the adaptation of the words and surveyed health professionals to select the non-words. The instrument was administered to a total sample of 249 participants and retested in a sub-sample of 45 after three months. Cut-offs were defined using the modified Angoff procedure. Construct validity was assessed through association with educational attainment and health-related occupation.

Results

Exploratory factor analysis revealed two dimensions of the instrument, one for words and another for non-words. METER showed a high degree of internal consistency, and acceptable test–retest reliability. Adequate health literacy was defined as scoring at least 35/40 in words and 18/30 in non-words. Physicians scored higher than any other group, followed by health researchers, researchers from other areas and by people with progressively lower levels of education (p < 0.001).

Conclusion

We culturally adapted a brief and simple instrument for health literacy assessment, and showed it was valid and reliable.

Practice implications

The Portuguese version of METER can be used to assess health literacy in Portuguese adults and to explore associations with health outcomes.     

Uma Tori! Evaluation of an STI/HIV-prevention intervention for Afro-Caribbean women in the Netherlands

Objective

This study describes the effectiveness of ‘Uma Tori’, an STI/HIV-prevention intervention for women of Afro-Surinamese and Dutch Antillean descent in the Netherlands, aimed at increasing awareness of sexual risk and power in relationships and improving sexual decision-making skills.

Methods

Intervention effects were evaluated in a pre–post-test design, using self-report questionnaires among a sample of 273 women. Data were analysed using intention-to-treat, MANOVA with repeated measures and Bonferroni correction for multiple comparisons. Additionally, a qualitative process evaluation, using logbooks and interviews, was conducted to assess fidelity and completeness of intervention implementation.

Results

The results showed positive effects on participants’ knowledge, risk perceptions, perceived norms and sexual assertiveness. In addition, after the programme, participants had stronger intentions to negotiate and practice safe sex. Furthermore participants communicated more with their partners about safe sex.

Conclusion

The effects of ‘Uma Tori’ are promising and the intervention seems to support attempts to reduce sexual-risk behaviour among Afro-Caribbean women.

Practice implication

The evaluation of the programme suggests that this interactive, multiple session, multi-faceted small-group intervention is successful in increasing participants’ awareness, sexual assertiveness, intentions to negotiate safe sex, and communication about sexual behaviour with partners. This programme is applicable in practice, provided that it is gender specific and culturally appropriate.     

Living donor kidney transplantation among ethnic minorities in the Netherlands: A model for breaking the hurdles

Objective

Despite living donor kidney transplantation (LDKT) being the optimal treatment option for patients with end-stage renal disease, we observed a significant inequality in the number of LDKT performed between patients of Dutch versus non-Dutch descent. We conducted a focus group study to explore modifiable hurdles to LDKT.

Methods

Focus group discussions and in-depth interviews were conducted among 50 end-stage renal patients. Analyses were conducted according to ‘grounded theory’ using Atlas.ti.

Results

We found nearly all patients to be in favor of LDKT (96%). However, multiple factors played a role in considering LDKT. Four potentially modifiable hurdles were derived: (1) inadequate patient education, (2) impeding cognitions and emotions, (3) restrictive social influences, and (4) suboptimal communication. With regard to solutions, we found that our patients were open to home-based group education on renal replacement therapy options (88% in favor).

Conclusion

The study highlights the need for sensitivity and awareness of the influence of cultural factors on decision-making when discussing living donation with culturally diverse populations.

Practice implications

Since the majority of our patients were open to a tailored group education in their own homes, we see this as an opportunity to address factors that influence equality in access to LDKT.     

Validation of the Seasonal Pattern Assessment Questionnaire (SPAQ)

The validity of the Seasonal Pattern Assessment Questionnaire (SPAQ) was examined by interviewing 81 individuals who had participated in an earlier community survey of seasonal affective disorder (SAD) in Iceland. When SAD and subsyndromal SAD (S-SAD) were combined into a ‘winter problem’ group, the questionnaire's sensitivity, specificity and positive predictive value for that group were 94%, 73% and 45%, respectively. The SPAQ discriminated poorly between SAD and S-SAD, and hence it had a poor case-finding ability for SAD. Clinical evaluation verified a diagnosis of SAD in individuals who had no previous information about this syndrome. The questionnaire furthermore identified a group of individuals who had generalized anxiety and marked seasonal variations. Clinical evaluation arrived at a similar prevalence rate of SAD as the questionnaire.     

Initial weight loss is the best predictor for success in obesity treatment and sociodemographic liabilities increase risk for drop-out

Objective

To identify pre-treatment factors related to weight loss in obesity treatment.

Methods

Weight-related and psychological factors were tested in relation to three different weight loss phases: spontaneous weight loss after screening visit (Pre-treatment), weight loss after a preparatory 5-week series of lectures (Step I) and after group treatment lasting two semesters (Step II) in 247 obesity patients.

Results

The strongest factor for predicting weight loss in the Step II treatment was initial Step I weight loss. At least 1 kg weight loss in Step I predicted 13% of the variation in Step II weight loss. Spontaneous pre-treatment weight loss after screening and a history of more weight losses were also related to more Step II weight loss. Psychological encumbrances such as eating disorders and mental distress were not related to weight loss, neither were self-reported motivation nor weight locus of control. The overall attrition rate was 63% and associated with lower education, being an immigrant, lack of occupation, fewer previous weight losses and higher body dissatisfaction.

Conclusion

Initial weight loss is the most certain factor for predicting treatment outcome.

Practice implication

A treatment design including an introductory phase with a minimum weight loss criterion for continuing treatment is suggested.     

Two longterm studies of seasonal variation in depressive symptoms among community participants

Background

There is evidence that seasonal variation in depressive symptoms is common in the population. However, research is limited by a reliance on longterm retrospective methods.

Methods

Seasonal patterns were tested in two samples of community participants recruited in separate prospective studies in the Midwestern (n=556 males/females) and Pacific Northwestern (n=206 males) United States. Participants completed self-report measures of depressive symptoms 10–19 times from ages 14 to 36 years (n=8316 person observations). These data were compared with local meteorological conditions (e.g., solar radiation) recorded across the 2 weeks prior to each self-report.

Results

In within-subjects analyses, participants’ depressive symptoms and the probability of clinically significant symptoms varied with the time of year, as hypothesized (highest in the weeks of early Winter; lowest in early Fall). However, effect sizes were modest and were not explained by recent sunlight or other meteorological conditions.

Limitations

Samples were not nationally representative. Participants did not complete retrospective reports of seasonal depression or measures of current vegetative symptoms.

Conclusions

Neither time of the year nor recent seasonally linked meteorological conditions were powerful influences on depressive symptoms experienced by community populations in relevant geographic regions. Prior studies may have overestimated the prevalence and significance of seasonal variation in depressive symptoms for the general population.     

Outcomes of online support and resources for cancer survivors: a systematic literature review

Objective

This study aims to review systematically the available literature on health outcomes of online cancer support and resources.

Methods

We searched major databases with the following selection criteria: (1) empirical study on use of online support or resources by cancer survivors, (2) reporting effects or outcomes of online support or resources, (3) focusing on adult cancer survivors, and (4) peer-reviewed articles published by 2010.

Results

A total of 24 studies (37 articles) were included in the review. Most studies were focused on breast cancer survivors and had small sample sizes. Fifteen studies employed a cross-sectional design including eight qualitative studies. Only five studies used pre-post design, and four employed RCT design. The outcome measures have focused on psychosocial effects; most studies reported positive effects, although none of the RCT studies reported significant outcomes.

Conclusion

Existing studies of online cancer support and resources have demonstrated preliminary but inconclusive evidence for positive outcomes. We call for additional studies with rigorous study designs and the inclusion of more diverse participants and cancer conditions.

Practice implications

Connecting diverse cancer survivors to culturally appropriate, evidence-based online support and resources is a strategy to enhance health outcomes.     

Seasonal affective disorder in eight groups in Turkey: a cross-national perspective

OBJECTIVE: Previous estimates of the prevalence of seasonal affective disorder (SAD) in community-based samples generally originated from western countries. We report prevalence rates in eight groups from four latitudes in Turkey. METHOD: Seasonal Pattern Assessment Questionnaire (SPAQ) was distributed to the community-based samples from eight different locations at four latitudes in Turkey. The prevalence rates of winter SAD and subsyndromal SAD (S-SAD) were estimated for the four groups at the same latitudes by using SPAQ responses. RESULTS: We distributed 3229 SPAQs, had an overall response rate of 54.16% and 1749 SPAQs were included in the analyses. Seasonality was reported as a problem by 549 subjects (31.57%) of our 1749 respondents. Prevalence of winter SAD and S-SAD are estimated as 4.86 and 8.35%, respectively, for the whole group. Prevalence rates were determined for each center and for four latitudes (two centers at the same latitude were grouped as one). In Adana-Gaziantep (lt. 37), Izmir-Elazi? (lt. 38), Eski?ehir-Ankara (lt. 39) and Trabzon-Edirne (lt. 41), the prevalence rates for winter SAD were 6.66, 2.25, 8.00 and 3.76%, respectively. CONCLUSIONS: Our prevalence estimates of winter SAD are similar to those found in previous community-based studies at the same latitudes; no correlation was found between latitude and prevalence of winter SAD, which could be related to the sampling methodology or to the fact that there were only 5 degrees of difference between the latitudes.     

Problem based learning in chronic disease management: A review of the research

Objective

To determine whether problem based learning (PBL) is an effective educational strategy in chronic disease management.

Methods

The databases CINAHL, EMBASE, HealthStar, Medline and PubMed were searched for articles which focused on PBL and patient education or patient learning.

Results

Individual studies using PBL as an intervention with chronic disease management reflect significant changes in cognitive and clinical outcomes among individuals experiencing diabetes, asthma, arthritis and coronary artery disease.

Conclusion

There is a need for more well designed studies that assess the impact of PBL on self-care management of a variety of chronic diseases.

Practice implications

There is some evidence that PBL is effective in promoting self-care with individuals experiencing diabetes, arthritis, asthma and coronary artery disease.     

Uncovering and validating clinicians' experiential knowledge when facing difficult conversations: a cross-cultural perspective

Objective

To explore clinicians’ experiential knowledge when conducting difficult conversations; and to verify if experiential knowledge is culturally based.

Method

Data were collected in Italy and the United States during the Program to Enhance Relational and Communication Skills (PERCS) workshops. At the beginning of each workshop, during a whiteboard exercise, clinicians shared the strategies they had found helpful in difficult conversations. The strategies were analyzed in each country through content analysis. Upon completion of this primary analysis, the themes identified within each country were synthesized into second-order themes by means of aggregated concept analysis.

Results

We conducted 14 Italian and 12 American PERCS-workshops enrolling a total of 304 clinicians. The suggestions that were similar across both countries were related to: organizational aspects and setting preparation; communication and relational skillfulness; clinician mindfulness; interpersonal qualities and sensibilities; and teamwork and care coordination. Additionally, US participants identified attention to cultural differences as a helpful strategy.

Conclusion

Clinicians can access relational strategies, tied to their experience, that are typically unrecognized in medical education. The whiteboard exercise is an effective teaching tool to uncover and validate already-existing relational knowledge.

Practice implications

Communication training programs can foster clinicians’ sense of preparation by building upon their already-existing knowledge.     

Testing health literacy skills in older Korean adults

Objective

The purpose of this study was to develop a valid and reliable screening test for limited health literacy for older Korean adults.

Methods

A pool of 102 items was generated based on empirical referents, which, after expert review, field study, and content validity, was reduced to 29 items with three subscales. Construct validity and reliability were established using a convenience sample of 411 community dwelling elderly participants and exploratory factor analysis, and Cronbach's alpha was employed. Rasch analysis was also performed to assess the unidimensionality of the construct and item adequacy.

Results

Rasch analysis showed that the scale was unidimensional and the majority of the items demonstrated good fit. The final instrument, the Korean Health Literacy Scale (KHLS), is a 24-item questionnaire containing short passages, pictures, and graphs with multiple-choice answer format, with an internal consistency of .891. There are 13 comprehension and numeracy questions and 11 questions about health-related terms; the test requires 15–20 min for administration.

Conclusion

KHLS is culturally suitable as a screening test for limited literacy for older Korean adults in the community.

Practice Implications

Korean investigators now have a validated health literacy tool for research with elderly participants.     

The Statin Choice decision aid in primary care: A randomized trial

Objective

To assess the impact of a decision aid on perceived risk of heart attacks and medication adherence among urban primary care patients with diabetes.

Methods

We randomly allocated 150 patients with diabetes to participate in a usual primary care visit either with or without the Statin Choice tool. Participants completed a questionnaire at baseline and telephone follow-up at 3 and 6 months.

Results

Intervention patients were more likely to accurately perceive their underlying risk for a heart attack without taking a statin (OR: 1.9, CI: 1.0–3.8) and with taking a statin (OR: 1.4, CI: 0.7–2.8); a decline in risk overestimation among patients receiving the decision aid accounts for this finding. There was no difference in statin adherence at 3 or 6 months.

Conclusion

A decision aid about using statins to reduce coronary risk among patients with diabetes improved risk communication, beliefs, and decisional conflict, but did not improve adherence to statins.

Practice implications

Decision aid enhanced communication about the risks and benefits of statins improved patient risk perceptions but did not alter adherence among patients with diabetes.     

A questionnaire on treatment satisfaction and disease specific knowledge among patients with acute coronary syndrome. I: Are treatment satisfaction and disease specific knowledge continuous latent traits?

Objective

To assess psychometric properties of a questionnaire covering treatment satisfaction and disease-specific knowledge among patients discharged after treatment for acute coronary syndrome.

Methods

Comparative scaling of the questionnaire using latent class analysis (LCA) and exploratory factor analysis (EFA) in a consecutive sample of 2015 patients.

Results

LCA revealed four qualitatively differing patterns of patients’ knowledge and five distinct patterns of treatment satisfaction. EFA for patients’ knowledge identified four uncorrelated “dimensions”. Patient satisfaction was scored in a two-factor solution despite proven heterogeneity of persons.

Conclusions

LCA was helpful to identify classes of patients that cannot be scaled according to a latent trait model.

Practice implications

Specific patterns of insufficient disease-specific knowledge and satisfaction requiring specific interventions became visible.     

Should culture affect practice? A comparison of prognostic discussions in consultations with immigrant versus native-born cancer patients

Objective

Poor prognosis is difficult to impart, particularly across a cultural divide. This study compared prognostic communication with immigrants (with and without interpreters) versus native-born patients in audio-taped oncology consultations.

Methods

Ten oncologists, 78 patients (31 Australian-born, 47 immigrants) and 115 family members participated. The first two consultations after diagnosis of incurable disease were audiotaped, transcribed and coded. 142 consultations were included in the analysis.

Results

Fifty percent of doctor and 59% of patient prognostic speech units were not interpreted or interpreted non-equivalently when an interpreter was present. Immigrant status predicted few prognostic facts, and oncologist characteristics no prognostic facts, disclosed. Oncologists were significantly less likely to convey hope to immigrants (p = 0.0004), and more likely to use medical jargon (p = 0.009) than with Australian-born patients. Incurable disease status and a limited life span were commonly acknowledged, generally with no timeframe provided. Physical issues were discussed more commonly than emotional aspects.

Conclusions

While culture did not appear to influence doctor speech, interpreters filtered or blocked much prognostic communication.

Practice implications

Initiatives to empower all patients to attain needed information, optimise communication when an interpreter is present and train cancer health professionals in culturally appropriate care, are urgently required.