Does stigma predict a belief in dealing with depression alone?

Background

Community surveys indicate that many people with depressive disorders do not obtain professional help and that a preference for self-reliance is an important factor in this treatment gap. The current study sought to investigate whether stigmatising attitudes predict a belief in the helpfulness of dealing with depression without external assistance.

Methods

Data were collected as part of a national household survey of 2000 Australian adults aged 18 years and above. Participants were presented with either a vignette depicting depression (n = 1001) or a vignette depicting depression with suicidal ideation (n = 999) and asked if it would be helpful or harmful to deal alone with the problem. Logistic regression analyses were conducted to determine if belief in dealing with depression alone was predicted by personal stigma, perceived stigma or sociodemographic characteristics.

Results

Higher levels of personal stigma independently predicted a belief in the helpfulness of dealing alone with both depression and depression with suicidal ideation. By contrast, lower levels of perceived stigma were associated with a belief in the helpfulness of dealing alone with depression without suicidal ideation.

Conclusions

Personal stigma is associated with a belief in the helpfulness of self-reliance in coping with depression. Public health programs should consider the possibility that a belief in self-reliance is partly attributable to stigma. The findings also point to the potential importance of providing evidence-based self-help programs for those who believe in self-care.     

Striatal and cortical midline activation and connectivity associated with suicidal ideation and depression in bipolar II disorder

Background

Considerable evidence implicates dysfunction of striatal and cortical midline structure (CMS) circuitry in mood disorders. Whether such aberrations exist in bipolar II depression is unknown.

Methods

Sixteen unmedicated subjects with bipolar II depression and 19 healthy controls were studied using functional MRI and a motor activation paradigm. Analyses of both activation and functional connectivity were conducted.

Results

A history of suicidal ideation (SI) was negatively correlated with activation of the left putamen while depression severity was positively correlated with activation of the left thalamus. The superior bilateral putamen was simultaneously correlated with depression severity and anti-correlated with SI. Striatal functional connectivity was altered with the bilateral CMS and right inferior parietal lobule. Depression severity was correlated with strength of connectivity between the bilateral striatum and the right lingual gyrus and left cerebellum.

Limitations

Only males experiencing an episode of major depression were studied.

Conclusions

Striatal and CMS circuit abnormalities likely contribute to the neurobiology of bipolar II depression. Altered connectivity of the striatum may directly impact depression severity. Further, dissociable components of activation associated with depression severity and suicidal ideation may exist. Finally, the motor activation paradigm used in this study appears to be a useful probe of some neural processes underlying bipolar II depression.     

Protective associations of importance of religion and frequency of service attendance with depression risk, suicidal behaviours and substance use in adolescents in Nova Scotia, Canada

Purpose

We examined relationships of measures of personal importance of religion and frequency of attendance at religious services with risk of depression and risk behaviours in high school students in Cape Breton, Canada. We examined the impact of confounding and explanatory factors on these relationships.

Methods

Data were drawn from self-report surveys of adolescents aged 15-19 (N = 1615) at three high schools in May, 2006. We used logistic regression to assess associations of religious importance and religious service attendance with risk of depression, suicidal behaviour, binge drinking and frequent marijuana use, controlling in multivariate models for sociodemographic factors, family structure and social capital.

Results

Among females, higher personal importance of religion was associated with decreased odds of depression, suicidal ideation, drinking and marijuana use, while more religious attendance was protective for substance use behaviours and suicidal ideation. In males, both measures of religiosity were associated with decreased substance use. In multivariate models, religious importance had weak protective effects for depression and suicidal thinking in females, which were respectively modified by social trust and substance use. Attendance was protective for suicidal thinking in females, and was modified by depression. These associations were not seen in males. Attendance was consistently associated with less substance use in females, while importance was not. Importance was consistently protective for marijuana use and attendance was protective for binge drinking in males.

Limitations

This was a cross-sectional self-report survey and causality cannot be inferred.

Conclusion

Protective associations of measures of religiosity are seen in Canadian adolescents, as they are elsewhere.     

Diabetes education in mainland China- a systematic review of the literature

Objective

In this review, we assess and summarize evidence and gaps in the literature regarding diabetes education in mainland China.

Methods

Using China/Chinese, diabetes and education as key words, articles were obtained from the National Science and Technology Library (NSTL), Chongqing Weipu and Qinghua Tongfang databases. Articles included in this review were further selected based on pre-determined criteria, including studying duration, outcome measurements, and inclusion of control groups.

Results

Based on the 34 articles, we found that studies often took place in inpatient and outpatient department. Popular methods used were class teaching, or one-on-one teaching, and knowledge and glycemic control were mostly selected as the outcome measurements. Beneficial effects of diabetes education on knowledge, and glycemic control were demonstrated in studies during a relatively short follow-up (3-6 months). Limitations to the studies selected were that the effects of interventions on behavior change, BMI, blood pressure, lipids, and medical costs were not clearly addressed, and long-term outcomes and adherence to diabetes education was unknown.

Conclusions

Diabetes education had positive impact on glycemic control in mainland China in short duration.

Practice implications

Future studies should use more creative ways of education, and the long-term impact of diabetes education should be evaluated.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Suicidal behaviors in elderly Koreans: One-month-point prevalence and factors related to suicidality

Background

Suicide prevention in the elderly is a major public health priority worldwide and in Korea in particular. We investigated the one-month-point prevalence and factors related to suicidality for suicidal behaviors in elderly Koreans.

Methods

A simple random sample (N=1588) was drawn from the residential roster of 14,051 Koreans aged 60 years or older who were residents of Osan in February 2010. All subjects were invited to participate in the survey through door-to-door home visits, and the response rate was 59.8%.

Results

The age- and gender-standardized prevalence rates of lifetime suicide attempts, current suicidal ideation without a plan or attempt, and current suicidal ideation with a plan or attempt were estimated at 9.2%, 19.6%, and 2.24%. The prevalence of suicidal ideation without a plan or attempt was higher in women and less-educated individuals and increased with advancing age, whereas the prevalence of suicidal ideation with a plan or attempt was higher in more-educated individuals, was not differentiated by gender, increased until age 70, and then decreased thereafter. The factors related to suicidal ideation differed by the presence of a suicide plan or attempt.

Conclusions

Depressive elders in their 70s who have recently developed suicidal ideation would be a prime target for suicide intervention programs.

Limitations

The sample was regional, although the suicide rate in Osan was comparable to the average suicide rate in Korea.     

Toward a new methodological paradigm for testing theories of health behavior and health behavior change

Objective

Traditional theory testing commonly applies cross-sectional (and occasionally longitudinal) survey research to test health behavior theory. Since such correlational research cannot demonstrate causality, a number of researchers have called for the increased use of experimental methods for theory testing.

Methods

We introduce the multi-methodological theory-testing (MMTT) framework for testing health behavior theory.

Results

The MMTT framework introduces a set of principles that broaden the perspective of how we view evidence for health behavior theory. It suggests that while correlational survey research designs represent one method of testing theory, the weaknesses of this approach demand that complementary approaches be applied. Such approaches include randomized lab and field experiments, mediation analysis of theory-based interventions, and meta-analysis.

Conclusion

These alternative approaches to theory testing can demonstrate causality in a much more robust way than is possible with correlational survey research methods. Such approaches should thus be increasingly applied in order to more completely and rigorously test health behavior theory.

Practice implications

Greater application of research derived from the MMTT may lead researchers to refine and modify theory and ultimately make theory more valuable to practitioners.     

Parotitis associated with Crimean Congo hemorrhagic fever virus

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal tick-borne viral disease, the course of which may accompanied by various clinical findings.

Objectives

We describe a picture of non-suppurative parotitis developing in association with CCHF virus.

Study design

A 48-year-old patient presenting to our hospital with lethargy, hemorrhage and pain and swelling below the left ear was diagnosed with CCHF through IgM antibody and polymerase chain reaction positivity in serum investigated for CCHF virus. A picture of non-suppurative parotitis developed on the 3rd day of admission.

Results

Other causes of parotitis were excluded with the help of serological tests, and the case was regarded as one of CCHF-associated parotitis. The patient was put on adjuvant therapy, an improvement in clinical findings was observed and he was discharged in a healthy condition on the 8th day.

Conclusions

Ours is the first case in the literature of parotitis seen during CCHF. CCHF should be considered in differential diagnosis in addition to other frequently encountered viral agents in patients from endemic regions presenting with a picture of non-suppurative parotitis.     

Mixed methods evaluation: pharmacists' experiences and beliefs toward an interactive communication approach to patient interactions

Objective

To characterize pharmacists’ experience and explore their beliefs toward an interactive communication technique, the three prime questions (3PQs),where pharmacists ask about patients’ understanding of medication's purpose, directions, and monitoring.

Methods

Mixed method design. Pharmacists were briefly trained and then integrated the 3PQs into their practice for two weeks. Pharmacists recorded their perceptions of patient interactions, completed a survey addressing self-efficacy and role beliefs toward the 3PQs, and participated in a focus group.

Results

Eleven pharmacists participated and the 3PQs were used with 176 patients. Most interactions were under 5 min. Pharmacists reported that questions about directions and monitoring were most effective in gathering new information with refills whereas medication purpose question was preferred for new fills. The majority of pharmacists were certain they could use the 3PQs and agreed it was their role. Five themes arose from the qualitative analysis: established communication routines, enhanced patient-pharmacist relationships, good medication history, tailoring of the 3PQs, and impact of pharmacy organization.

Conclusion

The 3PQs enabled pharmacists to briefly assess patient medication experiences and tailor education while fostering patient-centered relationships in pharmacy practice.

Practice implications

While the 3PQs may enhance pharmacists’ patient assessment; integration may challenge pharmacists’ work routine.     

Life-time and current suicide-ideation in Australian secondary school students: Socio-demographic,health and psychological predictors

Background

This study involved a multi-level analysis of factors related to self-reported suicidality (both current and life-time) in adolescents

Methods

A sample of 2552 students aged 14–16 years answered questions relating to demographics, social and familial functioning, psychological well-being and suicidality.

Results

Suicidality, defined as being at least some element of reported suicide ideation, Behaviourally, suicidality was also more likely if students smoked, drank alcohol without adult supervision or if they took illicit drugs was more likely in girls, and in those with poorer social, family and psychological functioning. Behaviourally, suicidality was also more likely if students smoked, drank alcohol or took illicit drugs. Multi-level modelling showed that negative affect, substance use and the presence of romantic relationships were most strongly associated with suicidality. Both current and life-time measures of suicidality showed similar results. Both models suggested that the presence of substance use in teenagers is a potentially useful indicator of elevated suicide risk and that many of the social problems commonly associated with suicidality are likely to be mediated by negative affective states.

Limitations

The study had several limitations. First, it was cross-sectional so it was not possible to examine how variables measured at one time predicted subsequent suicidality. Second, the present analyses were based on a single measure of suicidality that did not differentiate between ideation and attempts. Thus, the analyses did not indicate the severity of the suicidality: whether it involved ideation or actual attempts.

Conclusions

Adolescent girls and adolescents with poor social and family functioning and those who engage in substance use are at risk of suicidal ideation (a known precursor of suicide attempts). School counsellors and teachers need to be aware of the risks.     

Chemotherapy-induced anorexia is accompanied by activation of brain pathways signaling dehydration

Background and aims

Cancer chemotherapy is accompanied by anorexia and mucositis. To clarify the mechanisms of chemotherapy-induced anorexia, we studied the expression of c-fos and appetite-regulating neuropeptidergic and inflammatory mediators in the hypothalamus of rats treated with methotrexate (MTX).

Methods

Sprague-Dawley rats received MTX (2.5 mg/kg, subcutaneously) on three consecutive days and were compared with ad libitum- and pair-fed control rats five days after the first injection.

Results

MTX administration inhibited food and water intake and induced lean and fat mass losses. MTX also induced mucositis and diarrhea without changes in plasma osmolality. Pair-fed rats lost a similar amount of body weight but had no mucositis or diarrhea. Increased number of c-fos positive hypothalamic vasopressin neurosecretory neurons as well as numerous c-fos positive cells in the subfornical organ and in the organum vasculosum of the lamina terminalis were found in MTX-treated as compared to control or pair-fed rats. In both MTX and pair-fed rats, a decrease of hypothalamic proopiomelanocortin mRNA expression and low plasma levels of interleukin-1β (IL-1β) were found reflecting probably the energy deficit. No significant changes of IL-1β mRNA expression and intensity of microglial staining in the hypothalamus were found in MTX-treated rats.

Conclusion

The pattern of c-fos expression in the hypothalamus during MTX treatment is similar to that seen with systemic dehydration, which is known to cause anorexia. No evidence of inflammatory origin of anorexia was found, suggesting that chemotherapy accompanied by mucositis and diarrhea may cause anorexia associated with systemic dehydration.     

Patients’ experiences with continuum of care across hospitals. A multilevel analysis of Consumer Quality Index Continuum of Care

Objective

Communication between professionals is essential because it contributes to an optimal continuum of care. Whether patients experience adequate continuum of care is uncertain. To address this, a questionnaire was developed to elucidate this care process from a patients’ perspective. In this study, the instrument's ability to measure differences in “Consumer Quality Index Continuum of Care” scores between hospitals was investigated.

Methods

The questionnaire was mailed to a random sample of 2159 patients and comprised of 22 items divided over four domains, GP approach, GP referral, specialist and collaboration. Multilevel analysis was conducted to identify case-mix and determine this questionnaire's ability to measure differences in domain scores between hospitals.

Results

Based on a 65% response rate, 1404 questionnaires were available for analysis. Case-mix of patient characteristics across hospitals could not be demonstrated. Some differences in scores between hospitals were observed. At most two in eight hospitals showed different domain scores.

Conclusion

The ability of this questionnaire to measure differences in continuum of care scores between hospitals is limited. The outcome of this survey suggests that hospitals provide a similar level of continuum of care from a patient's perspective.

Practical implications

This questionnaire is especially useful for measuring differences between patients.     

Effort reward imbalance is associated with vagal withdrawal in Danish public sector employees

Objectives

The current study analyzed the relationship between psychosocial work environment assessed by the Effort Reward Imbalance Model (ERI-model) and heart rate variability (HRV) measured at baseline and again, two years later, as this relationship is scarcely covered by the literature.

Methods

Measurements of HRV during seated rest were obtained from 231 public sector employees. The associations between the ERI-model, and HRV were examined using a series of mixed effects models. The dependent variables were the logarithmically transformed levels of HRV-measures. Gender and year of measurement were included as factors, whereas age, and time of measurement were included as covariates. Subject was included as a random effect.

Results

Effort and effort reward imbalance were positively associated with heart rate and the ratio between low frequency (LF) and high frequency power (HF) and negatively associated with total power (TP) and HF. Reward was positively associated with TP.

Conclusion

Adverse psychosocial work environment according to the ERI-model was associated with HRV, especially in the form of vagal withdrawal and most pronounced in women.     

Emergent 2009 influenza A(H1N1) viruses containing HA D222N mutation associated with severe clinical outcomes in the Americas

Background

During the 2010-2011 influenza season, a small sub-group of 2009 influenza A(H1N1) viruses (hereafter referred to as 2009 A(H1N1)) emerged that was associated with more severe clinical outcomes in Ecuador and North America. Genetically, the haemagglutinin (HA) of this sub-clade was distinct from HAs found in viruses associated with severe outbreaks in 2010 from the United Kingdom and from other global specimens isolated earlier in the season.

Objective

We report the emergence of a novel 2009 A(H1N1) variant possessing a re-emergent HA D222N mutation obtained from patients with severe respiratory illnesses and phylogenetically characterise these D222N mutants with other severe disease-causing variants clustering within a common emerging sub-clade.

Case reports

In early 2011, three cases of 2009 A(H1N1) infection, two from Quito, Ecuador, and one from Washington, DC, USA, were complicated by severe pneumonia requiring mechanical ventilation, resulting in one fatality. These cases were selected due to the reported nature of the acute respiratory distress (ARD) that were captured in Department of Defence (DoD)-sponsored global influenza surveillance nets.

Results

Genetically, the 2009 A(H1N1) strains isolated from two of the three severe cases carried a prominent amino acid change at position 222 (D222N) within the primary HA receptor binding site. Furthermore, these cases represent an emerging sub-clade of viruses defined by amino acid changes within HA: N31D, S162N, A186T and V272I. Phylogenetically, these viruses share a high degree of homology with strains associated with recent fatal cases in Chihuahua, Mexico.

Discussion

Previously, enhanced virulence associated with the change, D222G, has been clinically linked to severe morbidity and mortality. Initial observations of the prevalence of a novel sub-clade of strains in the Americas suggest that viruses with a re-emergent D222N mutation may too correlate with severe clinical manifestations. These findings warrant heightened vigilance for emerging sub-clades of 2009 A(H1N1) and presumptive clinical implications.     

Integrating MPI and deduplication engines: a software architecture roadmap

Objectives

: The objective of this paper is to clarify the major concepts related to architecture and design of patient identity management software systems so that an implementor looking to solve a specific integration problem in the context of a Master Patient Index (MPI) and a deduplication engine can address the relevant issues.

Methods

: The ideas presented are illustrated in the context of a reference use case from Integrating the Health Enterprise Patient Identifier Cross-referencing (IHE PIX) profile. Sound software engineering principles using the latest design paradigm of model driven architecture (MDA) are applied to define different views of the architecture.

Results

: The main contribution of the paper is a clear software architecture roadmap for implementors of patient identity management systems. Conceptual design in terms of static and dynamic views of the interfaces is provided as an example of platform independent model. This makes the roadmap applicable to any specific solutions of MPI, deduplication library or software platform.

Conclusions

: Stakeholders in need of integration of MPIs and deduplication engines can evaluate vendor specific solutions and software platform technologies in terms of fundamental concepts and can make informed decisions that preserve investment. This also allows freedom from vendor lock-in and the ability to kick-start integration efforts based on a solid architecture.     

Attitudes of physical therapy students toward patient-centered care, before and after a course in psychosocial aspects of care

Objective

Patient-centered care is vital in developing the therapeutic relationship. Attitude may be an important measure of student potential for giving patient-centered care. The purpose of this study was to assess attitudes toward patient-centered care in doctor of physical therapy students before and after completion of a course that addresses communication skills and psychosocial aspects of care.

Methods

In 2009, forty-nine students in the Doctor of Physical Therapy educational program at Duke University took a required course which included recommended elements for teaching patient-centered care. Students completed the Patient-Practitioner Orientation Scale (PPOS) and the Tasks of Medicine Scale (TOMS) twice prior to the course and once at course completion. Demographic data were gathered and students responded to open-ended questions at final survey administration.

Results

There were statistically significant differences in student attitudes toward patient-centered care after the educational experience on the PPOS and the TOMS, which were supported by students’ written responses.

Conclusion

Changes in attitudes toward patient-centered care are possible with educational intervention.

Practice implications

The results of this study may help to inform educators of medical professionals about the education of practitioners to develop patient-centered attitudes.     

Synthesis of qualitative linguistic research--a pilot review integrating and generalizing findings on doctor-patient interaction

Objective

There is a broad range qualitative linguistic research (sequential analysis) on doctor-patient interaction that had only a marginal impact on clinical research and practice. At least in parts this is due to the lack of qualitative research synthesis in the field. Available research summaries are not systematic in their methodology. This paper proposes a synthesis methodology for qualitative, sequential analytic research on doctor-patient interaction.

Methods

The presented methodology is not new but specifies standard methodology of qualitative research synthesis for sequential analytic research.

Results

This pilot review synthesizes twelve studies on German-speaking doctor-patient interactions, identifies 45 verbal actions of doctors and structures them in a systematics of eight interaction components. Three interaction components (“Listening”, “Asking for information”, and “Giving information”) seem to be central and cover two thirds of the identified action types.

Conclusions

This pilot review demonstrates that sequential analytic research can be synthesized in a consistent and meaningful way, thus providing a more comprehensive and unbiased integration of research. Future synthesis of qualitative research in the area of health communication research is very much needed.

Practice implications

Qualitative research synthesis can support the development of quantitative research and of educational materials in medical training and patient training.     

From patient to client

Objective

To gain insight in the knowledge, attitude and practices of users and providers of reproductive health services in rural areas of Kyrgyzstan and Tajikistan before and after interventions.

Methods

KAP (Knowledge, Attitude, Practices) studies under 500 respondents.

Results

Training that addressed the determinants of behavioural change contributed to the motivation under health care providers to improve performances. The simultaneously implemented education program for users of health services enhanced the preparedness for birth of pregnant women and their family members. Both interventions had positive effects on health outcomes.

Conclusions

Behavioural change, from hierarchic and directive into client-centred and supportive, can be realized in Central Asia by enhancing the decision-making capacities of providers. A client-centred attitude of health care providers is the key condition for sustainable improvement of service delivery. Improving client-provider communication is a cost-effective way to enhance the quality of care in low resource settings, such as in Central Asia.

Practice implications

The providers can be best trained in a practical setting, when trainees are enabled to practice with real patients, under guidance of a highly skilled professional. Psychological components such as addressing emotions and exploring the values and beliefs of providers should be incorporated in separate training modules.     

Experiences of the encounter with the diabetes team—A comparison between obese and normal-weight type 2 diabetic patients

Objective

The aim of this study was to highlight and compare obese and normal-weight type 2 diabetic patients’ perceptions and reported behaviors in terms of their care encounter with the diabetes team.

Methods

Interviews were conducted with 28 diabetic patients. Qualitative content analysis was used as analysis method.

Results

The experiences revealed that when the care encounters took place from a health care perspective, there were no opportunities for individual support.For the obese diabetic patients, especially women, this gave rise to feelings of being stuck, defiance and shame, for those of normal weight, it created a sense of being left, despair and confusion.When encounters took place from the perspective of the individual, the diabetic patients need for support was fulfilled.For the obese diabetic patients this meant that the health care professionals recognised their needs and for those of normal weight, a feeling of security was created.

Conclusions

The results demonstrate differences in the experiences of obese and normal-weight diabetic patients’ men and women in terms of their encounters with the diabetes team.

Practice implication

Diabetic patients, especially the obese diabetic women, require tailor-made support provided by the health professionals in the diabetes team.