Holistic physicians and family practitioners: similarities, differences and implications for health policy

Although loosely defined, holistic or alternative medicine has been viewed by most observers as fundamentally at odds with mainstream biomedical approaches. Convergence or integration of the two are seen as highly unlikely. We attempt to assess the potential for such integration empirically through a survey of physicians, members of the American Holistic Medical Association (N = 340) and a comparison group of family practitioners (N = 142). Although social origins of the two groups are similar, they differ in their completion of residency training and a variety of practice characteristics. While the groups differ in the predicted directions in their evaluation and utilization of holistic techniques and in their attitudes toward the nature of medical practice, there is a good deal of overlap. Personal experiences, especially those in the area of religion/spirituality and psychotherapy differ sharply between the groups. Policy concerned with fostering cooperation or convergence between holistic and mainstream medicine should differentiate between clinical attitudes and behaviors (which appear to be more compatible than has been suggested), and the personal world views of physicians (which appear to be much further apart).     

Importance of obstetrics in a comprehensive family practice.

Four family practices in the San Francisco Bay Area, two of which did not include obstetrics and two of which did, were examined with reference to their patient populations and to the number of families for which they provided comprehensive, continuous family care. The groups practicing without obstetrics were found to do acute care primarily and, to a lesser extent, long-term care internal medicine, with very little pediatrics or gynecology. The groups practicing with obstetrics did significantly more minor surgery, gynecology, pediatrics, and psychotherapy. During the six-week study, the group practicing with obstetrics saw five times as many patients who were members of families receiving continuous, comprehensive care from the practice under observation. Psychotherapy done by the group including obstetrics was primarily family therapy; for the other group, individual therapy. If larger studies support these findings, then important implications are suggested for training programs in family practice and for the resident deciding to enter practice.     

Use of Psychotherapy by Rural and Urban Veterans

Purpose: To examine whether differences exist between rural and urban veterans in terms of initiation of psychotherapy, delay in time from diagnosis to treatment, and dose of psychotherapy sessions. Methods: Using a longitudinal cohort of veterans obtained from national Veterans Affairs databases (October 2003 through September 2004), we extracted veterans with a new diagnosis of depression, anxiety, or posttraumatic stress disorder (PTSD) (n = 410,923). Veterans were classified as rural (categories 6-9; n = 65,044) or urban (category 1; n = 149,747), using the US Department of Agriculture Rural-Urban Continuum Codes. Psychotherapy encounters were identified using Current Procedural Terminology codes for the 12 months following patients’ initial diagnosis. Findings: Newly diagnosed rural veterans were significantly less likely (P < .0001) to receive psychotherapy (both individual and group). Urban veterans were roughly twice as likely as rural veterans to receive 4 or more (9.46% vs 5.08%) and 8 or more (5.59% vs 2.35%) psychotherapy sessions (P < .001). Conclusions: Rural veterans are significantly less likely to receive psychotherapy services, and the dose of the psychotherapy services provided for rural veterans is limited relative to their urban counterparts. Focused efforts are needed to increase access to psychotherapy services provided to rural veterans with depression, anxiety, and PTSD.     

Patients in group psychotherapy

This study examines the patient in group psychotherapy, describing factors that provide changes during the process and the particularities of this therapeutic mode. Based on the available literature and the authors' systematic experience throughout thirty years of group therapeutic work, the variables that determine the commitment of the group members in a productive and well-succeeded therapeutic relation are discussed. It is emphasized how the patients assimilate the psychotherapeutic process and the way in which they participate in achieving their own improvement.     

Group therapy for bulimia. A year's experience

Nine patients with bulimia participated in a year-long therapy group that combined behavioral and psychodynamic approaches. Eight of the patients also participated in individual psychotherapy and three had medication trials. By the end of the year, six had complete cessation or considerable improvement of their bulimic symptoms. This paper provides a detailed case report of the procedures and processes of the group and, based on our experience, offers suggestions for selection and preparation of members, group rules and composition, how to minimize dropouts and toxic effects, and what we believe to be therapeutic about the group.     

社交网络在孕期健康教育中的应用与成效

笔者所在医院产科利用互联网社交网络进行孕期健康教育工作,探讨通过QQ群、爱婴论坛等形式开展公益性健康教育的可行性。笔者所在医院孕期健康教育中心2009年7月建腾讯QQ群,共管理5个超级群,拥有1800多名会员,从2010年7月筹建《番禺爱婴网-谈儿说女》论坛,当前注册会员800多人,发贴8000多条。本区孕产妇及家属对孕期健康知识掌握和满意度明显提高,认为在互联网基础上建立的社交网络能更好地满足孕产妇对孕期健康知识的需求,达到医院和孕产妇的双赢。     

The process and the meaning of hope for family members of traumatic coma patients in intensive care

In this study, the authors examined the process that family members go through when they are confronted with traumatic coma. They conducted 24 semistructured interviews with 22 family members of 16 coma patients and analyzed the data using the constant comparative method as proposed by grounded theory. Hope was the most prominent theme. It can be described as keeping a possible positive outcome in mind in an uncertain situation, knowing that this outcome is unlikely to happen. Hope was found to evolve stepwise up and down, dependent on further events and information: big steps at first, smaller later on. Hope helps family members to keep going and to manage care for the patient and for each other. Family members were found to protect themselves against false or unjustified hope by seeking valid information. They alternate their moments of despair, and in their interactions they respect each other's hope.     

Therapeutic factors in occupational group therapy identified by patients discharged from a psychiatric day centre and their significant others

Therapeutic factors in occupational group therapy have only been subjected to minimal investigation [AUTHOR –I'VE REWRITTEN THE FIRST SENTENCE AS THE ORIGINAL SOUNDED ODD IN ENGLISH. IS THIS OK?]. Previous research (Howe & Schwartzberg, 1986) indicated that these factors accord with factors recognized in group psychotherapy, but additional specific occupational therapy factors were distinguished as well. The aim of the present study was to examine factors in treatment identified by patients and their significant others as therapeutic. Interviews with 20 mentally ill individuals and 12 significant others were conducted when the patients were discharged from a psychiatric day-care unit. Four therapeutic dimensions emerged from an inductive analysis of statements from the interviews: the group, the occupational, the treatment milieu, and the individual therapy. The majority of the statements were categorized in the group or occupational dimension. Important factors of the group dimension were group interaction, talking in a group, and the therapist's attitude and behaviour. The group factors were consistent with factors previously identified in group psychotherapy research studies. Being occupied, being engaged in certain activities, and developing new skills were significant within the occupational dimension. Since knowledge of which factors are perceived as helping the patients is important a) future replication studies are needed to determine how the occupational dimension should be specified into therapeutic factors, and b) research is required that makes clear how interventions can be improved by such factors. Copyright © 1997 Whurr Publishers Ltd.     

The cultural context of suicide stigma in Taiwan

In the ethnographic study on which this article is based, the authors investigate experiences after a suicide attempt from the perspective of patients and their family members in Taiwan. Thirty-four patients and 49 family members or colleagues participated in interviews from the point of patients' hospitalization to their return to the community. The postsuicide stigma suffered by patients and their families was based on such cultural themes as Suicide is bu-hsiao (non-filial piety), Suicide results in an inability to transmigrate the soul, and Suicide is inherited. Patients, family members, and colleagues cope with the stigma through explaining suicide as due to "bad luck" or "a kan-huo (hot energy) problem," or by insisting that it was "not a true suicide." These findings suggest that health professionals can move closer to patients and their families and suggest appropriate health care policy through understanding the patient's and the family's explanation of suicide experiences.     

Narratives and healing: exploring one family's stories of cancer survivorship

This study investigates the narratives of one couple who lived through life-changing events following a cancer diagnosis. The narratives of the cancer survivor and her husband are explored as they struggle to cope with their situation, provide support for one another, and consider their changing personal identities. This research addresses the communication dilemmas that often occur when family members, friends, and providers do not know how to respond to an individual diagnosed with cancer. The rationale for this study is threefold. First, this study advocates the need for learning about the composition of survivor identities over the course of a life-threatening illness. Second, this study seeks to understand how illness survivors and their family members use narratives as a method of communicating their changing identities. Finally, communicating about illness is often perceived as 'taboo', and this study may encourage others to be a part of the participants' stories and learn more about why those stories are often concealed. We learn from these three narratives that supportive relationships are central to healing and that it is through communication among family members that identities are composed and recomposed throughout the illness journey. This research affects communication, social support, identity, and emotion literature and is aligned with human appraisal theories as well. Finally, it offers insights into the ways in which we talk about, hear about, and learn about illness.     

Decisions around the end of life on Intensive Care: making the transition from curative to palliative treatment

The decision to move from curative treatment to palliative care in the intensive-care situation is less related to morals and ethics than it is to the assessment of medical issues, professionalism, communication and orchestration. Treatment should be considered medically pointless if, in the view of the treating physicians, it does not offer realistic chance to return to a meaningful life. Continuing futile care can be seen as disrespectful, both to the patient, his partner and the family, as well as to the members of the ICU team. Intensivists are responsible for withholding or withdrawing life support to patients in whom further life support is considered futile and who are unable to express their wishes due to critical illness and sedation. The intensivist typically makes this type of decision after a period in which medical and other information has been collected and after intensive discussions with other medical professionals as well as the partner and family. This is based on the trust that is built up through their skill, attitude and behaviour and that is perpetuated in a continuing process of intensive communication. Conflicts should be prevented, or at least recognised early and discussed. Ifa conflict is ongoing then it should be tackled by planning a number of consecutive consultations.     

How Doctors Learn in a Balint Group

A Balint group offers doctors the experience of meeting togetherregularly to discuss their own patients. The discussions areled by a psychoanalyst, or someone in touch with the approachfostered by psychoanalysis, and the group is helped to developan atmosphere of tolerance and safety. Participants are thusable to discuss cases that represent the personal difficultiesthey are currently experiencing in their daily work. This reportis about one group whose members agreed to allow the processof their work to be studied. It describes how they went aboutlearning from their daily experience with patients by usingthe group to work through their difficulties. It also describesmethods used to assess the quality of learning and the changesin personal attitudes. A Balint group has a safe and definedmode of working but no specific agenda, save that provided bythe personal cases presented by those who come regularly toits sessions. This study aims to describe the kind of experiencesuch a group can offer to intending participants.     

健康教育在重症监护室中的应用效果

目的：探讨健康教育在重症监护室中的应用效果。方法：将2011年6月-2012年6月人住重症监护室的36例患者作为观察组，将2010年1月-2011年1月人住重症监护室的32例患者作为对照组。观察组由专门的责任组成员对患者进行系统的、全方位的、动态的、连续的健康教育，包括心理指导、饮食指导、用药指导、作息指导、健康知识传授和技能指导等。对照组应用传统的护理方法进行常规护理及睡眠卫生宣教，常规开展人院介绍，术前、术中、术后健康教育。比较两组患者对疾病相关知识的掌握情况，并发症发生率及患者和家属对护理工作的满意度。结果：观察组患者对疾病掌握情况和治疗效果明显好于对照组，观察组并发症发生率明显低于对照组，观察组患者和家属对护理工作的满意度明显高于对照组，两组比较差异均有统计学意义（P〈O．05）。结论：重症监护室实施系统的、全方位的、动态的、连续的健康教育可以促进患者尽早度过危险期，早日转到普通病房继续治疗，提高患者满意度。     

Size Matters – Patient Organisations Exaggerate Prevalence Numbers

Patient organisations serve their members with information and support concerning a specific disease. In many cases they also contribute to research funding and lobby to improve the situation for their members. The larger group of patients an organisation claims to represent, the bigger their potential influence. Our hypothesis is that patient organiations exaggerate the number of persons affected with a specific disease. Prevalence figures from patient organisations in Sweden were collected via their own web sites. About 93 patient organisations were identified, 29 of which presented the estimates of disease occurrence used in this study. We calculated the probability for a person to have at least one disease and the proportion of the population not having any of the diseases listed. About 60% of the Swedish population have at least one disease covered by our sample of patient organisations. Nine tenths (87%) of the population would be ill if one assumes that an individual could only have one disease. Our rough estimates suggest that patient organisations exaggerate the number of ill persons. To render other messages on their agenda more trustworthy, we propose that some patient organisations moderate their prevalence and/or incidence figures.     

Building skills of recovering women drug users to reduce heterosexual AIDS transmission

Although most women infected with HIV are intravenous drug users, some contact the virus through sexual contact with IV drug users. To reach at-risk women, public health officials must develop a range of prevention strategies. One approach, skills training, holds promise as a means of altering risk-related sexual behavior. In this study, 91 women methadone patients were pretested and randomly assigned to an information-only control control group or a skills-building intervention group. Skills-building intervention consisted of five sessions of small groups in which participants identified their own high risk sexual behaviors, discussed their negative associations with condoms, and practiced skills which involved asking partners to use condoms. Compared with members of the control group, respondents in the intervention group reported that they initiated discussion of sexual issues with their partners more frequently, felt more comfortable talking with them about safer sex, and reported using and carrying condoms more frequently. The high rates of attendance and program retention by skills-building participants suggest that such groups may be supportive and useful in the design of risk reduction and drug abuse treatment programs. The modest outcomes of this study underscore the difficulty of altering risk behavior but also serve as a basis for future AIDS prevention studies.     

Factors influencing informal care-giving

BACKGROUND: As downsizing of institutional care continues, patients discharged are likely to have more severe mental illnesses, and to have experienced longer tenures within institutions than patients who have been discharged in the past. As greater numbers of patients are removed from mental hospitals, the objective burden experienced by informal care-givers may increase, particularly if formal care levels are inadequate. AIMS OF THE STUDY: This paper documents who assumes informal care-giver roles, and the form such care-giving takes for patients discharged from a state hospital. Specifically, this paper identifies (i) what factors affect a person's decision to assume a care-giver role, including the participation of other network members in care-giving, (ii) what factors influence whether care-giving is provided in time or in direct purchase of care and (iii) how the patient's treatment location affects the decision of the network member to assume any care-giving role. DATA AND ANALYTICAL METHODS: Data for this paper are taken from a longitudinal study of the closure of a state mental hospital in central Indiana. Seventy-seven patients were asked to identify their community networks. Ninety-eight network members were surveyed about the informal care, both in time or through direct expenditures, they provided to these patients one year after discharge. Care-giving relationships were estimated using a multivariate probit model. Such a model estimates the extent to which the decision to provide care in either form depends on the care-giving activities assumed by other network members associated with a given patient, as well as the characteristics of individual patients and network members. RESULTS: Forty-one per cent of network members provided some level of informal care, with 13.3% providing some care in time, and 35.7% providing some care through direct expenditures. A positive relationship was found between participation in informal care-giving and the perception by the network member that patient needs were not being met by professionals. The decision to provide informal care was also found to be sensitive to the level of informal and formal care received by the patient. Care-giving in expense was found to be positively related to the care-giving decisions of other informal care-givers, but care-giving in time was not. Network members were more likely to provide care in time for patients who had been recently discharged to the community than for patients who remained in institutional settings. CONCLUSIONS: These results suggest the transfer of persons with severe mental illnesses from state hospitals to the community may shift the care burden between formal and informal providers. If this is the case, discharge criteria should include such factors as the community resources available to the patient. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The responsiveness of network members to perceived unmet need bespeaks the importance of informal care when the continuity of formal care cannot be assured. Findings also suggest there may be some substitution of formal and informal care when patients are discharged from institutions. Further analysis is required to determine whether network members' perceptions of unmet need are accurate, and means by which network members can be made better attuned to unmet needs actually experienced by patients.     

The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants

BACKGROUND: Postpartum depression is seen in approximately 13% of women who have recently given birth; unfortunately, it often remains untreated. Important causes for undertreatment of this disorder are providers' and patients' lack of information about the effectiveness of various treatments, and their concerns about the impact of treatment on nursing infants. This article presents research-based evidence on the benefits of various treatments for postpartum depression and their potential risks to nursing infants. METHODS: The medical literature on postpartum depression treatment was reviewed by searching MEDLINE and Current Contents using such key terms as "postpartum depression," "treatment," "therapy," "psychotherapy," and "breastfeeding." Results and CONCLUSIONS: There is evidence that postpartum depression improves with antidepressant drug therapy, estrogen, individual psychotherapy, nurse home visits, and possibly group therapy. Of the more frequently studied antidepressant drugs in breastfeeding women, paroxetine, sertraline, and nortriptyline have not been found to have adverse effects on infants. Fluoxetine, however, should be avoided in breastfeeding women. By administering effective treatment to women with postpartum depression, we can positively impact the lives of mothers, their infants, and other family members.     

Depression in US Hispanics: diagnostic and management considerations in family practice

US Hispanics, currently the largest minority group in the country, face disparities in the recognition and treatment of major depression. This article provides an evidence-based review of the prevalence, presentation, and management of major depression in primary care in this heterogeneous ethnic group. Under-recognition of depression in adult Hispanic Americans may be related to language differences, health literacy barriers, somatic presentations, and use of cultural idioms of distress. Hispanic patients are often agreeable to treatment but as a group may tend to prefer psychotherapy or combined counseling and medication to pharmacotherapy alone. Recent studies have found both psychological and pharmacologic treatment options are efficacious in this minority group. Treatment adherence should be actively monitored to help ensure its effectiveness. To help reduce the number of depressed Hispanic patients who pass through primary care undetected or inadequately treated, family physicians should make a concerted effort to increase their awareness of the presentation of major depression in this population and actively promote adherence to effective treatments.