Bethany M. Kwan

Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression.

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.

In-task and post-task affective response to exercise: Translating exercise intentions into behaviour

OBJECTIVES To test whether affective response to an acute bout of exercise can predict regular voluntary exercise, and specifically whether a positive affective response helps translate intentions into behaviour. DESIGN A prospective correlational design. METHODS Participants (N=127) recruited from the community reported intentions to engage in voluntary exercise and frequency of participation in voluntary exercise both at baseline and at a 3-month follow-up. Self-reported positive affect, negative affect, tranquillity, and fatigue were assessed during a bout of moderate intensity exercise. RESULTS Within subject slopes for increases in positive affect and decreases in fatigue during exercise, and increased tranquillity and decreased fatigue post-exercise were associated with more frequent participation in exercise at follow-up. Changes in negative affect did not predict exercise at follow-up; however, this was likely due to floor effects leading to lack of baseline variability in negative affect. Importantly, a positive affective response to exercise moderated the intention-behaviour relationship, such that those who responded to exercise more favourably exhibited stronger relationships between intentions and future exercise behaviour Conclusions: We conclude that exercise-related increases in positive affect and tranquillity and decreases in feelings of fatigue can aid in the successful translation of exercise intentions into behaviour.

A longitudinal diary study of the effects of causality orientations on exercise-related affect

According to self-determination theory, a tendency to view causes of a behavior as autonomous, controlled, or impersonal can influence motivation, self-regulation, and experience. We propose that causality orientations for exercise may shape self-determined regulations for exercise by leading to more positive exercise-related affect, leading to greater internalization of exercise behavior and more self-determined regulations to exercise (e.g., regulation on the basis of inherent interest and personally-held values). Methods: Participants (N = 104) kept an online diary for four weeks documenting exercise behavior and affect experienced during exercise. Exercise causality orientations were measured at baseline and exercise regulations were measured at follow-up. Analyses were performed using multilevel modeling and path analysis. Results: Exercise-related affect was more positive for those with higher levels of the autonomy orientation and lower levels of the impersonal orientation. Exercise-related affect partially mediated the relationship between autonomy and impersonal orientations and self-determined regulations for exercise. Conclusions: Affective responses to self-selected exercise were more positive for those who tend to perceive exercise opportunities as more autonomous, which in turn led to more self-determined regulations.

Effects of current physical activity on affective response to exercise: Physical and social-cognitive mechanisms

Affective responses during exercise are often important determinants of exercise initiation and maintenance. Current physical activity may be one individual difference that is associated with the degree to which individuals have positive (or negative) affective experiences during exercise. The objective of this study was to explore physical and cognitive explanations of the relationship between current activity status (more versus less active) and affective response during a 30-minute bout of moderate-intensity exercise. Participants reported their current level of physical activity, exercise self-efficacy and affect during a 30-minute bout of moderate-intensity exercise. More active individuals experienced higher levels of positive affect and tranquillity and lower levels of negative affect and fatigue during exercise. Multivariate models for each affective state indicated separate processes through which physical activity may be associated with changes in affect during exercise. These models indicate that affect experienced during physical activity is related to the current activity level and these relationships can be partially explained by the physical and cognitive factors explored in this study. Recommendations for future research to elucidate whether positive affective response to physical activity improves as a function of becoming more active over time are discussed.

The State of the Evidence for Integrated Behavioral Health in Primary Care

Integrated behavioral health care is a complex, multifaceted healthcare delivery approach that is geared towards addressing mental and behavioral health concerns in primary care. There are a number of different models for integrated behavioral health care, with components that can be conceptualized as structures of care, processes of care, or principles of care. Common models include the IMPACT model (care management for depression), the three-component model (care management, enhanced mental health support, and a prepared practice), and the primary mental health care model of colocated integrated behavioral health care (on-site mental health specialists who collaborate with primary care providers), among others. Meta-analysis has shown that integrated behavioral health care improves health outcomes, although the extant evidence primarily pertains to depression. It is not well known which components of integrated behavioral health care are either necessary or sufficient for improving outcomes. There are many evidence gaps in integrated behavioral health care, including implementation and dissemination and the effects of integrated behavioral health care on disease contexts other than depression, behavioral medicine (e.g., lifestyle change in primary care), diverse populations, and cost and sustainability outcomes. Multiple methodologies should be deployed to address these gaps, including quasi-experimental, mixed methods (quantitative and qualitative), and observational designs.

Stakeholder Engagement in a Patient-Reported Outcomes (PRO) Measure Implementation: A Report from the SAFTINet Practice-based Research Network (PBRN)

Purpose: Patient-reported outcome (PRO) measures offer value for clinicians and researchers, although priorities and value propositions can conflict. PRO implementation in clinical practice may benefit from stakeholder engagement methods to align research and clinical practice stakeholder perspectives. The objective is to demonstrate the use of stakeholder engagement in PRO implementation. Method: Engaged stakeholders represented researchers and clinical practice representatives from the SAFTINet practice-based research network (PBRN). A stakeholder engagement process involving iterative analysis, deliberation, and decision making guided implementation of a medication adherence PRO measure (the Medication Adherence Survey [MAS]) for patients with hypertension and/or hyperlipidemia. Results: Over 9 months, 40 of 45 practices (89%) implemented the MAS, collecting 3,247 surveys (mean = 72, median = 30, range: 0 - 416). Facilitators included: an electronic health record (EHR) with readily modifiable templates; existing staff, tools and workflows in which the MAS could be integrated (e.g., health risk appraisals, hypertension-specific visits, care coordinators); and engaged leadership and quality improvement teams. Conclusion: Stakeholder engagement appeared useful for promoting PRO measure implementation in clinical practice, in a way that met the needs of both researchers and clinical practice stakeholders. Limitations of this approach and opportunities for improving the PRO data collection infrastructure in PBRNs are discussed.

What to expect when you’re exercising: An experimental test of the anticipated affect–exercise relationship.

Objective: Anticipated affect may influence exercise behavior via experienced affective responses and intentions. Cognitive manipulations of anticipated affect may inform exercise intervention design. The purpose of this study was to experimentally test the effects of an expectation-based manipulation of affective responses to exercise on anticipated, experienced, and remembered affect and adherence to a 7-day exercise prescription. Method: Participants (N = 98) were randomly assigned to a positive anticipated affect manipulation, a negative anticipated affect manipulation, or a no affect manipulation control. They reported anticipated, experienced, and remembered affect during and after a standardized 30-min bout of treadmill exercise at an intensity just below ventilatory threshold. Participants were asked to try to complete the prescribed exercise daily for 1 week. Differences in affect and exercise behavior were examined across conditions, as were relationships between affect measures, intentions and behavior. Results: The manipulation influenced anticipated and experienced affective responses, but not behavior. Participants generally expected exercise to be less pleasant and more fatiguing that it actually was. Anticipated, experienced, and remembered affect were associated with intentions to exercise. Intentions and remembered affect were both directly associated with exercise behavior. Conclusions: Moderate-to-vigorous exercise can be more pleasant than people expect it to be. Additionally, encouraging exercisers to focus on the positive affective outcomes of exercise can yield a more positive affective experience than those who focus on negative affective outcomes or do not focus on affective outcomes at all. The role of affect in both reflective and automatic motivation to exercise is discussed.

Stakeholder engagement in diabetes self-management: patient preference for peer support and other insights

Background Self-management support (SMS) for patients with diabetes can improve adherence to treatment, mitigate disease-related distress, and improve health outcomes. Translating this evidence into real-world practice is needed, as it is not clear which SMS models are acceptable to patients, and feasible and sustainable for primary care practices. Objective To use the Boot Camp Translation (BCT) method to engage patient, practice, community resource and research stakeholders in translation of evidence about SMS and diabetes distress into mutually acceptable care models and to inform patient-centred outcomes research (PCOR). Participants Twenty-seven diabetes care stakeholders, including patients and providers from a local network of federally qualified health centres participated. Methods Stakeholders met in-person and by conference call over the course of 8 months. Subject matter experts provided education on the diabetes SMS evidence. Facilitators engaged the group in discussions about barriers to self-management and opportunities for improving delivery of SMS. Key Results BCT participants identified lack of social support, personal resources, trust, knowledge and confidence as barriers to diabetes self-management. Intervention opportunities emphasized peer support, use of multidisciplinary care teams and centralized systems for sharing information about community and practice resources. BCT informed new services and a PCOR study proposal. Conclusions Patients and family engaged in diabetes care research value peer support, group visits, and multidisciplinary care teams as key features of SMS models. SMS should be tailored to an individual patients health literacy. BCT can be used to engage multiple stakeholders in translation of evidence into practice and to inform PCOR.

Medical Home Characteristics and Asthma Control: A Prospective, Observational Cohort Study Protocol

Background: This paper describes the methods for an observational comparative effectiveness research study designed to test the association between practice-level medical home characteristics and asthma control in children and adults receiving care in safety-net primary care practices. Methods: This is a prospective, longitudinal cohort study, utilizing survey methodologies and secondary analysis of existing structured clinical, administrative, and claims data. The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) is a safety net-oriented, primary care practice-based research network, with federated databases containing electronic health record (EHR) and Medicaid claims data. Data from approximately 20,000 patients from 50 practices in four healthcare organizations will be included. Practice-level medical home characteristics will be correlated with patient-level asthma outcomes, controlling for potential confounding variables, using a clustered design. Linear and non-linear mixed models will be used for analysis. Study inception was July 1, 2012. A causal graph theory approach was used to guide covariate selection to control for bias and confounding. Discussion: Strengths of this design include a priori specification of hypotheses and methods, a large sample of patients with asthma cared for in safety-net practices, the study of real-world variations in the implementation of the medical home concept, and the innovative use of a combination of claims data, patient-reported data, clinical data from EHRs, and practice-level surveys. We address limitations in causal inference using theory, design and analysis.

Encouragement of patient self-management and adherence through use of a computerized tracking system for cervical and colon cancer screening.

Despite high rates of Papanicolaou smear (Pap) screening in the United States (more than 90%), nonadherence to follow-up recommendations is common, ranging from below 10% to more than 40%.[1][1]–[3][2] Ensuring completion of appropriate follow-up of abnormal Paps can be a significant clinical