Margaret M. Rea

FAMILY-FOCUSED TREATMENT VERSUS INDIVIDUAL TREATMENT FOR BIPOLAR DISORDER: RESULTS OF A RANDOMIZED CLINICAL TRIAL

Recently hospitalized bipolar, manic patients (N = 53) were randomly assigned to a 9-month, manual-based, family-focused psychoeducational therapy (n = 28) or to an individually focused patient treatment (n = 25). All patients received concurrent treatment with mood-stabilizing medications. Structured follow-up assessments were conducted at 3-month intervals for a 1-year period ofactive treatment and a 1-year period of posttreatment follow-up. Compared with patients in individual therapy, those in family-focused treatment were less likely to be rehospitalized during the 2-year study period. Patients in family treatment also experienced fewer mood disorder relapses over the 2 years, although they did not differ from patients in individual treatment in their likelihood of a first relapse. Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder.

Adolescent Primary Care Patients' Preferences for Depression Treatment

Despite efficacious treatments for depression in youth, current data indicate low rates of care. To better understand reasons for these low rates of care, we examined treatment preferences for depression treatment. Adolescents (N=444) who screened positive for depression at a primary care visit completed measures of predisposing, enabling, and need characteristics thought to be related to help seeking. Results indicated a strong tendency for adolescents to prefer active treatment (72%) versus watchful waiting (28%), and for youth to prefer counseling (50%) versus medication (22%). Female gender, prior treatment experience, and current depression and anxiety were related to preference for active treatment over watchful waiting. In multivariable analyses, female gender and current anxiety symptoms remained significant predictors of preference for active treatment. Ethnicity, attitudes about depression care, prior treatment experience, and anxiety symptoms were related to preference for medication over counseling. In multivariable analyses, those with negative attitudes about depression treatment generally, with positive attitudes about treatment via medication, or with current anxiety symptoms were more likely to prefer medication. Youth preference for counseling over medication may contribute to low adherence to medication treatment and underscores the importance of patient education aimed at promoting positive expectations for treatments.

Long-Term Benefits of Short-Term Quality Improvement Interventions for Depressed Youths in Primary Care

OBJECTIVE Quality improvement programs for depressed youths in primary care settings have been shown to improve 6-month clinical outcomes, but longer-term outcomes are unknown. The authors examined 6-, 12-, and 18-month outcomes of a primary care quality improvement intervention. METHOD Primary care patients 13-21 years of age with current depressive symptoms were randomly assigned to a 6-month quality improvement intervention (N=211) or to treatment as usual enhanced with provider training (N=207). The quality improvement intervention featured expert leader teams to oversee implementation of the intervention; clinical care managers trained in cognitive-behavioral therapy for depression to support patient evaluation and treatment; and support for patient and provider choice of treatments. RESULTS The quality improvement intervention, relative to enhanced treatment as usual, lowered the likelihood of severe depression (Center for Epidemiological Studies Depression Scale score > or =24) at 6 months; a similar trend at 18 months was not statistically significant. Path analyses revealed a significant indirect intervention effect on long-term depression due to the initial intervention improvement at 6 months. CONCLUSIONS In this randomized effectiveness trial of a primary care quality improvement intervention for depressed youths, the main effect of the intervention on outcomes was to decrease the likelihood of severe depression at the 6-month outcome assessment. These early intervention-related improvements conferred additional long-term protection through a favorable shift in illness course through 12 and 18 months.

Prodromal symptoms and signs of bipolar relapse: A report based on prospectively collected data

Prospectively collected data on 19 recently hospitalized patients with bipolar disorder were examined for prodromal changes preceding relapse. The 4-month periods before six manic and six depressive relapses were compared with each other and with a comparable period for seven patients who did not relapse. The Brief Psychiatric Rating Scale was used to assess symptoms. Significant elevations in unusual thought content were found 1 month before manic relapse. Depressive relapsers evidenced higher levels of conceptual disorganization throughout the prerelapse period. Nonrelapsers showed very stable symptom profiles.

Changes in eye tracking during clinical stabilization in schizophrenia.

Eye tracking abnormalities have been proposed as a trait marker for schizophrenia on the basis of their familial prevalence and the consistency of tracking over time in clinically stable patients. However, few studies have examined stability through acute episodes of illness, and most studies have not analyzed changes in different forms of eye movements. Therefore, the authors examined eye tracking, clinical state, and neuroleptic dose during 4 consecutive weeks in nine recently hospitalized schizophrenic patients. For the patients and controls, qualitative ratings of pursuit accuracy remained relatively stable over time. In contrast, saccade frequency increased significantly, with a 57% increase in small saccades and a 77% reduction in larger saccades. In comparison with cross-sectional studies which have found no correlation between neuroleptic dose and tracking performance, a reduction in large saccades was strongly correlated with increase in neuroleptic dose. The findings suggest that pursuit accuracy may be a trait characteristic of schizophrenia, while the frequency and size of saccades are state dependent characteristics.

Outcomes for Youths from Racial-Ethnic Minority Groups in a Quality Improvement Intervention for Depression Treatment

OBJECTIVE This study examined racial-ethnic differences in the impact of the Youth Partners in Care quality improvement intervention. The intervention was designed to improve access to evidence-based depression care, primarily cognitive-behavioral therapy and medication, through primary care. Previous analyses have shown that the quality improvement intervention was associated with improved depression and quality-of-life outcomes at the end of the six-month intervention period. METHODS A randomized controlled trial comparing quality improvement and usual care for youths from diverse racial-ethnic groups from five health care organizations, including managed care, the public sector, and academic center clinics, was conducted. Depressed youths (N=325), who self-identified as black (N=59), Latino (N=224), and white (N=42), aged 13-21 years, were included in these analyses. To evaluate intervention effects within racial-ethnic groups, regression models were constructed, which adjusted for baseline and study site variation in depression symptoms, mental health status, satisfaction with mental health care, and mental health service utilization. RESULTS Differential intervention effects were found across racial-ethnic groups. Black youths in the intervention group experienced significant reductions in depression symptoms and had higher rates of use of specialty mental health care at the six-month follow-up. Among Latino youths, the intervention was associated with significantly greater satisfaction with care. Intervention effects were weak among white youths. CONCLUSIONS Quality improvement interventions may help to reduce disparities in mental health care for youths from racial-ethnic minority groups. (

The State of Medical Student Wellness: A Call for Culture Change

In recent years, multiple studies exploring medical student mental health highlight the increased frequency and severity of emotional problems during physicians’ formative years. Although these studies demonstrate a clear burden on medical students, we have not achieved a broader understanding of malleable factors in student wellness, and, thus, effective interventions to promote wellness are lagging behind. The development of evidence-based preventive and clinical programs in academic centers requires an appropriate focus on overall medical student wellness, encompassing academic and institutional elements. Successful models of student wellness programs exist (1); however, best-practices in this area have not yet been developed. A systematic review of studies among U.S. and Canadian medical students showed a higher prevalence of anxiety and depression among these students than in their age-matched peers (2). Even more worrisome, 11% of students in a longitudinal cohort from seven medical schools admitted to having had suicidal thoughts in the previous year (3). Over time, medical student health centers have seen an increased utilization of services (4, 5). It is unclear whether this is due to a higher prevalence and/or severity of mental disorders, increased identification of disorders, improved availability of services, reduced stigma, or a combination of these factors. This commentary will review factors that may contribute to student distress and discuss suggestions for effective interventions to address these. Our purpose is to provoke thought and debate about student wellness and to inspire action through the development of evidence-based interventions to improve wellness at medical schools across the country. Contributing Factors and Strategies for Culture Change Factors contributing to students’ mental health difficulties during medical school may be individual (intrapersonal and interpersonal) and/or environmental (institutional; see Table 1). These may include preexisting or de novo medical and/or mental illness; academic difficulties; emotional intelligence (EI) deficits (being unaware of one’s own or others’ emotions and having limited ability to effectively communicate and work with others); intolerable stress due to high workload, with high performance expectations and exposure to human suffering; confronting the hierarchical culture of medicine, including intergenerational clashes; neglect of social support networks, leading to isolation; and interpersonal stressors (e.g., a family member’s illness, divorce, separation, long-distance relationships, and financial pressures) (6, 7). The following sections outline factors contributing to student distress, paired with potential strategies for addressing them. In some cases, solutions have been described in the literature. Additional suggestions are presented, based on our institutions’ experiences.

The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review

BackgroundThere has been increasing interest in examining the relationship between physician wellbeing and quality of patient care. However, few reviews have specifically focused on resident burnout and quality of patient care. The purpose of this systematic literature review of the current scientific literature is to address the question, “How does resident burnout affect the quality of healthcare related to the dimensions of acceptability and safety?”MethodsThis systematic literature review uses a multi-step screening process of publicly available peer-reviewed studies from five electronic databases: (1) Medline Current, (2) Medline In-process, (3) PsycINFO, (4) Embase, and (5) Web of Science.ResultsThe electronic literature search resulted in the identification of 4638 unique citations. Of these, 10 articles were included in the review. Studies were assessed for risk of bias. Of the 10 studies that met the inclusion criteria, eight were conducted in the US, one in The Netherlands, and one in Mexico. Eight of the 10 studies focused on patient safety. The results of these included studies suggest there is moderate evidence that burnout is associated with patient safety (i.e., resident self-perceived medical errors and sub-optimal care). There is less evidence that specific dimensions of burnout are related to acceptability (i.e., quality of care, communication with patients).ConclusionsThe results of this systematic literature review suggest a relationship between patient safety and burnout. These results potentially have important implications for the medical training milieu because residents are still in training and at the same time are asked to teach students. The results also indicate a need for more evidence-based interventions that support continued research examining quality of care measures, especially as they relate to acceptability.