Melissa D. Pinto

Advance directives lessen the decisional burden of surrogate decision‐making for the chronically critically ill

AIMS AND OBJECTIVES To identify the relationships between advance directive status, demographic characteristics and decisional burden (role stress and depressive symptoms) of surrogate decision-makers (SDMs) of patients with chronic critical illness. BACKGROUND Although the prevalence of advance directives among Americans has increased, SDMs are ultimately responsible for complex medical decisions of the chronically critically ill patient. Decisional burden has lasting psychological effects on SDMs. There is insufficient evidence on the influence of advance directives on the decisional burden of surrogate decision-makers of patients with chronic critical illness. DESIGN The study was a secondary data analysis of cross-sectional data. Data were obtained from 489 surrogate decision-makers of chronically critically ill patients at two academic medical centres in Northeast Ohio, United States, between September 2005-May 2008. METHODS Data were collected using demographic forms and questionnaires. A single-item measure of role stress and the Center for Epidemiological Studies Depression (CESD) scale were used to capture the SDMs decisional burden. Descriptive statistics, t-tests, chi-square and path analyses were performed. RESULTS Surrogate decision-makers who were nonwhite, with low socioeconomic status and low education level were less likely to have advance directive documentation for their chronically critically ill patient. The presence of an advance directive mitigates the decisional burden by directly reducing the SDMs role stress and indirectly lessening the severity of depressive symptoms. CONCLUSIONS Most SDMs of chronically critically ill patients will not have the benefit of knowing the patients preferences for life-sustaining therapies and consequently be at risk of increased decisional burden. RELEVANCE TO CLINICAL PRACTICE Study results are clinically useful for patient education on the influence of advance directives. Patients may be informed that SDMs without advance directives are at risk of increased decisional burden and will require decisional support to facilitate patient-centred decision-making.

Stigma Scale for Receiving Psychological Help (SSRPH) An Examination Among Adolescent Girls

Stigma is one of the greatest obstacles to care and impedes recovery. The Stigma Scale for Receiving Professional Psychological Help (SSRPH), a measure of public stigma, has been used in young adults and has limited psychometric data in adolescents. This article reports the reliability and validity of the SSRPH in adolescent girls (N = 156, age = 13-17). Discriminant validity was supported, but concurrent validity was not. The confirmatory factor analysis revealed excellent model fit and serves as beginning evidence for construct validity. Cronbach’s alpha for the SSRPH was .65. The SSRPH was stable over 8 weeks. Findings suggest that the SSRPH can serve as a foundation for further instrument development. Future studies may explore enhancing the reliability and validity of the SSRPH and use advanced analytic techniques to examine the overall global construct of stigma, the latent constructs of public and private stigma, and associations of individual items to these constructs.

Multimedia decision support intervention: A promising approach to enhance the intention to complete an advance directive among hospitalized adults

Purpose: We examined the acceptability and initial efficacy of a multimedia decision support (MDS) intervention to improve intention to complete an advanced directive (AD) among hospitalized adults following an episode of critical illness. Data sources: We used comparative quasi‐experimental posttest only design. Forty‐nine hospitalized adults, recovering from a critical illness, received either MDS or AD educational brochure. Demographic characteristics and self‐report measures of AD knowledge were captured at baseline and used as covariates. Helpfulness of the intervention (acceptability) and the outcome variable, intention to complete an AD decision, were assessed after exposure to the MDS intervention or educational brochure (information‐only control condition). Conclusions: The MDS was a more acceptable form of education compared to a brochure. After adjusting for covariates, participants exposed to the MDS intervention were 24.7 times more likely to intend to complete an AD compared to those who were assigned to the information‐only control condition. Implications for practice: This pilot study establishes the acceptability and initial efficacy of the MDS intervention among individuals with critical illness, who are at high risk for hospital readmission life‐sustaining treatment. This study illuminates a teachable moment in which patients are more receptive to interventions to complete an AD.

Exploring the Relationships Among Level of Contact, Nature of Contact, and Mental Illness Stigma in Adolescent Girls

This study explored the relationship of individuals’ level of contact with someone with mental illness, and the nature of that contact, to mental illness stigma in adolescent females (N = 156). There were no significant associations among stigma and level of contact. The nature of the contact was significantly associated with stigma, such that those who knew someone who received treatment in a psychiatric facility had lower stigma, and those who attributed a deterioration of a past personal relationship to mental illness reported greater stigma.

Risky Tests of Etiological Models in Psychopathology Research: The Need for Meta-Methodology

Progress in elucidating the causes of mental illness has been frustratingly slow (Insel, 2009). Hence, we welcomed Vaidyanathan, Vrieze, and Iacono’s (this issue) provocative and well-reasoned essay calling for reform in the modal ways of doing business in psychopathology research. To be sure, some of this slow progress stems from inherent challenges in our subject matter (Meehl, 1978). For example, the causes of most or all major mental disorders appear to be exceedingly multifactorial (Kendler, 2005), and a full understanding of these causes necessitates a consideration of multiple levels of analysis ranging from the molecular to the physiological to the personological to the sociocultural (Lilienfeld, 2007). Needless to say, these difficulties are daunting. At the same time, as Vaidyanathan et al. note, the glacial progress of psychopathology research is also in large measure a self-inflicted wound. Perhaps in part for self-serving reasons, such as an understandable reluctance to subject our favored theories to intense scrutiny, we have often been reluctant to undertake “risky tests” of our models—those that place them at grave theoretical risk by maximizing the odds that they will be falsified if they are indeed false (Meehl, 1978; Popper, 1959). We concur with all of Vaidyanathan et al.’s principal arguments and recommendations. For example, we share their well-stated concerns regarding “statisticism” (Duncan, 1984) and “technomyopia” (Tavris, 2012; see also Satel & Lilienfeld, 2013). Although we applaud the increasing migration of advanced statistical procedures, such as structural equation modeling and confirmatory factor analysis, into psychological and psychiatric journals, we worry that the growing popularity of techniques may at times engender the illusion of methodological rigor in its absence. In particular, these methods may unjustifiably reassure investigators that they can aggregate suboptimal indicators of psychopathology into latent variables, thereby circumventing shortcomings with their designs and measures. Hence, an overreliance on these methods may inadvertently generate a misleading sense of comfort with the research status quo and a further reluctance to undertake risky tests of theoretical models. In some ways, this paradoxical result reminds us of the well-documented “risk compensation effect” in the health psychology literature (Pinkerton, 2001). Just as mandatory seat belt laws may sometimes backfire by reassuring automobile drivers that they are safe and can therefore drive dangerously (Evans & Graham, 1991), the use of high-level statistical techniques may sometimes backfire by reassuring researchers that they can always salvage less than adequate methodology by resorting to highwire acts of impressive quantitative sophistication. But one cannot make a silk’s purse out of a sow’s ears. Advanced statistical methods, as valuable as they are, cannot substitute for carefully conceptualized research designs, well-validated measures, and clinically significant translational research that generalizes to real-world settings outside the laboratory, nor can they allow for risky tests of theories in the absence of internally valid designs, those that rule out many or most rival threats to inferring causality. Indeed, we enthusiastically second Vaidyanathan et al.’s exhortation to use research designs, especially genetically informed designs, which permit risky tests of causal hypotheses. If we hold a different perspective from Vaidyanathan et al., it is almost certainly one of degree rather than of kind. Specifically, we suspect that we place somewhat more weight than they do on meta-methodological issues (Turner & Durham, 2014)—those that bear on the evaluation of theories across multiple studies—in the appraisal of etiological hypotheses. In fairness, Vaidyanathan et al. offer a brief nod to issues of replicability, multiple testing, and research practices that can lead to false positive results (p. 5), and it is evident that they are well aware of the importance of meta-methodological issues in theory appraisal. Because of the serious inferential problems posed by auxiliary hypotheses (e.g., the measures used, the samples examined; see Meehl, 1978) in the “soft” areas of psychology, such as psychopathology research, however, there are precious few, if any, definitive studies or “experimenta crucis” (Lohne, 1968): isolated investigations that definitely refute a theory. Instead, refutation of theories in psychopathology requires the gradual accumulation of negative evidence across multiple well-conducted studies, just as corroboration of theories requires an accumulation of supportive evidence across many studies.

Exploring the Mechanism of the Clinical Encounter on Depressive Symptoms in Young Adults: A Path Analysis

ABSTRACT Elucidating mechanisms of how high quality clinical encounters with providers may alleviate depressive symptoms in young adults are critical to reduce psychological morbidity and disability. Guided by Streets Model of Health Communication (SMHC), this study explores the predictive relationships of the clinical encounter, which includes communication functions (patient-provider communication and patient self-appraisal of communication skills with provider) and proximal outcomes (patient activation; PA) to improve health outcomes (depressive symptoms) in young adults. This study of young adults (n = 60) employed path analysis to examine the overall model fit and direct and indirect effects of each variable on depressive symptoms. The final SMHC had excellent model fit (X2 = 2.26, p =.32, TLI =.99, CFI = 1.00, RMSEA =.05). Patient-provider communication and self-appraised communication skills with providers had indirect effects on depressive symptoms and a direct effect on PA; PA had a direct effect on depressive symptoms (R2 =.30, p <.01). Findings elucidate potential novel targets, amenable to behavioral intervention, to improve depressive symptoms within the clinical encounter, and provide a foundation for hypothesis-driven model testing among young adults with depressive symptoms.

Preventive strategies to reduce depressive symptoms in overweight and obese young adults.

This study examined the relationships among problem-solving, physical activity self-efficacy, leisure-time physical activity, and depressive symptoms in overweight/obese young adults vulnerable to many health risks. Data from 96 young adults were used. The mean age and body mass index were 24.0±3.3 years old, and 36.9±7.9, respectively. There was a positive association between physical activity self-efficacy and leisure-time physical activity in African Americans, but not in non-African Americans. Better problem solving was associated with fewer depressive symptoms regardless of gender and race.