Rendelle E. Bolton

Postpartum depression, suicidality, and mother-infant interactions

To date, few studies have examined suicidality in women with postpartum depression. Reports of suicidal ideation in postpartum women have varied (Lindahl et al. Arch Womens Ment Health 8:77–87, 2005), and no known studies have examined the relationship between suicidality and mother-infant interactions. This study utilizes baseline data from a multi-method evaluation of a home-based psychotherapy for women with postpartum depression and their infants to examine the phenomenon of suicidality and its relationship to maternal mood, perceptions, and mother-infant interactions. Overall, women in this clinical sample (nu2009=u200932) had wide ranging levels of suicidal thinking. When divided into low and high groups, the mothers with high suicidality experienced greater mood disturbances, cognitive distortions, and severity of postpartum symptomotology. They also had lower maternal self-esteem, more negative perceptions of the mother-infant relationship, and greater parenting stress. During observer-rated mother-infant interactions, women with high suicidality were less sensitive and responsive to their infants’ cues, and their infants demonstrated less positive affect and involvement with their mothers. Implications for clinical practice and future research directions are discussed.

Evaluating a home-based dyadic intervention: Changes in postpartum depression, maternal perceptions, and mother–infant interactions†

Psychotherapeutic treatments that focus on improving the relational processes between mothers with postpartum depression (PPD) and their infants, as well as the mothers individual therapeutic needs, have a great potential to positively impact the mother, her infant, and their relationship (K.J. Nylen, T.E. Moran, C.L. Franklin, & M. OHara, 2006). Utilizing pilot data from an evaluation of a home-based dyadic therapy for mothers with PPD and their infants, this article reports on a recent academic-community partnership study. The effectiveness of the intervention was examined, specifically regarding changes in mothers mood, parenting experience, and relationship with her infant. In addition, associations were examined among maternal self-report variables measuring change from pre- to posttreatment in PPD, psychological distress, and maternal perceptions of parenting and those variables measuring change in observer ratings of maternal-infant interactions. Results showed improvements in mothers depression, distress, and perceptions of parenting as well as many ratings of mothers interactions with their infants. However, only improvements in maternal perceptions of parenting, such as maternal self-esteem and parenting stress, were associated with better mother--infant interactions. Importance of this research for the field of infant mental health as well as clinical implications are discussed.

A National Survey of Pulmonologists' Views on Low-Dose Computed Tomography Screening for Lung Cancer.

RATIONALEnMultiple guidelines now recommend low-dose computed tomography (LDCT) screening for lung cancer. Given their central role in the planning of LDCT screening programs, pulmonologists beliefs about LDCT screening will affect the safety, cost-effectiveness, and success of LDCT screening implementation.nnnOBJECTIVESnTo assess pulmonologists propensity to offer lung cancer screening and their perceptions about LDCT screening.nnnMETHODSnWe performed a national web-based survey, administered July 2013 to February 2014, among all staff pulmonologists active in Veterans Health Administration pulmonary clinics. The primary outcome was screening propensity (on the basis of responses to clinical vignettes) in relation to guidelines. Using bivariate and multinomial logistic regression, we assessed how perceptions of the evidence, trade-offs, and barriers to implementation of LDCT screening programs affected propensity to screen.nnnMEASUREMENTS AND MAIN RESULTSnOf 573 eligible pulmonologists e-mailed, 286 (49.9%) participated. Approximately one-half (52.4%) had a propensity for guideline-concordant screening, 22.7% for overscreening, and 24.9% for underscreening. In bivariate analyses, guideline concordance was associated with acceptance of trial evidence, guidelines, and the efficacy of screening. In multivariable models, underscreeners were more likely to cite the potential harms of screening (e.g., false-positive findings, radiation exposure, incidental findings, unfavorable cost-benefit ratio), as influential factors (relative risk, 3.9; 95% confidence interval, 1.5-9.67) and were less influenced by trial evidence and guidelines (relative risk, 0.06; 95% confidence interval, 0.02-0.2), as compared with guideline-concordant screeners. Local resource availability did not significantly affect screening propensity, but insufficient infrastructure and personnel were commonly perceived barriers to implementation.nnnCONCLUSIONSnPulmonologists have varied perceptions of the evidence and trade-offs of LDCT screening, leading to the potential for over- and underscreening. To minimize potential harms as LDCT screening is widely implemented, physicians must understand which patients are appropriate candidates and engage those patients in a shared decision-making process regarding the trade-offs of LDCT screening.

Mental Health Providers' Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD.

It is estimated that <15% of veterans with posttraumatic stress disorder (PTSD) have engaged in two evidence-based psychotherapies highly recommended by VA—cognitive processing therapy (CPT) and prolonged exposure (PE). CPT and PE guidelines specify which patients are appropriate, but research suggests that providers may be more selective than the guidelines. In addition, PTSD clinical guidelines encourage “shared decision-making,” but there is little research on what processes providers use to make decisions about CPT/PE. Sixteen licensed psychologists and social workers from two VA medical centers working with ≥1 patient with PTSD were interviewed about patient factors considered and decision-making processes for CPT/PE use. Qualitative analyses revealed that patient readiness and comorbid conditions influenced decisions to use or refer patients with PTSD for CPT/PE. Providers reported mentally derived and instances of patient-involved decision-making around CPT/PE use. Continued efforts to assist providers in making informed and collaborative decisions about CPT/PE use are discussed.

MOTHER―INFANT PSYCHOTHERAPY: EXAMINING THE THERAPEUTIC PROCESS OF CHANGE

Les traitements qui incluent la dyade mere-nourrisson ont fait preuve dune grand potentiel pour mitiger les effets deleteres des problemes de sante mentale maternelle pour la mere, le nourrisson et la relation mere-nourrisson. Cette etude utilise des donnees de groupes de discussion de cliniciens offrant une psychotherapie mere-nourrisson dans un programme americain appele Early Connections (rapports precoces), une psychotherapie mere-nourrisson a domicile pour le traitement des troubles postpartum de lhumeur. Les resultats mettent en evidence les aspects du processus de la psychotherapie mere-nourrisson qui cointribuent a changer et a positiver le developpement relationnel dans la dyade mere-nourrisson, ainsi que lalliance therapeutique. Vus a travers le prisme des theories relationnelles pertinentes au traitement mere-nourrisson (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991; Stern, Bruschweiler-Stern, Harrison, Lyons-Ruth, Morgan et al., 1998) les resultats de cette etude soutiennent limportance du rapport relationnel et du moment present (Stern et al., 1998, p. 304) en tant que facteurs catalytiques dans le changement et la croissance qui surviennent durant la psychotherapie. Les implications pour la pratique clinique et les directions de recherches a venir sont discutees.

Evaluations of Implementation at Early-Adopting Lung Cancer Screening Programs: Lessons Learned

Background Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high‐quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early‐adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation. Methods We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory. Results Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care “buy‐in.” To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre‐existing relationships and including a designated program champion helped facilitate intradisciplinary communication. Conclusions Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early‐adopting programs may inform subsequent design and implementation of LCS programs.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care

Patient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing.

Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study

ABSTRACTBackgroundGuidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings.ObjectiveTo characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making.DesignQualitative study entailing semi-structured interviews and focus groups.ParticipantsWe enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net).ApproachUsing content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making.Key ResultsClinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making.ConclusionsDue to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening’s rationale, trade-offs, and process.

The moral discourse of HIV providers within their organizational context: An ethnographic case study

OBJECTIVEnProviders make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts.nnnMETHODSnOur ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes.nnnRESULTSnWe interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as good, behaving, or socio-paths, and flakes. Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients life challenges.nnnCONCLUSIONS AND PRACTICE IMPLICATIONSnWhen self-management is viewed as an individuals responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients behaviors as socially embedded.

Biopsychosocial benefits of movement-based complementary and integrative health therapies for patients with chronic conditions:

Objectives Complementary and integrative health practices are growing in popularity, including use of movement-based therapies such as yoga, tai-chi, and qigong. Movement-based therapies are beneficial for a range of health conditions and are used more frequently by individuals with chronic illness. Yet little is known about how patients with chronic conditions characterize the health benefits of movement-based therapies. Methods We conducted focus groups with 31 patients enrolled in yoga and qigong programs for chronic conditions at two VA medical centers. Transcripts were analyzed using conventional content analysis with codes developed inductively from the data. Participants’ descriptions of health benefits were then mapped to Engel’s biopsychosocial model. Results Participants described improvements in all biopsychosocial realms, including improved physical and mental health, reduced opiate and psychotropic use, enhanced emotional well-being, and better social relationships. Changes were attributed to physical improvements, development of coping skills, and increased self-awareness. Discussion Patients with chronic illnesses in our sample reported multiple benefits from participation in movement-based therapies, including in physical, mental, and social health realms. Providers treating patients with complex comorbidities may consider referrals to movement-based therapy programs to address multiple concerns simultaneously, particularly among patients seeking alternatives to medication or adjunctive to an opiate reduction strategy.