Robert J. Ferguson

Postconcussion syndrome following sports-related head injury: expectation as etiology.

Mild head trauma is often complicated by a persistent set of symptoms known as postconcussion syndrome (PCS). Past research has suggested that an expectancy-guided, retrospective-recall bias may account for much of the variance in PCS symptom reporting. The present study examined the influence of symptom expectations on mild head trauma symptom reports among participants in contact sports. Head-injured athletes reported symptom rates that did not differ from those of uninjured athletes but consistently underestimated the preinjury incidence of symptoms. Athletes with no head trauma history overestimated the expected degree of pre- to postinjury change in symptom status. Results suggest that individuals with mild head injury tend to overestimate postconcussion symptom change in a manner consistent with their symptom expectations. A cognitive-behavioral model that explains the persistence of PCS is proposed.

Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression.

Although anxiety disorders have been associated with impairments in self-reported health functioning, the relative effect of various anxiety disorders has not been studied. We compared health functioning of patients with a principal diagnosis of posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Patients with PTSD and MDD were equally impaired on overall mental health functioning, and both were significantly worse than patients with PD and GAD. PTSD was associated with significantly worse physical health functioning relative to PD, GAD, and MDD. Hierarchical regression showed that the association of PTSD with physical health functioning was unique and was not caused by the effects of age, depression, or comorbid anxiety disorders. Both PTSD and comorbid anxiety accounted for unique variance in mental functioning. These results highlight the association of PTSD with impaired physical and mental functioning and suggest that effective treatment of PTSD may affect overall health.

Use of the reliable change index to evaluate clinical significance in SF-36 outcomes.

The SF-36 Health Survey is the most widely used self-report measure of functional health. It is commonly used in both randomized controlled trials (RCT) and non-controlled evaluation of medical or other health services. However, determining a clinically significant change in SF-36 outcomes from pre-to-post-intervention, in contrast to statistically significant differences, is often not a focus of medical outcomes research. We propose use of the Reliable Change Index (RCI) in combination with SF-36 norms as one method for researchers, provider groups, and health care policy makers to determine clinically significant healthcare outcomes when the SF-36 is used as a primary measure. The RCI is a statistic that determines the magnitude of change score necessary of a given self-report measure to be considered statistically reliable. The RCI has been used to determine clinically significant change in mental health and behavioral medicine outcomes research, but is not widely applied to medical outcomes research. A usable table of RCIs for the SF-36 has been calculated and is presented. Instruction and a case illustration of how to use the RCI table is also provided. Finally, limitations and cautionary guidelines on using SF-36 norms and the RCI to determine clinically significant outcome are discussed.

Distinguishing between excessive daytime sleepiness and fatigue: toward improved detection and treatment.

INTRODUCTION Excessive daytime sleepiness (EDS) and fatigue occur in high percentages in the general population. They are common complaints in primary care and in specialty medicine. Although they may represent distinct or overlapping phenomena, the general medical literature does not normally distinguish between EDS and fatigue. Despite their prevalence, both EDS and fatigue are identified and treated in a relatively small proportion of those affected. The similarity of EDS and fatigue may create diagnostic ambiguity and thereby contribute to under-identification and under-treatment. Fatigue, in particular, is thought to be difficult to manage when it is identified. METHODS The literature was searched for reviews, meta-analysis and similar levels of papers focused on EDS or fatigue. RESULTS EDS and fatigue are operationalized in ways that contribute to blurring rather than to distinguishing between them. Existing measures of both EDS and fatigue may also contribute to their misidentification. Effective treatments for both symptoms have been established. Behavioral interventions are effective and underutilized. DISCUSSION We suggest more precise operationalization of EDS and fatigue, leading to a refinement of existing measures or development of new tools, a structured interview with fatigue and EDS sections in the clinical setting, and more consideration for behavioral interventions.

Private body consciousness, anxiety and pain symptom reports of chronic pain patients

An information processing model of pain symptom perception and reporting predicts that individuals prone to high levels of attentional self-focus and negative affect will report more pain than individuals low in these characteristics. Past research on college student and medical patient samples has shown that individuals high in private body consciousness (PBC), or attentional self-focus and who report higher levels of anxiety report more pain symptoms than counterparts low in PBC and anxiety. The present study examined effects of PBC and anxiety on pain reports of individuals suffering chronic pain (N = 144). Pain patients suffering chronic headache, low back pain, rheumatoid arthritis and fibromyalgia were included in the sample. A non-pain control sample (N = 31) was also studied to examine potential differences between controls and pain patients. Results indicated that pain patients reporting high levels of PBC reported more pain, although the effects of anxiety on pain reports among pain patients was not significant. Controls did not differ from pain patients on PBC, nor did the 4 groups of pain patients differ on PBC, suggesting PBC is a dispositional variable. Implications for the importance of attentional self-focus in pain symptom reporting are discussed.

Differential Reinforcement of other Behavior (DRO) to Reduce Aggressive Behavior Following Traumatic Brain Injury

Severe brain injury can result in significant neurobehavioral and social functioning impairment. In rehabilitation settings, behavioral problems of aggression and nonadherence to therapeutic activities can pose barriers to maximal recovery of function. Behavioral interventions seem to be effective in reducing problem behavior among individuals recovering from severe brain trauma, but well-controlled studies examining the efficacy of such interventions are sparse. This article presents a single-case, multiple-baseline study of a differential reinforcement of other behavior (DRO) procedure in a 28-year-old, brain-injured male with aggressive behavior problems. The procedure successfully reduced the frequency of problem behavior by up to 74%, maintained at 1-month follow-up. Implications of this intervention for individuals with brain injury are discussed, and testing of this procedure using a between-group design seems indicated.

The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease.

OBJECTIVE To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. METHODS Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. RESULTS The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiatives evidence-base and methods for others to replicate our work. CONCLUSIONS The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.

Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease

OBJECTIVE The spread of evidence-based care is an important challenge in healthcare. We evaluated spread of an evidence-based large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease (COMPASS). METHODS Primary care patients with depression and comorbid diabetes or cardiovascular disease were recruited. Collaborative care teams used care management tracking systems and systematic case reviews to track and intensify treatment for patients not improving. Targeted outcomes were depression remission and response (assessed with the Patient Health Questionnaire-9) and control of diabetes (assessed by HbA1c) and blood pressure. Patients and clinicians were surveyed about satisfaction with care. RESULTS Eighteen care systems and 172 clinics enrolled 3609 patients across the US. Of those with uncontrolled disease at enrollment, 40% achieved depression remission or response, 23% glucose control and 58% blood pressure control during a mean follow-up of 11 months. There were large variations in outcomes across medical groups. Patients and clinicians were satisfied with COMPASS care. CONCLUSIONS COMPASS was successfully spread across diverse care systems and demonstrated improved outcomes for complex patients with previously uncontrolled chronic disease. Future large-scale implementation projects should create robust processes to identify and reduce expected variation in implementation to consistently provide improved care.

Cognitive—Behavioral Treatment of Postconcussion Syndrome

Postconcussion Syndrome (PCS) is a disorder that occurs following about 75% to 80% of all mild head injuries (Alves, Colohan, O’Leary, Rimel, & Jane, 1986; Rimel, Girodani, Barth, Boll, & Jane, 1981). Whereas severe head injury generally produces neuropsychological deficits in memory and intellectual function, mild concussion can result in more subtle disruptions in daily functioning in the months following head trauma. This consistent cluster of postconcussive symptoms includes difficulty with attention and concentration, disturbances in memory, headache, vertigo, anxiety, depression, fatigue, irritability, blurred vision, and sensitivity to light (Mittenberg, DiGiulio, Perrin, & Bass, 1992; World Health Organization, 1978). Given that nearly 325,000 head injuries that annually occur in the United States are classified as mild (Levin, Eisenberg, & Benton, 1989), design of effective treatment for PCS appears warranted.

Management of Chemotherapy-Related Cognitive Dysfunction

Dysfunction in memory and attention associated with cancer treatment has gained increased attention over the past two decades. In 1999 the President’s Cancer Panel1 and the National Coalition for Cancer Survivorship2 formally recognized the problem as a quality of life matter that deserved higher priority in clinical research. With nearly 1 million chemotherapy recipients annually in the United States alone, the problem is widespread. Over this same time span, research has clearly documented persistent cognitive deficits following various cancer treatments, especially for the pediatric population, but there has been increasing investigation on the effects of systemic chemotherapy among adult cancer survivors. The nature of these findings will be summarized here to illustrate the rationale for cognitive and behavioral strategies that may help improve management of chemotherapy-related cognitive dysfunction. This chapter will describe a recently developed cognitive–behavioral treatment that is being studied to aid survivors with chemotherapy-related cognitive problems and outline future directions of management.