Sapana R. Patel

Randomized Controlled Trial of Yoga Among a Multiethnic Sample of Breast Cancer Patients: Effects on Quality of Life

PURPOSE This study examines the impact of yoga, including physical poses, breathing, and meditation exercises, on quality of life (QOL), fatigue, distressed mood, and spiritual well-being among a multiethnic sample of breast cancer patients. PATIENTS AND METHODS One hundred twenty-eight patients (42% African American, 31% Hispanic) recruited from an urban cancer center were randomly assigned (2:1 ratio) to a 12-week yoga intervention (n = 84) or a 12-week waitlist control group (n = 44). Changes in QOL (eg, Functional Assessment of Cancer Therapy) from before random assignment (T1) to the 3-month follow-up (T3) were examined; predictors of adherence were also assessed. Nearly half of all patients were receiving medical treatment. RESULTS Regression analyses indicated that the control group had a greater decrease in social well-being compared with the intervention group after controlling for baseline social well-being and covariates (P < .0001). Secondary analyses of 71 patients not receiving chemotherapy during the intervention period indicated favorable outcomes for the intervention group compared with the control group in overall QOL (P < .008), emotional well-being (P < .015), social well-being (P < .004), spiritual well-being (P < .009), and distressed mood (P < .031). Sixty-nine percent of intervention participants attended classes (mean number of classes attended by active class participants = 7.00 +/- 3.80), with lower adherence associated with increased fatigue (P < .001), radiotherapy (P < .0001), younger age (P < .008), and no antiestrogen therapy (P < .02). CONCLUSION Despite limited adherence, this intent-to-treat analysis suggests that yoga is associated with beneficial effects on social functioning among a medically diverse sample of breast cancer survivors. Among patients not receiving chemotherapy, yoga appears to enhance emotional well-being and mood and may serve to buffer deterioration in both overall and specific domains of QOL.

National trends in ethnic disparities in mental health care.

Objective:To compare trends in office-based treatment of mental disorders between Hispanics and non-Hispanics. Design, Setting, and Participants:Analysis of a nationally representative sample of visits to office-based physicians conducted between 1993 and 2002 (N = 251,905). Visits were grouped into 3 discrete time periods, 1993–1996, 1997–1999 and 2000–2002. Main Outcome Measures:Rate of diagnosis, type of mental health visit, type of treatment received (medication or psychotherapy), rate of psychotropic medications prescription, and specialty of the treating physician. Results:From 1993–1996 to 2000–2002, the proportion of office visits in which mental health care was provided decreased for Hispanics from 12.2% to 11.7% while it increased from 13.1% to 15.7% for non-Hispanics (P < 0.05). Visits with a diagnosis of mental disorder decreased from 5.2% to 5.1% in Hispanics but increased from 6.0% to 8.8% in non-Hispanics (P < 0.05). Visits resulting in prescription of a psychotropic medication decreased from 10.2% to 9.3% in Hispanics, while they increased from 10.2% to 12.5% in non-Hispanics (P < 0.05). Psychotherapy visits decreased from 2.4% to 1.3% in Hispanics (P < 0.05), whereas they remained constant (2.5%) in non-Hispanics. Visits to a psychiatrist decreased from 2.5% to 1.3% in Hispanics (P < 0.05), while they increased (nonsignificantly) from 3.1% to 3.5% for non-Hispanics. Most differences persisted after adjusting for age and insurance status. Conclusions:From 1993 to 2002, there was an increase in mental health care disparities between Hispanics and non-Hispanics treated by office-based physicians. Improvement of the mental health care for Hispanics continues to be an important public health priority, with clear opportunities and challenges for health care policy-makers and practitioners.

Recent advances in shared decision making for mental health

Purpose of review Shared decision making (SDM) in nonmental health populations has documented positive services and health benefits. To advance integration of SDM into mental healthcare, researchers have outlined several priorities for future research. These include (1) clarifying the role of SDM in mental healthcare; (2) understanding patient and provider perspectives on SDM; (3) assessment of SDM practice in mental health settings; and (4) outcomes of SDM in mental health populations. This article will review recent advances in these areas. Recent findings The current literature shows that SDM can play a role in the mental health treatment process from entry into care to recovery. Patients and providers find SDM acceptable and express a willingness to engage in SDM for reasons that are multifactorial. Barriers to SDM exist in mental health decision making including patient preferences and provider-level biases. Lastly, outcome research provides encouraging preliminary evidence for feasibility and effectiveness of SDM during the mental health encounter. Summary Although there have not been a great number of SDM studies in mental health to date, the positive effects of SDM are comparable to those documented in general nonmental health patient groups, suggesting that future research has the potential to result in findings that are likely to be helpful for patients with psychiatric disorders.

Patient preferences for obsessive-compulsive disorder treatment.

OBJECTIVE To explore preferences for the treatment of obsessive-compulsive disorder (OCD). We hypothesized that OCD patients will select a combination of medication and psychotherapy as their most preferred choice overall. METHOD The authors designed a treatment-preference survey using 2 health economics methods, forced-choice and contingent-ranking methods, to elicit preferences for OCD treatment available in mainstream care (serotonin reuptake inhibitors [SRIs], exposure and response prevention [EX/RP], and their combination) and for novel treatments under development at OCD research clinics. This survey was given by telephone to 89 individuals with OCD who called the OCD research clinic at the New York State Psychiatric Institute between July 2008 and January 2009. Diagnosis of OCD was based on a telephone screening evaluation adapted from the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS Most participants chose combination treatment (43%) or EX/RP (42%) over SRI medication (16%). Participants ranked investigational psychotherapy as their most-preferred novel treatment (endorsed by 48% of participants) and deep brain stimulation as their least-preferred novel treatment (endorsed by 77% of participants). Qualitative data suggest that prior treatment experience, concerns about medications, and logistical and practical concerns about treatment regimens affect preferences. CONCLUSIONS Patients with OCD have identifiable treatment preferences. In this sample of convenience, most preferred either combination treatment or psychotherapy. Future studies should investigate prospectively what modifies these preferences and how these preferences affect treatment outcome.

The Cross-Cultural Assessment of Dissociation

Dissociation is a human capacity that can fulfill an adaptive or maladaptive function in specific circumstances, and which appears to be particularly recruited as a response to trauma in most cultural settings around the world. Although much of the initial work on dissociation was done in Europe and the United States, recent expansion of research on this topic in other cultural regions has led to welcome progress toward a more global understanding of dissociation. This progress is reflected in a greater ethno-cultural diversity of populations under study, expansion of the known phenomenology of dissociation and thus the conceptualization of the construct, creation of new assessment instruments, and renewed debate over existing diagnostic categories. This chapter reviews current understandings of the phenomenology and classification of dissociation from a cross-cultural perspective, including its relationship to trauma, with a focus on current assessment methodologies. These topics are illustrated with recent dissociation research from two non-US, nonEuropean cultural settings, Puerto Rico and Turkey.

Barriers to the Delivery of Psychosocial Care for Cancer Patients: Bridging Mind and Body

Harold Alan Pincus, The New York State Psychiatric Institute; Department of Psychiatry, Columbia University, College of Physicians and Surgeons; Irving Institute for Clinical and Translational Research, Columbia University and NewYork-Presbyterian Hospital, New York, NY; and RAND Corp, Pittsburgh, PA Sapana R. Patel, The New York State Psychiatric Institute; and Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, NY

Primary care providers' bereavement care practices: recommendations for research directions

Bereaved patients are often seen in primary care settings. Although most do not require formal support, physicians may be called upon to provide support to some bereaved, particularly those with bereavement‐related mental health disorders like complicated grief and bereavement‐related depression. Research evidence on physician bereavement care is scant. We make recommendations for future research in this area.

Acceptability of treatments and services for individuals with hoarding behaviors

OBJECTIVE To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors. METHOD Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable] -10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale. RESULTS Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders (n=203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2 ±3.1 on the Likert scale), professional organizing service (6.1 ±3.2), and use of a self-help book (6.0 ±3.0). CONCLUSION In this sample of individuals with self-reported clinically significant hoarding behaviors (n=203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Primary Care Professional’s Perspectives on Treatment Decision Making for Depression with African Americans and Latinos in Primary Care Practice

Increasing interest has been shown in shared decision making (SDM) to improve mental health care communication between underserved immigrant minorities and their providers. Nonetheless, very little is known about this process. The following is a qualitative study of fifteen primary care providers at two Federally Qualified Health Centers in New York and their experience during depression treatment decision making. Respondents described a process characterized in between shared and paternalistic models of treatment decision making. Barriers to SDM included discordant models of illness, stigma, varying role expectations and decision readiness. Respondents reported strategies used to overcome barriers including understanding illness perceptions and the role of the community in the treatment process, dispelling stigma using cultural terms, orienting patients to treatment and remaining available regarding the treatment decision. Findings from this study have implications for planning SDM interventions to guide primary care providers through treatment engagement for depression.

Patient Preferences and Acceptability of Evidence-Based and Novel Treatments for Obsessive-Compulsive Disorder

OBJECTIVE This study examined preferences for and acceptability of treatments for obsessive-compulsive disorder (OCD). METHODS Through an online survey, adults who self-reported OCD chose their preferred evidence-based treatments, rated acceptability of novel treatments, and answered open-ended questions about their preferences. Analyses examined associations between demographic, clinical, and treatment variables and first-line and augmentation treatment preferences. Latent class analysis (LCA) explored whether distinct profiles among participants predicted preferences. Data from open-ended questions were analyzed by using qualitative methods. RESULTS Among 216 adults with at least moderate OCD symptoms, first-line preferences for exposure and response prevention (EX/RP) and serotonin reuptake inhibitor (SRI) medications were similar (55% and 45%). However, EX/RP was significantly preferred over antipsychotic medication as an augmentation treatment for SRIs (68% and 31%; p<.001). Regarding first-line preferences, no factors were associated with EX/RP preference, but participants who preferred SRIs were currently receiving OCD treatment (p=.011) or taking SRIs (p<.001) and reported a positive treatment experience overall (p=.043) and with medications (p<.001). Participants who preferred EX/RP as augmentation treatment were younger (p<.001) and female (p=.021) and taking benzodiazepines (p=.050). LCA analyses generated two distinct profiles, one of which preferred SRIs: those with a history of OCD diagnosis and treatment, higher income, and private insurance (p=.001). For novel treatments, acceptance and commitment therapy was the most acceptable and deep brain stimulation the least. CONCLUSIONS Preferences for OCD treatments varied by individual characteristics. Future research should examine whether incorporating preferences into treatment planning has an impact on clinical care.