mHealth and patient generated health data: stakeholder perspectives on opportunities and barriers for transforming healthcare.

BACKGROUND: Wearable devices, mobile health apps, and geolocation technologies place the ability to track, monitor and report data in the individuals' hands - or on their bodies. These innovations create an opportunity for "connected health," where individuals collect data outside of the healthcare encounter and report it to care providers. Collection of such patient-generated health data (PGHD) has the potential to impact the delivery of healthcare through remote monitoring, and by allowing patients and healthcare teams to provide targeted and efficient care that aligns with the health status of individual patients. METHODS: To understand the value and barriers associated with clinical integration of PGHD we engaged a range of stakeholders, examining their perspectives and experiences of PGHD use. We conducted open-ended interviews with healthcare consumers (patients and care partners), healthcare providers, and healthcare administrators. Open recruitment and purposive sampling were utilized to identify participants that represented the breadth of PGHD use in research and clinical care. Interview guides focused on the value and barriers of PGHD use. Interviews were recorded, transcribed, and analyzed for emergent themes. RESULTS: Themes emerged around the value of PGHD to support care decisions and improve patient-provider communication and engagement, and the promise of applying PGHD to formal care pathways and measurement-based care. Significant barriers included data validity and actionability, and the burden of integrating PGHD into existing care processes. Interviews highlighted areas for future research to better understand how PGHD can advance care transformation. CONCLUSIONS: These findings provide rich context for understanding the experiences and needs of the individuals who interface with PGHD. Translating advances in technology and data tracking into successful clinical implementation requires understanding how stakeholders conceptualize and make use of PGHD, the potential value that PGHD can add to care, and the challenges that may limit PGHD's promise. Our results illustrate the value and challenges associated with health-system implementation of PGHD. Efforts to increase the scale and spread of PGHD will benefit from an approach that addresses the value and challenges PGHD brings to clinical care.

Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation.

Many people with depression or anxiety turn to nonpharmacologic and nonconventional interventions, including exercise, yoga, meditation, tai chi, or qi gong. Meta-analyses and systematic reviews have shown that these interventions can improve symptoms of depression and anxiety disorders. As an adjunctive treatment, exercise seems most helpful for treatment-resistant depression, unipolar depression, and posttraumatic stress disorder. Yoga as monotherapy or adjunctive therapy shows positive effects, particularly for depression. As an adjunctive therapy, it facilitates treatment of anxiety disorders, particularly panic disorder. Tai chi and qi gong may be helpful as adjunctive therapies for depression, but effects are inconsistent. As monotherapy or an adjunctive therapy, mindfulness-based meditation has positive effects on depression, and its effects can last for six months or more. Although positive findings are less common in people with anxiety disorders, the evidence supports adjunctive use. There are no apparent negative effects of mindfulness-based interventions, and their general health benefits justify their use as adjunctive therapy for patients with depression and anxiety disorders.

Bright Light Therapy as Augmentation of Pharmacotherapy for Treatment of Depression: A Systematic Review and Meta-Analysis.

BACKGROUND: Bright light therapy has demonstrated efficacy and is an accepted treatment for seasonal depression. It has been suggested that bright light therapy may have efficacy in nonseasonal depressions. Also, there is evidence that bright light therapy may improve responsiveness to antidepressant pharmacotherapy. DATA SOURCES: We searched PubMed/MEDLINE, PsycINFO, PsycARTICLES, CINAHL, EMBASE, Scopus, and Academic OneFile for English-language literature published between January 1998 and April 2016, using the keywords bright light therapy AND major depression, bright light therapy AND depress*, bright light therapy AND bipolar depression, bright light therapy AND affective disorders, circadian rhythm AND major depression, circadian rhythm AND depress*, and circadian rhythm AND affective disorder. STUDY SELECTION AND DATA EXTRACTION: Studies that reported randomized trials comparing antidepressant pharmacotherapy with bright light therapy ≥ 5,000 lux for ≥ 30 minutes to antidepressant pharmacotherapy without bright light therapy for the treatment of nonseasonal depression were included. Studies of seasonal depression were excluded. Following review of the initial 112 returns, 2 of the authors independently judged each trial, applying the inclusionary and exclusionary criteria. Ten studies were selected as meeting these criteria. Subjects in these studies were pooled using standard techniques of meta-analysis. RESULTS: Ten studies involving 458 patients showed improvement using bright light therapy augmentation versus antidepressant pharmacotherapy alone. The effect size was similar to that of other accepted augmentation strategies, roughly 0.5. CONCLUSIONS: Analysis of pooled data from randomized trials provides evidence for the efficacy of use of bright light therapy ≥ 5,000 lux for periods ≥ 30 minutes when used as augmentation to standard antidepressant pharmacotherapy in the treatment of major depressive disorder and bipolar depression without a seasonal pattern.

Role of Leadership in Narrowing the Gap between Science and Practice: Improving Treatment Outcomes at the Systems Level.

It's been well documented that health care does not reliably transfer what we know from science into clinical practice. As a result, Americans do not always receive the care suggested by the scientific evidence. Despite the best intentions of a dedicated and skilled healthcare workforce, this can often lead to poor clinical outcomes. As research and technology rapidly advance, this gap between science and practice appears to be widening. There is an increasing public concern about a lack of access to appropriate treatment, pervasiveness of unsafe practices, and wasteful uses of precious health care resources leading to suboptimum treatment outcomes. Leadership has a critical role in creating and sustaining the environment that supports health services for individuals and populations that increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Leadership has some responsibility to improve outcomes by insuring effective use of evidence-based treatment guidelines; measurement-based care; knowledge and skills management; care coordination; and information technologies. This paper addresses leadership issues in these components of a system's ability to improve treatment outcomes.

Treatment-specific changes in decentering following mindfulness-based cognitive therapy versus antidepressant medication or placebo for prevention of depressive relapse.

OBJECTIVE: To examine whether metacognitive psychological skills, acquired in mindfulness-based cognitive therapy (MBCT), are also present in patients receiving medication treatments for prevention of depressive relapse and whether these skills mediate MBCT's effectiveness. METHOD: This study, embedded within a randomized efficacy trial of MBCT, was the first to examine changes in mindfulness and decentering during 6-8 months of antidepressant treatment and then during an 18-month maintenance phase in which patients discontinued medication and received MBCT, continued on antidepressants, or were switched to a placebo. In total, 84 patients (mean age = 44 years, 58% female) were randomized to 1 of these 3 prevention conditions. In addition to symptom variables, changes in mindfulness, rumination, and decentering were assessed during the phases of the study. RESULTS: Pharmacological treatment of acute depression was associated with reductions in scores for rumination and increased wider experiences. During the maintenance phase, only patients receiving MBCT showed significant increases in the ability to monitor and observe thoughts and feelings as measured by the Wider Experiences (p < .01) and Decentering (p < .01) subscales of the Experiences Questionnaire and by the Toronto Mindfulness Scale. In addition, changes in Wider Experiences (p < .05) and Curiosity (p < .01) predicted lower Hamilton Rating Scale for Depression scores at 6-month follow-up. CONCLUSIONS: An increased capacity for decentering and curiosity may be fostered during MBCT and may underlie its effectiveness. With practice, patients can learn to counter habitual avoidance tendencies and to regulate dysphoric affect in ways that support recovery.

Use of telepsychiatry to improve care for people with mental illness in rural North Carolina.

Telehealth improves access to medical services, especially for people living in rural areas. In North Carolina, the advantages of telepsychiatry also go beyond improving access. This article describes a diverse program of telehealth and telepsychiatric service delivery and discusses its advantages and disadvantages.

Mood-linked responses in medial prefrontal cortex predict relapse in patients with recurrent unipolar depression.

BACKGROUND: Altered cognitive processing following mood challenge is associated with elevated relapse risk in remitted unipolar depressed patients, but little is known about the neural basis of this reactivity and its link to depressive relapse and prophylaxis. METHODS: Remitted unipolar depressed participants (n = 16) and healthy control subjects (n = 16) underwent functional magnetic resonance imaging (fMRI) while viewing sad and neutral film clips. Correlations were determined between emotional reactivity (neural responses to sad vs. neutral films) in remitted patients and subsequent relapse status over an 18 month follow-up period. A receiver operating characteristic analysis was used to determine signal cutoffs for predicting relapse. Emotional reactivity in relapse prognostic areas was compared between groups. RESULTS: Within the remitted group, relapse was predicted by medial prefrontal cortical (mPFC; Brodmann's area 32) activity and contraindicated by visual cortical activity (Brodmann's area 17). mPFC reactivity predicted rumination, whereas visual cortical reactivity predicted distress tolerance (acceptance). Compared with control participants, remitted depressed patients demonstrated a more pronounced tradeoff between mPFC and visual cortex reactivity. The difference score between mPFC and visual reactivity yielded excellent prediction of depressive relapse. CONCLUSIONS: Medial prefrontal cortical reactivity to mood provocation in remitted unipolar depressed patients serves as a marker of relapse risk rather than successful emotion regulation. Enduring remission is characterized by normalization of the mPFC to that of healthy control subjects. Furthermore, visual cortex reactivity predicts resilience against depressive relapse, indicating a prophylactic role for sensory rather than ruminative cognitive reactivity in the processing of negative emotion.

Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression.

CONTEXT: Mindfulness-based cognitive therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse. OBJECTIVE: To compare rates of relapse in depressed patients in remission receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care. DESIGN: Patients who met remission criteria after 8 months of algorithm-informed antidepressant treatment were randomized to receive maintenance antidepressant medication, MBCT, or placebo and were followed up for 18 months. SETTING: Outpatient clinics at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and St Joseph's Healthcare, Hamilton, Ontario. PARTICIPANTS: One hundred sixty patients aged 18 to 65 years meeting DSM-IV criteria for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to 1 of the 3 study conditions. INTERVENTIONS: Patients in remission discontinued their antidepressants and attended 8 weekly group sessions of MBCT, continued taking their therapeutic dose of antidepressant medication, or discontinued active medication and were switched to placebo. MAIN OUTCOME MEASURE: Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on module A of the Structured Clinical Interview for DSM-IV. RESULTS: Intention-to-treat analyses showed a significant interaction between the quality of acute-phase remission and subsequent prevention of relapse in randomized patients (P = .03). Among unstable remitters (1 or more Hamilton Rating Scale for Depression score >7 during remission), patients in both MBCT and maintenance treatment showed a 73% decrease in hazard compared with placebo (P = .03), whereas for stable remitters (all Hamilton Rating Scale for Depression scores ≤7 during remission) there were no group differences in survival. CONCLUSIONS: For depressed patients achieving stable or unstable clinical remission, MBCT offers protection against relapse/recurrence on a par with that of maintenance antidepressant pharmacotherapy. Our data also highlight the importance of maintaining at least 1 long-term active treatment in unstable remitters.

Telepsychiatry assessments of child or adolescent behavior disorders: a review of evidence and issues.

BACKGROUND: The limited number of mental health specialists for children has led to an increased need for child and adolescent psychiatrists to provide primary care consultations and treatment recommendations. Psychiatric assessments and treatments provided via two-way videoconferencing (telepsychiatry) have been used to increase the availability of child psychiatrists. This article reviews the literature on telepsychiatry assessment of children and adolescents. METHODS: Research on telepsychiatry has focused on the comparability of telepsychiatric treatments to in-person treatment for adult patients. Relatively little research has addressed the ability of telepsychiatric assessments to facilitate favorable treatment outcomes, particularly for child or adolescent patients. This was a literature search using Medline via Ovid. It focused on English-language material published between 1996 and 2009. A range of search terms relating to assessment, mental health, telemedicine, and children was used. Any studies focusing on child and adolescent psychiatric assessment were included. RESULTS: The limited literature on children is usually related to project descriptions or case reports. The studies tend to find acceptance and the diagnoses and recommendations are not seen as different from in-person assessments. Practical considerations that arise in giving telepsychiatric assessments are discussed. CONCLUSION: Although there are significant weaknesses in the research justifying telepsychiatric assessments in children and adolescents, there are no data that suggest that this process contributes to negative outcomes. Details on the setting for telepsychiatry assessments and camera view have not been studied.

Exercise, yoga, and meditation for depressive and anxiety disorders.

Anxiety and depression are among the most common conditions cited by those seeking treatment with complementary and alternative therapies, such as exercise, meditation, tai chi, qigong, and yoga. The use of these therapies is increasing. Several studies of exercise and yoga have demonstrated therapeutic effectiveness superior to no-activity controls and comparable with established depression and anxiety treatments (e.g., cognitive behavior therapy, sertraline, imipramine). High-energy exercise (i.e., weekly expenditure of at least 17.5 kcal per kg) and frequent aerobic exercise (i.e., at least three to five times per week) reduce symptoms of depression more than less frequent or lower-energy exercise. Mindful meditation and exercise have positive effects as adjunctive treatments for depressive disorders, although some studies show multiple methodological weaknesses. For anxiety disorders, exercise and yoga have also shown positive effects, but there are far less data on the effects of exercise on anxiety than for exercise on depression. Tai chi, qigong, and meditation have not shown effectiveness as alternative treatments for depression and anxiety.

Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry.

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio-video communication-videoconferencing-is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.

Sensitivity of a system of care in recognizing communication disorders in children with serious emotional disorders.

This study evaluated the sensitivity and specificity of a system of care (SOC) in identifying communication disorders in children with serious emotional disorders (SED). Speech/language screenings were completed on 39 children. Children showing possible communication disorders received comprehensive speech-language evaluations. Records were reviewed for communication disorders suspected and identified by the SOC and for services provided. Results showed that the SOC was poor in identifying communication disorders in children with SED. This study underscores the importance of SOCs addressing the needs for appropriate identification and treatment of communication disorders in children with SED.

Herbal and dietary supplements for treatment of anxiety disorders.

Use of complementary and alternative medicine has increased over the past decade. A variety of studies have suggested that this use is greater in persons with symptoms or diagnoses of anxiety and depression. Data support the effectiveness of some popular herbal remedies and dietary supplements; in some of these products, particularly kava, the potential for benefit seems greater than that for harm with short-term use in patients with mild to moderate anxiety. Inositol has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. Physicians should not encourage the use of St. John's wort, valerian, Sympathyl, or passionflower for the treatment of anxiety based on small or inconsistent effects in small studies. Although the evidence varies depending on the supplement and the anxiety disorder, physicians can collaborate with patients in developing dietary supplement strategies that minimize risks and maximize benefits.

Lessons learned in implementing evidence-based practices: implications for psychiatric administrators.

Factors related to the dissemination and implementation of evidence-based practices (EBPs) are discussed. Extensive effort is required to successfully implement and sustain EBPs that improve clinical outcomes. There is a rapid rate of discovery of new EBPs. Examples of large-scale implementations of EBPs in mental health are described with emphasis on the factors thought critical for success. The need for designing systems which can cost-effectively implement new EBPs is highlighted. Finally, the implications for psychiatric administrators are discussed.

Long-distance transport of ventilated patients: advantages and limitations of air medical repatriation on commercial airlines.

INTRODUCTION: To illustrate the advantages and limitations of transporting ventilated intensive care unit patients over intercontinental distances on commercial airlines, this case series reports 8 ventilated patients repatriated by an air medical transport company. PATIENTS: Eight ventilated patients, 3 suffering from internal and 5 from neurologic diseases. Distances ranged from 1700 to 10280 nautical miles with transport times from 04:10 hours to 21:55 hours. For 3 patients, a dedicated patient transport compartment (PTC) in the aircraft cabin was used. All patients were ventilator-dependent for a minimum of 11 days before transport (48 days median, 113 days maximum). RESULTS: One patient went into cardiac arrest during the flight and died. None of the other patients experienced any emergency or invasive procedures, other than peripheral venous access necessary during the flight. In all patients, ventilation was adjusted with respect to the blood gas analysis at least once during the transport. No technical failures or drop-outs occurred during the flights. None of the flights had to be diverted for technical or medical reasons. CONCLUSION: Long distance international transport of ventilated intensive care unit patients is an extremely cost intensive and logistically challenging task. In a certain subgroup of relatively stable ventilated patients, transport on commercial airlines offers advantages in terms of cost effectiveness and reduced transport time and acceleration/deceleration trauma as a result of multiple fuel stops.

Ginseng reduces the micronuclei yield in lymphocytes after irradiation.

To assess the effect of Chinese ginseng in modifying the radiation-induced micronuclei (MN) yield in human G(o) peripheral blood lymphocytes (PBL), we conducted the cytokinesis-blocked (CB) MN assay in blood samples obtained from healthy volunteers (n=4). Before (137)Cs ex vivo irradiation, mononuclear cell cultures from each sample were incubated 24 h with different concentrations (0-2000 microg ml(-1)) of crude water extract of ginseng dry root. We found that (1) at 0 Gy and without the presence of ginseng, MN yield (mean+/-S.E.M.) was 11.7+/-2.7 per 1000 binucleated (BN) cells. Different concentrations of ginseng crude water extract did not affect the MN yields and the proliferative activity of PBL; (2) after 1 and 2 Gy exposure, radiation alone sharply increased the MN yields, respectively, to 119.6+/-17.4 and 340.5+/-20.9 per 1000 BN cells. However, treatment with ginseng for 24 h before radiation exposure, resulted in a significant linear decline of MN yields as ginseng concentration increases. Compared to radiation alone, the extent to which ginseng water extract reduced the MN yields induced by 1 Gy exposure was 46.0% at 1500 microg ml(-1) and 61.5% at 2000 microg ml(-1), and with 2 Gy exposure, it was 38.6% at 1500 microg ml(-1) and 46.5% at 2000 microg ml(-1); (3) MN data suggested a tendency for overdispersion relative to the Poisson model; and (4) over the different levels of ginseng concentrations, the trend in micronucleated BN index was as similar as that of the MN yields. These results indicated that (1) ginseng crude water extract exerts no apparent cytogentic effect on human PBL at concentrations up to 2000 microg ml(-1) as evaluated by the CBMN assay; and (2) the protection of ginseng water extract against (137)Cs-induced MN in human PBL is concentration-dependence. Therefore, our findings indicated that ginseng may have therapeutic value as a possible radioprotector for normal tissue during radiotherapy of cancer patients.

Emotional and somatic distress in eastern North Carolina: help-seeking behaviors.

Socio-demographic and cultural factors have been reported to shape help-seeking behavior. However, not much effort has been made to determine the effects of these factors on help-seeking among rural populations. A telephone survey using random-digit dialing was used to explore socio-demographic characteristics and ethnic differences in the types of professionals sought for unexplained somatic and emotional problems (N = 1161) in rural eastern North Carolina. Ethnic differences in comfort with participating in support groups were also examined. The effect of a large natural disaster, Hurricane Floyd and subsequent flooding, on help-seeking choices and comfort with support groups was also assessed. Results showed that the rural population makes a sharp distinction between somatic symptoms and stress-related symptoms. This distinction seemed more pronounced for European-Americans than for African-Americans. In general African-Americans selected help-seeking from clergy more often than European-Americans, although for unexplained somatic symptoms this difference was fostered by Hurricane Floyd with its flooding. African-Americans showed markedly increased comfort with support groups after the hurricane, while European-Americans showed no changes in comfort with support groups as a function of the hurricane. The effects of Hurricane Floyd on African-Americans are interpreted as reflecting an increased salience of community support for African-Americans, significantly through the Baptist Church. Training of clergy should include recognition of stress-related somatic and emotional symptoms and the potential for an important referral role, especially following disasters.