Psychological complexities of visual restoration.

In this paper, we report the psychological and emotional experience of a patient who regained vision after over a decade of vision loss. The negative psychological implications of blindness are well recognised and there is a robust link between visual impairment and low mood and depressive symptoms. Although uncommon, low mood and depressive symptoms have been reported in patients whose sight has been restored, and lack of research gives rise to the possibility their prevalence may be grossly under-recognised in such patient groups. The effects can be so severe that patients may revert to living in darkness in mimicry of their previous lifestyle, effectively obviating the sight-restoring surgery. Healthcare professionals have a responsibility to address this traditionally neglected need by facilitating social, psychological and medical interventions that may ease the return to vision.

Predicting the Effectiveness of Work-Focused CBT for Common Mental Disorders: The Influence of Baseline Self-Efficacy, Depression and Anxiety.

Purpose This study examined who benefits most from a cognitive behavioural therapy (CBT)-based intervention that aims to enhance return to work (RTW) among employees who are absent due to common mental disorders (CMDs) (e.g., depression, anxiety, or adjustment disorder). We researched the influence of baseline work-related self-efficacy and mental health (depressive complaints and anxiety) on treatment outcomes of two psychotherapeutic interventions. Methods Using a quasi-experimental design, 12-month follow-up data of 168 employees were collected. Participants either received work-focused cognitive behavioural therapy (W-CBT) that integrated work aspects early into the treatment (n = 89) or regular cognitive behavioural therapy (R-CBT) without a focus on work (n = 79). Results Compared with R-CBT, W-CBT resulted in a faster partial RTW, irrespective of baseline self-efficacy. Among individuals with high self-efficacy, W-CBT also resulted in faster full RTW. The effectiveness of W-CBT on RTW did not depend on baseline depressive complaints or anxiety. The decline of mental health complaints did not differ between the two interventions, nor depended on baseline self-efficacy or mental health. Conclusions Considering the benefits of W-CBT for partial RTW, we recommend this intervention as a preferred method for employees with CMDs, irrespective of baseline self-efficacy, depression and anxiety. For individuals with high baseline self-efficacy, this intervention also results in higher full RTW. For those with low self-efficacy, extra exercises or components may be needed to promote full RTW.

Internet-Based Self-Help Intervention for ICD-11 Adjustment Disorder: Preliminary Findings.

Adjustment disorder is one of the most diagnosed mental disorders. However, there is a lack of studies of specialized internet-based psychosocial interventions for adjustment disorder. We aimed to analyze the outcomes of an internet-based unguided self-help psychosocial intervention BADI for adjustment disorder in a two armed randomized controlled trial with a waiting list control group. In total 284 adult participants were randomized in this study. We measured adjustment disorder as a primary outcome, and psychological well-being as a secondary outcome at pre-intervention (T1) and one month after the intervention (T2). We found medium effect size of the intervention for the completer sample on adjustment disorder symptoms. Intervention was effective for those participants who used it at least one time in 30-day period. Our results revealed the potential of unguided internet-based self-help intervention for adjustment disorder. However, high dropout rates in the study limits the generalization of the outcomes of the intervention only to completers.

After critical care: Challenges in the transition to inpatient rehabilitation.

PURPOSE/OBJECTIVE: The aftermath of treatment for critical illness and/or critical injury in the intensive care unit (ICU) often includes persisting cognitive and emotional morbidities as well as severe physical deconditioning (a constellation termed post-intensive care syndrome, or PICS), but most patients do not receive psychological services before they enter the inpatient rehabilitation facility (IRF). Although a burgeoning literature guides the efforts of critical care providers to reduce risk factors for PICS - for example, reducing the use of sedatives and enacting early mobilization, there is need for a corresponding awareness among IRF psychologists and other providers that the post-ICU patient often arrives in a state of significantly reduced capacity, with persisting cognitive impairments and acute psychological distress. Many are at risk for long-term complications of posttraumatic stress disorder, general anxiety and/or clinical depression, and assuredly all have experienced a profound life disruption. This paper offers a multilevel perspective on the adaptation of post-ICU patients during inpatient rehabilitation, with discussion of the psychologist's role in education and intervention. RESEARCH METHOD/DESIGN: Clinical review paper. RESULTS: NA. CONCLUSIONS: To optimize response to rehabilitation, it is important to understand the behavior of post-ICU patients within a full biopsychosocial context including debility, cognitive and emotional impairment, disruption of role identities, and environmental factors. The psychologist can provide education about predictable barriers to participation for the post-ICU patient, and guide individual, family and team interventions to ameliorate those barriers. (PsycINFO Database Record

Development of an ICF-based core set of activities and participation for patients with mental disorders: an approach based upon data.

OBJECTIVE: To use data and patient involvement to identify categories within the International Classification of Functioning, Disability and Health (ICF) component activities and participation relevant for patients with affective, somatoform, anxiety and adjustment disorders. DESIGN: The first step was to identify systematically, outcome instruments used in randomized controlled trials, to relate item content to the ICF. Then four patient focus group discussions (n = 21 participants) were conducted, and finally an expert panel (n = 11 participants) was used to identify the most relevant categories in therapy settings. PARTICIPANTS: Focus groups: inpatient psychotherapy patients. Expert panel: clinicians, stakeholders, patient representative. RESULTS: In the literature search, 313 measures were identified, which included 1562 meaningful concepts (separate content units). These were allocated to ICF categories that were validated and complemented in focus groups and by an expert panel. The resulting core set includes 27 categories related to the nine chapters of the ICF component activities and participation. CONCLUSIONS: A core set of items, set within the World Health Organization ICF and relevant to the treatment of people with affective, somatoform, anxiety and adjustment disorders, has been developed based on existing evidence.

An online emotional regulation system to deliver homework assignments for treating adjustment disorders.

Adjustment Disorders (AD) is a very common mental health problem in primary care. Only general treatment guidelines are available for its treatment. Our research team has developed a cognitive-behavioural treatment (CBT) supported by Virtual reality (EMMA system) that has shown its utility in the treatment of AD. EMMA is a VR adaptive display that adapts its presentation to the patient' therapeutic needs. So far, researchers have been centered on how to use the Information and Communication Technologies to deliver treatment within the therapeutic context. TEO is a completely open Online Emotional Therapy web-based system that allows creating personalized therapeutic material. The patient can access this material over the Internet. Preliminary data about the acceptability of TEO system in a case study has already been obtained. The aim of the present work is to describe the session protocol regarding the homework assignments component in the treatment of AD designed in TEO system. Also, data about preferences and efficacy of TEO system versus traditional homework assignments implementation in a single case study with AD are presented. A web-based system of this kind increases the possibilities for therapy.

Work-focused treatment of common mental disorders and return to work: a comparative outcome study.

The aim of this study was to compare the effectiveness of two individual-level psychotherapy interventions: (a) treatment as usual consisting of cognitive-behavioral therapy (CBT) and (b) work-focused CBT (W-CBT) that integrated work aspects early into the treatment. Both interventions were carried out by psychotherapists with employees on sick leave because of common mental disorders (depression, anxiety, or adjustment disorder). In a quasi-experimental design, 12-month follow-up data of 168 employees were collected. The CBT group consisted of 79 clients, the W-CBT group of 89. Outcome measures were duration until return to work (RTW), mental health problems, and costs to the employer. We found significant effects on duration until RTW in favor of the W-CBT group: full RTW occurred 65 days earlier. Partial RTW occurred 12 days earlier. A significant decrease in mental health problems was equally present in both conditions. The average financial advantage for the employer of an employee in the W-CBT group was estimated at $5,275 U.S. dollars compared with the CBT group. These results show that through focusing more and earlier on work-related aspects and RTW, functional recovery in work can be substantially speeded up within a regular psychotherapeutic setting. This result was achieved without negative side effects on psychological complaints over the course of 1 year. Integrating work-related aspects into CBT is, therefore, a fruitful approach with benefits for employees and employers alike.

The role of relationship quality and perceived partner responses with pain and disability in those with back pain.

OBJECTIVE: The objectives of this study were to investigate the associations of key constructs of relationship quality (cohesion, consensus, and satisfaction) and perceived partner responses to pain behavior (e.g., solicitous and negative responses) with the outcomes of pain and disability in those with long-term low back pain, and to explore the role of the patient's depressive symptom mood state on those associations. METHODS: Self-report questionnaires on pain intensity, disability, relationship quality, perceived partner reactions to pain, and depressive symptoms were collected from participants (N = 174) taking part in a longitudinal study on low back pain within a primary care sample. RESULTS: Participants reporting more consensus (e.g., agreement about sexual intimacy, level of affection) in their relationships had significantly higher pain intensity (P = 0.03), and solicitous partner responses (P = 0.04) were significantly positively associated with disability levels. However, the findings for pain intensity were only present in those with higher levels of depression, while the association of solicitous responses with disability was only significant in those with lower levels of depression, indicating a suppression effect of depression on pain and disability. CONCLUSIONS: Depressive symptoms play a significant role in determining the associations between relationship quality, perceived partner reactions, and pain and disability. The relationship construct of consensus and perceived solicitous responses were associated with pain and disability. These findings illustrate the importance of social context and patient mood state on the outcomes for those with low back pain.

Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001.

OBJECTIVE: To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001. METHOD: Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center. RESULTS: In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications. CONCLUSIONS: In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.

Integrated employee assistance program/managed behavioral health care benefits: relationship with access and client characteristics.

This study examined service user characteristics and determinants of access for enrollees in integrated EAP/behavioral health versus standard managed behavioral health care plans. A national managed behavioral health care organization's claims data from 2004 were used. Integrated plan service users were more likely to be employees rather than dependents, and to be diagnosed with adjustment disorder. Logistic regression analyses found greater likelihood in integrated plans of accessing behavioral health services (OR 1.20, CI 1.17-1.24), and substance abuse services specifically (OR 1.23, CI 1.06-1.43). Results are consistent with the concept that EAP benefits may increase access and address problems earlier.

Domestic violence: variation in case-management by the general practitioner in Belgium.

OBJECTIVES: to describe the medical interventions and referrals carried out by the general practitioner (GP) when taking care of victims and to quantify the between-physician variability in management of domestic violence. METHODS: A nationwide sentinel network of 150 general practitioners, covering 1.5 % of the Belgian population, registered in 2002-2004 all episodes of domestic violence for which they were consulted, via paper registration forms. A multilevel analysis was carried out by fitting a random effects logistic regression model for every intervention/referral. RESULTS: The most frequent interventions of the GP were providing a certificate of injury (54 %), and making an appointment for a next visit (33 %). Half of the patients were referred or hospitalised upon the first consultation, most frequently they were advised to go to the police (17 %) or referred to a psychologist or psychiatrist (11 %). The intra cluster correlation coefficient (ICC) of the interventions varied between 11 % and 39 % and the median odds ratios between 1,82 and 3,96. CONCLUSIONS: GP consultations for domestic violence are frequent and involve considerable between-physician variability in care.

The problem of not developing normally and pediatric neuropsychological rehabilitation: theMitchell Rosenthal Lecture.

Children who suffer moderately severe-to-severe traumatic brain injury often fail to develop normal cognitive and affective functioning necessary for independent adult living. The cognitive and psychiatric consequences of pediatric traumatic brain injury are outlined and 6 barriers to providing neuropsychological rehabilitation for these children are identified. Suggestions are made to help reduce the impact of those barriers.

The 'afterthought' diagnosis: rehabilitating adjustment disorders.

Although a common diagnosis, adjustment disorder has received little scientific attention, and instead the focus has been on major depression. It is likely that adjustment disorder and major depression have been conflated and the reasons for this are explored. Delineating one from the other clearly has crucial therapeutic and financial implications.

An alternative model for psychiatric service delivery for people with intellectual disabilities in a vocational rehabilitation center.

The prevalence of mental illness in the intellectually disabled (ID) population is high. Because of their special characteristics, such as involvement of multiple carers (family, social services, protected housing staff, vocational instructors), linguistic limitations and the need for a familiar and steady environment, these patients require special therapeutic consideration. In Israel, as in many other countries, people with ID (PWID) receive psychiatric services from general psychiatric outpatient clinics and hospitals; their treatment is generally not specifically tailored to their needs, and hence often suboptimal. In this article we will review some models of psychiatric service delivery for PWID and present an alternative model that we have developed. Our service has been operating since December 1998; it is based upon cooperation between the municipal social services and the local psychiatric outpatient clinic, and is provided in a vocational rehabilitation center where most mild to moderate ID individuals in our area, the city of Bat Yam, are employed. During the first five years (1999-2004) of the operation of the service, 42 people (about half the total number of clients passing through the vocational rehabilitation center during this period) were examined by the psychiatrist; 37 of them (88%) had at least one psychiatric diagnosis. There were especially high rates of adjustment disorder (26% of all principal diagnoses) and of behavior disorder (24% of all principal diagnoses). This model for psychiatric service delivery for PWID in a vocational-rehabilitation center, based as it is on cooperation between the different care agencies, facilitates more accurate psychiatric diagnosis and hence the provision of more appropriate treatment, which in practice usually consists of a combination of pharmacological and behavioral treatment together with educational programs and support for families and staff. Based on our positive experience with this model, we believe that it is the most suitable framework of treatment for adults with dual diagnosis, and that it should be adopted in other areas.

[Motivation for psychosomatic-psychotherapeutic treatment of vocational stresses -- development and validation of a questionnaire]. / Motivation zur psychosomatisch-psychotherapeutischen Bearbeitung von beruflichen Belastungen -- Entwicklung und Validierung eines Fragebogens.

BACKGROUND: There is a lack of questionnaires assessing the motivation of inpatients to scrutinize occupational stresses and deal with them as part of their psychotherapeutic treatment. Work-related stress contributes significantly to the development of mental disorders. Vocational reintegration is an outcome criterion for the success of vocational rehabilitation. Patients are often not motivated for dealing with occupational stresses during inpatient medical rehabilitation. Therefore it is necessary to assess patient motivation at the beginning of treatment, in order to assign them to specific interventions, e. g. promoting motivation. METHOD: A questionnaire (Fragebogen zur berufsbezogenen Therapiemotivation -- FBTM) consisting of 84 items was developed, based on published questionnaires for psychotherapy motivation. 283 psychosomatic rehabilitation inpatients were administered the FBTM, subsequently analyzed by item and factor analyses. Based on a second sample (n = 282) confirmatory factor analyses and validation of the questionnaire were executed. RESULTS: Item and factor analyses revealed a four factor structure. 24 items constituted the subscales that could be described as "intention to change", "wish for pension", "negative treatment expectations" and "active coping". Reliability (Cronbach's Alpha) was satisfactory with coefficients between 0.69 and 0.87, and only low correlations could be found between the four subscales. Correlations with other measures were most pronounced for the subscale "intention to change". Some significant but low correlations could be reported between the FBTM and a standardized questionnaire of psychotherapy motivation (FMP). Confirmatory factor analyses of a second sample (n = 282) confirmed the original four factors. First evidence of sensitivity could be observed in a sample of patients who took part in an intervention promoting work-related therapy motivation during psychosomatic inpatient rehabilitation. CONCLUSIONS: The FBTM is a reliable and valid instrument assessing work-related therapy motivation of inpatients, as a relevant therapeutic measure in psychosomatic rehabilitation. Further validation, especially the analysis of predictive validity is desirable.

[Case report long-term depressive adjustment disorder. Occupational therapy diagnosis and psychotherapy treatment of an adjustment disorder]. / Kasuistik einer länger dauernden depressiven Anpassungsstörung. Ergotherapeutische Diagnostik und psychotherapeutische Behandlung einer Anpassungsstörung.

Stressing live events can lead to serious deficits of emotional and social function and decrease in vitality. Depressive mood, anxiety and a considerable reduction in the mastering of daily live activities are symptoms of these disorders. Social medical and economical consequences can be reduced by early diagnosis of left performance and psychotherapeutic interventions. The example of a 41 year old man with adjustment disorder after an embolic brain injury shows how diagnosis of performance, and special psychotherapeutic treatment allowed the reintegration on the labour market.

Quality of rehabilitation among workers with adjustment disorders according to practice guidelines; a retrospective cohort study.

AIMS: To assess the quality of occupational rehabilitation for patients with adjustment disorders and to determine whether high quality of care is related to a shorter period of sickness absence. METHODS: A retrospective cohort study was conducted by means of an audit of 100 files of patients with adjustment disorders who visited their occupational physicians. Quality of rehabilitation was assessed by means of 10 performance indicators, derived from the guidelines for the treatment of employees with mental health disorders. Performance was dichotomised into optimal and deviant care according to explicit criteria. The performance rates were related to time until work resumption during a one year follow up period. Kaplan-Meier survival analyses and Cox proportional hazards analysis were used to study this relation. RESULTS: Four of 10 performance rates were below 50%: continuity of care (34%), interventions aimed at providers of care in the curative sector (39%), assessment of impediments in the return to work process (41%), and assessment of symptoms (45%). The highest performance rate concerned assessment of work related causes (94%). Overall optimal care was found in 10% of the cases. Median time to complete recovery was 195 days (IQR 97 to 365), and 73% of all patients recovered completely after one year. Optimal continuity of care was significantly related to a shorter time to both partial and complete work resumption (hazard ratio (HR) 0.3; CI 0.2 to 0.6) independently of other performance indicators. Performance regarding interventions aimed at the organisation was also related to a shorter time until first return to work (HR 0.5; CI 0.3 to 0.9). CONCLUSIONS: This study shows that the rehabilitation process of employees with adjustment disorders leaves significant room for improvement, especially with regard to continuity of care. Quality of care was partly related to a better outcome. More rigorous study designs are needed to corroborate these findings.

Reducing long term sickness absence by an activating intervention in adjustment disorders: a cluster randomised controlled design.

AIMS: To compare an innovative activating intervention with "care as usual" (control group) for the guidance of employees on sickness leave because of an adjustment disorder. It was hypothesised that the intervention would be more effective than care as usual in lowering the intensity of symptoms, increasing psychological resources, and decreasing sickness leave duration. METHODS: A prospective, cluster randomised controlled trial was carried out with 192 patients on first sickness leave for an adjustment disorder. Symptom intensity, sickness duration, and return to work rates were measured at 3 months and 12 months. Analyses were performed on an intention to treat basis. RESULTS: At 3 months, significantly more patients in the intervention group had returned to work compared with the control group. At 12 months all patients had returned to work, but sickness leave was shorter in the intervention group than in the control group. The recurrence rate was lower in the intervention group. There were no differences between the two study groups with regard to the decrease of symptoms. At baseline, symptom intensity was higher in the patients than in a normal reference population, but decreased over time in a similar manner in both groups to approximately normal levels. CONCLUSION: The experimental intervention for adjustment disorders was successful in shortening sick leave duration, mainly by decreasing long term absenteeism.