Implementing integrative therapies in adult critical care: Barriers and strategies.

BACKGROUND: Critically ill patients experience intense physical and psychological stressors in the intensive care unit (ICU). More than half of ICU survivors report overwhelming mental health symptoms after ICU discharge, such as post-traumatic stress symptoms, anxiety, and depression. Relaxation-inducing integrative therapies such as guided imagery, massage, therapeutic touch, music therapy, and spirituality-based healing practices have the potential to promote comfort and relaxation and improve patient outcomes. OBJECTIVES: The aim of this study was to explore the attitudes of healthcare professionals towards the implementation of relaxation-inducing integrative therapies in critical care, barriers to implementation, and potential strategies to overcome them. METHODS: We conducted seven focus group interviews with 23 critical care clinicians (70% nurses, 17% allied health professionals, 13% physicians). Interviews were audiotaped and transcribed verbatim. Data were thematically analysed using an inductive content analysis approach. FINDINGS: Results reveal a constant interplay between mostly positive personal attitudes towards implementation of integrative therapies and the perceived culture and priorities of the unit. The main benefits for critically ill patients as perceived by participants were promotion of comfort, sleep, and coping, increase of trust, and decrease of pain and stress. As for barriers, dominant themes were a perceived lack of evidence, cost, and time constraints and the fear of loss of professional credibility. Participants related nurses' education and training, family involvement, and leadership were seen as main strategies for implementation. CONCLUSIONS: The dominant ICU culture needs to be considered when implementing integrative therapies. Education, access to evidence, and role modelling are proposed as means to shift the ICU culture towards utilisation of integrative therapies in critical care.

Mundo de Pólus serious game for people with bipolar disorder.

BACKGROUND: Serious games are play-based technologies designed to teach users a wide range of concepts and skills applicable in the non-virtual environment. OBJECTIVES: This paper describes the process of developing a serious game for people with bipolar disorder to promote symptom recognition and the safe use of medications. METHODS: This study was based on the User-Centered Design methodological model and the theoretical framework for Participatory Design. We conducted interviews with health professionals and discussion circles with people with bipolar disorder and their family members in order to identify the learning needs related to symptom recognition and safe medication use. A categorical analysis was completed of the participants' reports and the scientific literature and formed the basis for the design of Mundo de Pólus. RESULTS: The game development process had three pillars (detailed in this manuscript): missions, simulation, and journal. The serious game focuses on the users' perceptions about their experience with the disorder, their interpersonal relationships, coping strategies, use of medications, and non-pharmacological treatments. CONCLUSIONS: These scientific and technological outcomes are useful to promote literacy and safety in medication therapy for people with bipolar disorder.

Effects of childhood adversity on the volumes of the amygdala subnuclei and hippocampal subfields in individuals with major depressive disorder.

Background: Reductions in total hippocampus volume have frequently been reported in MRI studies in major depressive disorder (MDD), but reports of differences in total amygdala volume have been inconsistent. Childhood maltreatment is an important risk factor for MDD in adulthood and may affect the volume of the hippocampus and amygdala. In the present study, we examined associations between the volumes of the amygdala subnuclei and hippocampal subfields and history of childhood maltreatment in participants with MDD. Methods: We recruited 35 patients who met the DSM-IV criteria for MDD and 35 healthy controls. We acquired MRI data sets on a 4.7 T Varian Inova scanner. We manually delineated the amygdala subnuclei (lateral, basal and accessory basal nuclei, and the cortical and centromedial groups) and hippocampal subfields (cornu ammonis, subiculum and dentate gyrus) using reliable volumetric methods. We assessed childhood maltreatment using the Childhood Trauma Questionnaire in participants with MDD. Results: In participants with MDD, a history of childhood maltreatment had significant negative associations with volume in the right amygdala, anterior hippocampus and total cornu ammonis subfield bilaterally. For volumes of the amygdala subnuclei, such effects were limited to the basal, accessory basal and cortical subnuclei in the right hemisphere, but they did not survive correction for multiple comparisons. We did not find significant effects of MDD or antidepressant treatment on volumes of the amygdala subnuclei. Limitations: Our study was a cross-sectional study. Conclusion: Our results provide evidence of negative associations between history of childhood maltreatment and volumes of medial temporal lobe structures in participants with MDD. This may help to identify potential mechanisms by which maltreatment leads to clinical impacts.

'And when a certain health issue happen, they try to cover it': Stakeholder perspectives on the health of temporary foreign workers and their families.

This study examines stakeholders' perspectives on the health and well-being of temporary foreign workers (TFWs) and their families in Alberta, Canada. We used a critically informed qualitative methodology. We interviewed 13 stakeholders, including service providers and policy makers. Stakeholders involved in providing services to TFWs perceived that the workers experience (1) barriers in accessing mental health services, (2) mental health challenges, (3) family health challenges, (4) occupational health challenges, and (5) income and social status as a social determinant of health. Immigration and class status intersect to influence the health of this vulnerable population in Canada.

Systematic review of gender- dependent outcomes in sepsis.

BACKGROUND: Men and women appear to exhibit different susceptibilities to sepsis and possibly divergent outcomes. However, the effect of sex and gender in critical illness outcomes is still controversial and the underlying mechanisms appear to be complex. OBJECTIVES: We aimed to systematically review and synthesize evidence on the influence of sex on outcomes in critically ill adult patients with sepsis, as reported in published studies specifically including investigation of the effect of sex among their aims. Primary outcome measures include in-hospital mortality, intensive care unit (ICU) mortality and length of stay (LOS) in the ICU. SEARCH STRATEGY: The review was based on focused literature searches (CINAHL, PUBMED, EMBASE and COCHRANE). Methodological quality was assessed through the STROBE checklist and the Cochrane Tool for Bias in Cohort Studies. Meta-analysis was performed using STATA. Published observational studies addressing outcomes of sepsis among their primary aims and having included gender comparisons among primary outcomes in critically ill adult patients were included. RESULTS: A total of eight eligible studies were included. With the exception of mortality, it was not possible to perform meta-analysis for other outcomes. Included studies reported data on 25,619 patients with sepsis (14 309 male/11 310 female). There is a paucity of well-designed studies addressing the effect of sex on mortality among patients with sepsis, and absence of studies addressing the effects of sex on multiple organ dysfunction of non-infectious origin. There was significant heterogeneity among study estimates (p = 0·001; I2 =78·1%). CONCLUSIONS: Although results of data syntheses appear to point towards a small disadvantage for survival among women, our results suggest that data on the impact of sex on sepsis outcomes remain equivocal. Implications for future research include approaches to adjustment for confounders and prospective designs. RELEVANCE TO CLINICAL PRACTICE: Clarifying sex-related differences in sepsis, if any, is crucial for informing evidence-based care.

An investigation of light and sound levels on intensive care units in China.

BACKGROUND: The intensive care units' (ICU) environment is considered clinically relevant sources of stress for patients. OBJECTIVES: To measure 24-h sound and light levels in 7 ICUs in China [four medical (MICU), two surgical (SICU) and one coronary (CCU) ICUs] and to identify the main sources related to increased sound levels. METHODS: Sound pressure and light levels were monitored for specific times over a 24-h period using a digital sound level meter and a light detector in 7 ICUs. Sound pressure levels were measured for 20min every hour. The main events at the time of peak noise levels were recorded. Light levels were measured every 2h at three locations for each ICU: near a window, in the centre of the room, at eye level of a patient receiving assisted ventilation. RESULTS: The mean value of 24-h sound pressure levels exceeded 50dB(A) in all ICUs, ranging from 56.5 to 70.1dB(A). The SICUs and CCU had higher sound pressure readings from 0700h to 1600h, compared to the MICUs where the sound pressure readings reflected less variability across the 24-h period. Marked differences were observed in luminance levels among various ICUs and also across the 24-h period for all three locations. The mean highest level of nocturnal luminance at eye level of patients receiving assisted ventilation ranged from 15 to 489lx before midnight (1800-2400h) and 10 to 239lx after midnight (2401-0759h). CONCLUSIONS: High sound pressure levels are prevalent throughout 24h in the ICUs, especially in the SICU. Many of the readings exceeded international standards. Peak sound pressure levels were related primarily to staff activities and the alarm sounds of machines. ICU patients are exposed to high levels of artificial light continuously throughout the day and night.

Common Mental Disorders in Primary Health Care Units: Associated Factors and Impact on Quality of Life.

BACKGROUND: Considering the high worldwide prevalence of common mental disorders (CMDs), characterizing the association between CMD and quality of life (QoL) constitute a valuable measure to gauge patient's functional impairment due to CMD symptoms. OBJECTIVE: To investigate factors associated with the incidence of CMD and its impact on the QoL in primary health care (PHC) patients. DESIGN: Cross-sectional study completed in a municipality in Brazil. Standardized tools included the Self-Reporting Questionnaire-20 to detect CMDs and the WHOQOL-brief to assess QoL, in addition to a sociodemographic and treatment-related questionnaire. RESULTS: A total of 41.4% of the patients met cutoff scores for a CMD, and the presence of a CMD was associated with female gender and marital status. Patients with CMDs had lower QoL scores than patients who were negative for a CMD. CONCLUSIONS: CMDs are highly prevalent in PHC settings and affect patients' QoL. The high frequency of CMD in those that seek care through PHC necessitate incorporating mental health services into the range of available services.

Adverse childhood experiences are associated with spontaneous preterm birth: a case-control study.

BACKGROUND: More than 1 in 10 infants are born prematurely worldwide, making preterm birth the leading cause of neonatal mortality and morbidity. Chronic maternal stress is increasingly recognized as one of the contributing risk factors for preterm birth, yet its specific role remains largely unknown. Examining the exposure to stressors over a mother's life course might provide more perspective on the role of maternal stress in preterm birth. Our aim was therefore to retrospectively explore the associations between chronic, lifelong stressors and protective factors and spontaneous preterm birth. METHODS: This study was part of a large case-control study based in Edmonton, Canada, examining gene-environment interactions and preterm birth. Cases were mothers with a spontaneous singleton preterm birth (<37 weeks) without preterm premature rupture of membranes. Controls were mothers with an uncomplicated singleton term birth without a history of preterm birth. Sociodemographic and medical data were collected. A postpartum telephone questionnaire was administered to assess stressors across the lifespan. Both individual and contextual variables that could influence stress response systems were examined. Overall, 622 women were included, of which 223 subjects - 75 cases and 148 controls - completed the stress questionnaire. Univariate and multivariate logistic regression analyses were performed. RESULTS: Multivariate analysis showed that exposure to two or more adverse childhood experiences (ACEs) was associated with a two-fold risk of preterm birth, regardless of maternal age, smoking status, educational status, and history of miscarriage (adjusted OR, 2.09; 95 % CI, 1.10-3.98; P = 0.024). The adjusted odds ratio for the ACE score was 1.18 (95 % CI, 0.99-1.40), suggesting that for every increase in childhood adverse event endorsed, the risk of preterm birth increased by 18 %. Lifetime physical and emotional abuse was also associated with spontaneous preterm birth in our study population (adjusted OR, 1.30; 95 % CI, 1.02-1.65; P = 0.033). CONCLUSIONS: A strong relationship between ACEs and preterm birth was observed. It has been shown that two or more ACEs have a notable two-fold increase in the risk of spontaneous preterm birth. These data demonstrate that stressors throughout life can have a significant effect on pregnancy outcomes such as preterm birth.

Effects of earplugs and eye masks combined with relaxing music on sleep, melatonin and cortisol levels in ICU patients: a randomized controlled trial.

INTRODUCTION: Intensive care unit (ICU) environmental factors such as noise and light have been cited as important causes of sleep deprivation in critically ill patients. Previous studies indicated that using earplugs and eye masks can improve REM sleep in healthy subjects in simulated ICU environment, and improve sleep quality in ICU patients. This study aimed to determine the effects of using earplugs and eye masks with relaxing background music on sleep, melatonin and cortisol levels in ICU patients. METHODS: Fifty patients who underwent a scheduled cardiac surgery and were expected to stay at least 2 nights in Cardiac Surgical ICU (CSICU) were included. They were randomized to sleep with or without earplugs and eye masks combined with 30-minute relaxing music during the postoperative nights in CSICU. Urine was analyzed for nocturnal melatonin and cortisol levels. Subjective sleep quality was evaluated using the Chinese version of Richards-Campbell Sleep Questionnaire (a visual analog scale, ranging 0-100). RESULTS: Data from 45 patients (20 in intervention group, 25 in control group) were analyzed. Significant differences were found between groups in depth of sleep, falling asleep, awakenings, falling asleep again after awakening and overall sleep quality (P < 0.05). Perceived sleep quality was better in the intervention group. No group differences were found in urinary melatonin levels and cortisol levels for the night before surgery, and the first and second nights post-surgery (P > 0.05). The urinary melatonin levels of the first and second postoperative nights were significantly lower than those of the night before surgery (P = 0.01). The opposite pattern was seen with urinary cortisol levels (P = 0.00). CONCLUSION: This combination of non-pharmacological interventions is useful for promoting sleep in ICU adult patients; however, any influence on nocturnal melatonin levels and cortisol level may have been masked by several factors such as the timing of surgery, medication use and individual differences. Larger scale studies would be needed to examine the potential influences of these factors on biological markers and intervention efficacy on sleep. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR-IOR-14005511 . Registered 21 November 2014.

[Common mental disorders and use of psychotropic medications in women consulting at primary care units in a Brazilian urban area]. / Transtornos mentais comuns e uso de psicofármacos em mulheres atendidas em unidades básicas de saúde em um centro urbano brasileiro.

OBJECTIVE: To investigate the prevalence of common mental disorders (CMD) in women consulting at primary health care units in a Brazilian urban area, as well as to determine the impact of CMD on quality of life (QoL), the association of sociodemographic factors with CMD and QoL, and the prevalence and pattern of psychotropic medication use in the study sample. METHODS: In this quantitative, cross-sectional, correlational-descriptive study, a stratified sample of 365 women was interviewed between May 2012 and January 2013 in five primary health care units in Brazil. Data were collected using sociodemographic and drug use questionnaires. The self-reporting questionnaire (SRQ-20) was used to estimate the prevalence of CMD; and the World Health Organization Quality of Life (WHOQOL)-bref instrument was used to assess quality of life. To evaluate the impact of CMD on QoL, the t test and linear regression models were employed. The chi-square test was used to verify associations between CMD and sociodemographic variables. Descriptive analysis was used for psychotropic drug use. RESULTS: The prevalence of CMD was 44.1%. The prevalence of psychotropic medication use was 27.1%. Only 5.6% of participants had a psychiatric diagnosis recorded in their medical chart. Psychotropic drugs were used by 41.6% of participants with CMD according to the SRQ-20 and by 15.7% of those without CMD. There was no association between CMD and sociodemographic variables, but CMD and QoL were significantly associated. Women with CMD had the worst QoL, without impact of sociodemographic variables. CONCLUSIONS: Further attention should be given to the pattern of psychotropic medication use and prescription in primary care settings. Women with CMD had functional impairment, as shown by significantly lower QoL scores. The fact that sociodemographic factors did not impact the present results seems to support the notion of a different basis for CMD in women.

Predictors of depressive symptoms and physical health in caregivers of individuals with schizophrenia.

This cross-sectional study examined relationships among factors influencing caregiver burden, depressive symptoms, and physical health in family caregivers of individuals with schizophrenia. Two hundred family caregivers of individuals with schizophrenia completed standardized questionnaires related to depressive symptoms, physical health, perceptions of burden, coping, and social support. The results revealed that 19.5% of family caregivers of individuals with schizophrenia experienced significant depressive symptoms and 65.5% perceived themselves in poor physical health. Burden, self-controlling coping strategies, and physical health status were all independently predictive of depressive symptoms. Two emotion-focused coping strategies (self-controlling and escape-avoidance) were independently predictive of caregiver burden. Only burden predicted physical health status. The findings suggest that health professionals who provide community care for those with schizophrenia need to consider the "unit of care" as the family rather than the individual. The health status of family caregivers should be routinely assessed. Individualized interventions to reduce family burden could include community-based health professionals as well as trained community volunteers, opportunities for social interaction, and improving self-care for all family members.

Parental Vigilance in Caring for Their Children with Hypoplastic Left Heart Syndrome.

Hypoplastic left heart syndrome (HLHS) is a complex heart malformation that requires life-saving treatments. Parents experience numerous challenges as they learn to parent a child with complex care requirements. The following research question guided this qualitative study: Is the parenting process among parents of a child with HLHS characterized by exaggerated vigilant parental action, and if so, how does this influence parental response? Situated within a larger program of pediatric cardiology research, this study included data from two grounded theory studies with parents of children with HLHS. This secondary analysis involved a thematic content analysis using sensitizing concepts of uncertainty, protectiveness, support, and mastery of complex care. Transcribed data from 55 interviews with 24 mothers and 17 fathers of young children with HLHS were analyzed for relevant and recurring themes. In mastering skills required to care for their child with HLHS, parents contrasted what was in their hands with what was out of their hands. Vigilant parental actions were evident as parents became skilled at providing complex care. Parents said they were sometimes excessive in their vigilant actions. In retrospect they viewed this vigilance as appropriate in some situations but exaggerated in other situations. Understanding parents' vigilant actions in response to their child's complex care can guide health care providers' interactions with families. Long-term follow up, both clinically and through research, is needed to assess the long-term consequences of exaggerated vigilant parental action on the child, parent, and family, and to determine and evaluate appropriate and timely intervention.

Workforce resilience supporting staff in managing stress: A coherent breathing intervention for the long-term care workforce.

BACKGROUND: Staff in long-term care (LTC) homes have long-standing stressors, such as short staffing and high workloads. These stressors increased during the COVID-19 pandemic; better resources are needed to help staff manage stress and well-being. The purpose of this study was to evaluate the effect of a simple stress management strategy (coherent breathing). METHODS: We conducted a pre-post intervention study to evaluate a self-managed coherent breathing intervention from February to September 2022. The intervention included basic (breathing only) and comprehensive (breathing plus a biofeedback device) groups. Six hundred eighty-six participants were initially recruited (359 and 327 in the comprehensive and basic groups respectively) from 31 LTC homes in Alberta, Canada. Two hundred fifty-four participants completed pre-and post-intervention questionnaires (142 [55.9%] in comprehensive and 112 [44.1%] in basic). Participants were asked to use coherent breathing based on a schedule increasing from 2 to 10 min daily, 5-7 times a week over 8 weeks. Participants completed self-administered online questionnaires pre- and post-intervention to assess outcomes-stress, psychological distress, anxiety, depression, resilience, insomnia, compassion satisfaction, compassion fatigue, and burnout. We used a mixed-effects regression model to test the main effect of time (pre- and post-intervention) and group while testing the interaction between time and group and controlling for covariates. RESULTS: We found statistically significant changes from pre- to post-intervention in stress (b = -2.5, p < 0.001, 95% CI = -3.1, -1.9), anxiety (b = -0.5, p < 0.001, 95% CI = -0.7, -0.3), depression (b = -0.4, p < 0.001, 95% CI = -0.6, -0.2), insomnia (b = -1.5, p < 0.001, 95% CI = -2.1, -0.9), and resilience (b = 0.2, p < 0.001, 95% CI = 0.1, 0.2). We observed no statistically significant differences between the two intervention groups on any outcome. CONCLUSIONS: Our findings suggest that coherent breathing is a promising strategy for improving stress-related outcomes and resilience. This intervention warrants further, more rigorous testing.

Immigrant Women's Experiences of Domestic Violence in Canada: A Qualitative File Audit.

Purpose: Domestic violence (DV) experienced by immigrant women is a global health concern. Precarious immigration status, language barriers, and discrimination can lead to reluctance in seeking support. Is a non-profit charitable organization and support center for immigrant women. Participants in this study were immigrant women who attended Changing Together. The aim of this study is to illustrate immigrant women's experiences of DV and identify the community services they access. Methods: The files of a social worker at Changing Together were audited for this project. There were 1,034 files available to audit. The six steps of thematic analysis were used to create themes from the notes of each file, specifically to answer the question: what are the experiences of immigrant women with domestic violence and what are the services they access through Changing Together? Results: Three themes were developed: Building Independence, Surviving Abuse, and Services to Support Surviving. Building Independence centres on women building solid foundations to start their lives in Canada to support themselves and their families. Surviving Abuse encompasses the hardships women endured for the perceived sake of their children until there was an event leading to the unavoidable need for change. Services to Support Surviving explores the services women accessed through the social worker at Changing Together. Conclusions: This study highlights the complexities of immigrant women enduring DV in a foreign country. The file notes described women's experiences of living with hardships and endurance of challenges. Further research should identify community resources for this population.

Mental Health of Immigrant Children and Adolescents (6-17 Years) in Canada: Evidence from the Canadian Health Measures Survey.

BACKGROUND: Studies indicate a higher prevalence of mental health problems among immigrants, but findings on immigrant children and adolescents are mixed. We sought to understand the magnitude of differences in mental health indicators between immigrant and non-immigrant children and adolescents in Canada and the influence of age, sex, household income, and household education. METHODS: We completed a secondary analysis of data from the Canadian Health Measures Survey, using a pooled estimate method to combine data from four survey cycles. A weighted logistic regression was used to estimate the unadjusted and adjusted odds ratios with 95% confidence intervals. RESULTS: We found an association between the mental health of immigrant versus non-immigrant children and adolescents (6-17 years) as it relates to emotional problems and hyperactivity. Immigrant children and adolescents had better outcomes with respect to emotional problems and hyperactivity/inattention compared to non-immigrant children and adolescents. Lower household socioeconomic status was associated with poorer mental health in children and adolescents. CONCLUSION: No significant differences in overall mental health status were evident between immigrant and non-immigrant children and adolescents in Canada but differences exist in emotional problems and hyperactivity. Sex has an influence on immigrant child mental health that varies depending on the specific mental health indicator.

Symptoms of acute stress disorder in mothers of premature infants.

PURPOSE: : To determine whether significant symptoms of acute stress disorder (ASD) are present in mothers of premature infants in the neonatal intensive care unit (NICU). SUBJECTS: : Forty mothers of premature infants born less than 33 weeks and admitted into NICU. DESIGN: : Prospective, cohort, within-subjects. METHODS: : Mothers completed the Stanford Acute Stress Reaction Questionnaire, Edinburgh Postnatal Depression Scale, and the Acute Stress Disorder Interview to explore the number and severity of stress-related symptoms at 2 separate time periods, 7 to 10 days after birth, and 1 month after birth. RESULTS: : Twenty-eight percent of the mothers met diagnostic criteria of ASD at 7 to 10 days after birth, and at 1 month after birth ASD symptoms persisted. The majority of the mothers described premature birth as a traumatic stressor. The most commonly met criteria were dissociation and anxiety. Significant symptoms of depression were found in 43% of mothers and persisted 1 month after birth. Rates of depression and moderate to severe symptoms of ASD were significantly related in mothers at 1 week and at 1 month after birth. CONCLUSIONS: : The premature birth experience is traumatic for mothers and may lead to various emotional responses including stress-related symptoms such as depression and/or ASD. Mothers with significant symptoms of depression and those with symptoms of stress seem to be more at risk for developing symptoms of ASD.

The complexity of postpartum mental health and illness: a critical realist study.

The complexity of postpartum mental health and illness: a critical realist study Postpartum depression (PPD) is a major public health issue that profoundly impacts the woman, her infant and family. Although it may be linked to hormone changes, no direct hormonal aetiology has been established. A large body of evidence implicates numerous psychosocial predictors of PPD. While a history of depression predicts about 50% of cases of PPD, it remains unclear why some women with a history do not develop depression following childbirth, even taking psychosocial factors into account. The aim of this study was to identify the main mechanisms and factors associated with the presence or absence of PPD in women with a history of depression, and the presence of PPD in women without a history, using a critical realist approach. The findings indicate a number of personal and contextual factors that influence postpartum mental health and illness. In addition, and perhaps most importantly, women who did not develop depression identified goal-oriented actions that were protective. These factors and processes did not exist in isolation and the interplay among them in influencing health was apparent. More research is needed to explore the effects of these mechanisms in different contexts.

Domestic Violence and Immigrant Women: A Glimpse Behind a Veiled Door.

Domestic violence (DV) experienced by immigrant women is a public health concern. In collaboration with a community agency, researchers undertook a retrospective review of 1,763 client files from 2006-2014. The three aims were to document the incidence of DV, service needs associated with DV, and identification of risk factors associated with DV in the extracted file data. About 41% reported DV and required multiple services. Separated and divorced women, and women on visitor/temporary visas showed the highest risk. The results underscore the value of research partnerships with community-based service agencies in increasing our understanding of DV among immigrant women.

Tiredness, fatigue, and exhaustion in the context of a major depressive disorder.

Framed in a multimethod design using ethnoscience and grounded theory, the purpose of this study was to characterize the attributes of tiredness, fatigue, and exhaustion, and to explore their influences on illness experiences in individuals with major depressive disorder. Two domains, mind (attributes: cognitive function, sleep quality, emotional reactivity, social interaction) and body (attributes: stamina and control over body processes), were identified. These attributes changed qualitatively with participants' progression from tiredness to fatigue and from fatigue to exhaustion, and determined whether participants "faced outward" to engage with others or "faced inward" to protect energy reserves--a decision largely influenced by the capacity "to hold up a mask" to conceal symptoms. The mask was energy depleting, and if participants could not hold up their mask, they withdrew to preserve energy. Findings regarding the role of the mask could contribute to the development of patient self-care strategies and caregiver interventions.