Measuring ICD shock anxiety: Status update on the Florida Shock Anxiety Scale after over a decade of use.

INTRODUCTION: Approximately 44% of patients with implantable cardioverter defibrillators (ICDs) experience some form of shock anxiety, associated with cardiac fear, physical inactivity, and increased morbidity and mortality. The Florida Shock Anxiety Scale (FSAS) was created to measure ICD-specific fears for a more precise target of patient psychologic distress and potential need for intervention. The current paper describes results from a focused literature review of studies using FSAS over the past 15 years, with the aim of summarizing its current reliability and validity, associated outcomes, and potential future directions for its clinical and research implementation. METHODS: In this review, 26 peer-reviewed articles were analyzed and selected from an in-depth literature search of two electronic databases. RESULTS: The reliability and validity of FSAS has been upheld since its initial validation and remain positive. The majority of studies used FSAS as an assessment tool to evaluate a clinical need for psychologic support or psychoeducation. The most frequently reported predictors of FSAS shock anxiety include experience of shock, appropriate and inappropriate, and number of shocks experienced. Common correlates of higher FSAS scores include lower device-related knowledge, lower perceived support from healthcare providers, greater posttraumatic stress disorder symptoms, and negative attitudes about device dependency. Younger age and female gender are also associated with increased shock anxiety. CONCLUSIONS: Since 2006, FSAS has been widely represented as a valid and reliable assessment tool for quantifying device-related anxiety in ICD recipients in diverse populations. Future directions for FSAS should explore its potential role in support of measurement-based care.

Psychiatry's integration with medicine: the role of DSM-5.

Mental disorders represent a significant global burden whose effects are exacerbated by gaps in diagnosis and service provision. A substantial number of individuals seek services not through specialty psychiatric clinics but through primary care. Thus, the interface between psychiatry and the rest of medicine represents an appropriate area of focus in which to improve the detection and treatment of mental disorders. Development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) can play a key role in this process. DSM-5 is expected to include specific revisions in diagnostic criteria, chapter organization, text structure, and classification approach that are designed to improve use of DSM by nonpsychiatrist physicians. Furthermore, revisions to DSM-5 will inform development of the primary care version of DSM-5. The goal is to publish a manual that enhances clinical utility in a manner that is concise and more amenable to use in primary care.

Climate Change and Mental Health: Implications for the Psychiatric Workforce.

Climate change is a major global public mental health crisis that is expected to increase the need for mental health services. Psychiatrists and other mental health care providers must address workforce needs through recruitment, training and education, prevention and intervention, public policy and advocacy, and direct efforts to reduce climate change. This column discusses concrete steps for the psychiatric workforce to take to prepare for growing mental health needs associated with climate change.

Dimensional approaches to psychiatric diagnosis in DSM-5.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders is the compendium of disorder listings and diagnostic criteria used by clinicians in the United States and many other countries. The forthcoming fifth edition of the manual (DSM-5) represents an opportunity to not only update diagnostic information in concert with recent advances in the science and practice of psychiatry, but also to more strongly consider the integration of systematically gathered patient self-assessments of symptom severity. AIMS OF THE STUDY: To present information on planned changes to the DSM diagnostic assessment strategies that incorporate patient-reported data. METHODS: Activities of the DSM-5 work groups and study groups related to patient-reported assessments are summarized. These activities include critical reviews of past research, reviews of assessment instruments, development of assessment strategies incorporating dimensional assessments of patients' clinical symptoms, and testing of proposed strategies. RESULTS: Limitations of the current DSM diagnostic assessment system are discussed. With the current approach to diagnosis used in DSM-IV, clinicians must decide whether a patient meets the diagnostic criteria set forth for a disorder and then diagnose the disorder as present or absent. This categorical approach to the diagnostic threshold constricts the range of clinical information that may be of high importance to treatment planning, prognosis, and monitoring treatment outcomes. Advantages to incorporation of a dimensional assessment strategy are also discussed. A dimensional approach to psychiatric diagnosis provides clinicians with more information, and with standardized dimensional rating scales, can give patient self-reports a greater role in the clinical process. A description of the proposed methods for integrating dimensional assessments into DSM-5 is presented. Initial pilot testing of these changes to DSM indicate that clinicians and patients/patient informants found the dimensional measures to be useful, simple, and relevant to clinical care. DISCUSSION: The introduction of patient-reported symptom assessments as part of the DSM would represent a major change in psychiatric practice, with implications for patient care, mental health policy, and health care funding. The ultimate goal of such a change is to increase patient satisfaction with care and improve treatment outcomes. These goals will be the subject of continuing evaluation after the DSM-5 is published. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The use of patient-reported dimensional assessments of symptom severity will aid in more comprehensive and systematized characterizations of baseline clinical status and subsequent changes in clinical status with treatment. IMPLICATIONS FOR HEALTH POLICIES: The use of principles of evidence-based medicine and measurement-based care are likely to increase in the United States as health care reform measures are put into place. The DSM-5 proposals for patient-reported measures can serve as an initial method for gauging the outcomes of treatments. IMPLICATIONS FOR FURTHER RESEARCH: As with previous editions of the DSM, the changes implemented in DSM-5 will continue to be the focus of research efforts after publication. Results from this research will serve as the basis for further refinements in measurement recommendations.

Association between depressive symptoms and fibrosis markers: the Cardiovascular Health Study.

OBJECTIVE: Fibrosis plays an important role in heart failure (HF) and other diseases that occur more frequently with increasing age. Depression is associated with an increased risk of heart failure and other age-related diseases. This study examined the association between depressive symptoms and fibrosis markers in adults aged 65 years and above. METHODS: Fibrosis markers and depressive symptoms were assessed in 870 participants (age=80.9+/-5.9 yrs, 49% women) using a case-control design based on heart failure status (307 HF patients and 563 age- and sex-matched controls, of whom 284 with CVD risk factors (hypertension, diabetes mellitus, or hypercholesterolemia) and 279 controls without these CVD risk factors). Fibrosis markers were procollagen type I (PIP), type I collagen (CITP), and procollagen type III (PIIINP). Inflammation markers included C-reactive protein, white blood cell counts and fibrinogen. Depression was assessed using the Center for Epidemiological Studies-Depression (CES-D) scale using a previously validated cut-off point for depression (CES-D > or = 8). Covariates included demographic and clinical variables. RESULTS: Depression was associated with higher levels of PIP (median=411.0, inter-quartile range (IQR)=324.4-472.7 ng/mL vs. 387.6, IQR=342.0-512.5 ng/mL, p=0.006) and CITP (4.99, IQR=3.53-6.85 vs. 4.53, IQR=3.26-6.22 microg/L, p=0.024), but not PIIIINP (4.07, IQR=2.75-5.54 microg/L vs. 3.58, IQR=2.71-5.01 microg/L, p=0.29) compared to individuals without depression. Inflammation markers were also elevated in depressed participants (CRP, p=0.014; WBC, p=0.075; fibrinogen, p=0.074), but these inflammation markers did not account for the relationship between depression and fibrosis markers. CONCLUSIONS: Depression is associated with elevated fibrosis markers and may therefore adversely affect heart failure and other age-related diseases in which extra-cellular matrix formation plays a pathophysiological role.

COVID-related family separation and trauma in the intensive care unit.

Due to stringent but necessary infection control mandates, the COVID-19 pandemic is increasingly resulting in family separation from loved ones admitted to intensive care units (ICUs). Even in normal circumstances, ICU families frequently experience significant psychological dysfunction-including posttraumatic stress disorder and other trauma-related reactions, especially during the end of life period. The COVID pandemic likely will exacerbate these reactions as more and more families are being barred from the ICU. Consequently, ICU families are facing additional barriers in fully understanding the complex medical needs of their loved ones (and hence being able to make informed care decisions on their behalf); establishing rapport and bonding with nurses and other members of the ICU treatment team; and, in the event that a loved one passes, achieving closure. ICU health care providers can take steps to mitigate these outcomes by being mindful of the unique stressors ICU families are currently facing and tailoring their communication and behavior accordingly. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Patient-assisted computerized education for recipients of implantable cardioverter defibrillators: a randomized controlled trial of the PACER program.

BACKGROUND AND RESEARCH OBJECTIVE: Patients with implantable cardioverter defibrillators (ICDs) are at risk for postimplant anxiety. Computerized treatments for anxiety are well supported and desirable because of accessibility, anonymity, and cost-effectiveness. However, there currently exists no computerized psychosocial treatment for ICD populations. Our objective was to evaluate whether a pilot program (patient-assisted computerized education for recipients of ICDs [PACER of ICDs]) of a computerized intervention for ICD patients would improve ICD-related knowledge and psychological outcomes versus usual care. Outcomes were also compared with those from a related study that used the same intervention but in an in-person format. SUBJECTS AND METHODS: Patients (N = 30) with an ICD were randomized to PACER or usual care. Mean time from implantation was 10.71 months (SD, 21.81 months). Outcomes included ICD-related knowledge, trait anxiety, defibrillation-related anxiety, patient acceptance of the ICD, and quality of life. Patients were assessed at baseline and at 1 month follow-up. RESULTS AND CONCLUSIONS: Knowledge score over time did not differ by treatment group, although both groups improved their scores. Among treatment patients, increased knowledge accounted for a significant amount of variance in device acceptance (R2 change = 0.30, P =.02), irrespective of age, education, ejection fraction, and time from implantation. There was no relationship between knowledge and device acceptance among control patients. Compared with previous recipients, new device recipients (< 3 months) were more likely to demonstrate an increase in knowledge (P =.01), greater defibrillation anxiety (P =.02), and worse patient acceptance (P =.04). Patient-assisted computerized education for recipients of ICDs resulted in comparable improvements in trait anxiety, quality of life, and device acceptance as the in-person treatment. The potential utility of PACER to enhance device acceptance lends support for further testing among larger samples.

Use of Auditing and Feedback in an Outpatient Hospice Setting: Quality and Pharmacoeconomic Oversight.

BACKGROUND: Clinicians play an important role in containing pharmaceutical spending at the patient level, as well as ensuring efficacy and quality outcomes, yet little research has examined how to achieve this goal. MEASURES: Using auditing and feedback (A&F) as part of a Pharmacy and Therapeutics (P&T) Committee, we evaluated our community-based hospice program's prescribing habits for opioids, antipsychotics, and antidepressants and calculated oral pharmaceutical prescription costs per-patient-day. Quality of care was reflected by patient pain scores in electronic medical records. INTERVENTION: Our P&T Committee adopted an A&F approach to monitor and assess provider prescribing habits and cost. An already-existing pain quality improvement program assessed care quality. OUTCOMES: Pain relief either improved or was maintained while medication costs were reduced by over $1.00 per-patient-day from 2010 to 2011. CONCLUSIONS/LESSONS LEARNED: An active, hospice P&T Committee featuring A&F can significantly affect medication costs for a hospice program while maintaining or improving patient outcomes.

Age-specific differences in women with implantable cardioverter defibrillators: an international multi center study.

BACKGROUND: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers. METHODS: Eighty-eight female ICD patients were recruited at three medical centers: Shands Hospital at the University of Florida, Brigham and Women's Hospital in Boston, and Royal North Shore Hospital in Sydney, Australia. Women completed individual psychological assessment batteries, measuring the constructs of shock anxiety, death anxiety, and body image concerns. Medical record review was conducted for all patients regarding cardiac illnesses and ICD-specific data. RESULTS: Multivariate and univariate analyses of variance revealed that younger women reported significantly higher rates of shock and death anxiety (Pillai's F=3.053, P=0.018, eta2p=0.067) and significantly greater body image concerns (Pillai's F=4.198, P=0.018, eta2p=0.090) than middle- and older-aged women. CONCLUSIONS: Women under the age of 50 appear to be at greater risk for the development of psychosocial distress associated with shock anxiety, death anxiety, and body image. Clinical-based strategies and interventions targeting these types of adjustment difficulties in younger women may allow for improved psychosocial and quality of life outcomes.

A Systematic Assessment and Monitoring Intervention to Improve Pain Management and Quality Reporting Among Home Hospice Patients.

BACKGROUND: Validated and reproducible means to systematically improve pain documentation and outcomes in home-based hospice populations are generally lacking. This article describes a novel electronic medical record (EMR)-embedded pain monitoring and management program for home-based hospice patients. MEASURES: Pain relief was measured by patients' self-defined pain within 48 hours of initiating care, recorded on a 0-10 pain scale. INTERVENTION: The Pain Continuous Quality Improvement Program consisted of EMR enhancements, staff engagement and training, and incentivizing techniques. OUTCOMES: The Pain Continuous Quality Improvement Program effectively improved documentation of pain and reduced the prevalence of unresolved problematic pain (e.g., lower average pain score ratings, decrease in patients reporting problematic pain after 48 hours of initiating care). CONCLUSIONS/LESSONS LEARNED: Integrating the upgraded EMR system into routine practice and workflow was critical to facilitating rapid recognition of escalating pain and inadequate pain management as well as allowing improving monitoring of patient outcomes and staff performance.

Device implant technique and consideration of body image: specific procedures for implantable cardioverter defibrillators in female patients.

OBJECTIVES: The purpose of this paper is to describe the psychological effects of implantable cardioverter defibrillator (ICD) implantation in female patients and to make clinical recommendations for providers to optimize health outcomes for women. BACKGROUND: Traditional ICD implantation produces visible scarring. Changes in physical appearance affect body image in all ICD recipients but may be more onerous in female ICD recipients. Electrophysiologists have described cosmetic approaches to device placement that appear promising and may warrant consideration in female patients. CONCLUSIONS: Active discussion and consideration of alternative device implant techniques are indicated in female patients. Female patients should also be given time to make preoperative decisions, and family members should be engaged in decision making. The investigation of cosmetic implants is noteworthy and could improve quality of life, adjustment, and psychological fitness of female ICD recipients.

Comparison of rural and urban residents' implicit and explicit attitudes related to seeking medical care.

CONTEXT: The decision whether or not to consult a physician draws from a variety of attitudes within an individual's health schema. While rural Americans are in greater need of health care, many of them have fewer external resources than urbanites available to them. PURPOSE: The objective of this study was to elicit implicit and explicit attitudes related to seeking medical treatment for a condition described as fairly serious. Participants were asked to rate how often they comply with treatment regimens and practice good health habits. METHODS: The sample of rural (N = 586) and urban (N = 433) North Carolina residents was derived based on random-digit dialing. Multiple regression analyses were performed to investigate how attitudes associated with perceived compliance and health behaviors. FINDINGS: While rural and urban residents offered very similar responses, the associations between attitudes and behaviors were different. One healthy and 2 unhealthy schema patterns emerged. First, fear of hospitals was associated with effective compliance for rural residents and good health habits for urbanites. Second, affordability concerns were ascribed to rural community residents but seemed to reflect personally relevant implicit attitudes since they were associated with poor health adherence and habits for rural residents. Third, mistrust of doctors predicted low adherence for both groups and was also associated with poorer health habits for urbanites. With inconsistencies among implicit and explicit attitudes and behaviors, some residents seemed to be ambivalent about seeking health care.

Internet-based behavioral change and psychosocial care for patients with cardiovascular disease: a review of cardiac disease-specific applications.

BACKGROUND: Web-based interventions (WBIs) seem to be an efficacious method of addressing behavioral and psychosocial maladjustment among patients with chronic illness (eg, diabetes), behavioral concerns (eg, smoking cessation), and psychologic maladjustment (eg, panic disorder). Cardiology seems particularly well suited to the application of WBIs given its strong association with behavioral (eg, lifestyle) and cognitive (eg, stress and coping) factors. To date, few studies have been published that explore the use of WBIs on psychosocial and quality of life variables among populations with cardiac disease. OBJECTIVE: The purpose of this study is to review the use of WBIs in patients with cardiovascular disease to date, and to provide recommendations as to how future WBIs can be developed specifically to meet the needs of different populations with heart disease (eg, recipients of implantable cardioverter defibrillators, patients with congestive heart failure, and patients with congenital heart disease). CONCLUSIONS: We conclude that, although limitations exist, WBIs are a reasonable modus of improving patient outcomes.

The DSM-5: Classification and criteria changes.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) marks the first significant revision of the publication since the DSM-IV in 1994. Changes to the DSM were largely informed by advancements in neuroscience, clinical and public health need, and identified problems with the classification system and criteria put forth in the DSM-IV. Much of the decision-making was also driven by a desire to ensure better alignment with the International Classification of Diseases and its upcoming 11th edition (ICD-11). In this paper, we describe select revisions in the DSM-5, with an emphasis on changes projected to have the greatest clinical impact and those that demonstrate efforts to enhance international compatibility, including integration of cultural context with diagnostic criteria and changes that facilitate DSM-ICD harmonization. It is anticipated that this collaborative spirit between the American Psychiatric Association (APA) and the World Health Organization (WHO) will continue as the DSM-5 is updated further, bringing the field of psychiatry even closer to a singular, cohesive nosology.

DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses.

OBJECTIVE: The DSM-5 Field Trials were designed to obtain precise (standard error,0.1) estimates of the intraclass kappa asa measure of the degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods. METHOD: Eleven academic centers in the United States and Canada were selected,and each was assigned several target diagnoses frequently treated in that setting.Consecutive patients visiting a site during the study were screened and stratified on the basis of DSM-IV diagnoses or symptomatic presentations. Patients were randomly assigned to two clinicians for a diagnostic interview; clinicians were blind to any previous diagnosis. All data were entered directly via an Internet-based software system to a secure central server. Detailed research design and statistical methods are presented in an accompanying article. RESULTS: There were a total of 15 adult and eight child/adolescent diagnoses for which adequate sample sizes were obtained to report adequately precise estimates of the intraclass kappa. Overall, five diagnoses were in the very good range(kappa=0.60­0.79), nine in the good range(kappa=0.40­0.59), six in the questionable range (kappa = 0.20­0.39), and three in the unacceptable range (kappa values,0.20). Eight diagnoses had insufficient sample sizes to generate precise kappa estimates at any site. CONCLUSIONS: Most diagnoses adequately tested had good to very good reliability with these representative clinical populations assessed with usual clinical interview methods. Some diagnoses that were revised to encompass a broader spectrum of symptom expression or had a more dimensional approach tested in the good to very good range.

DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches.

OBJECTIVE: This article discusses the design,sampling strategy, implementation,and data analytic processes of the DSM-5 Field Trials. METHOD: The DSM-5 Field Trials were conducted by using a test-retest reliability design with a stratified sampling approach across six adult and four pediatric sites in the United States and one adult site in Canada. A stratified random sampling approach was used to enhance precision in the estimation of the reliability coefficients. A web-based research electronic data capture system was used for simultaneous data collection from patients and clinicians across sites and for centralized data management.Weighted descriptive analyses, intraclass kappa and intraclass correlation coefficients for stratified samples, and receiver operating curves were computed. The DSM-5 Field Trials capitalized on advances since DSM-III and DSM-IV in statistical measures of reliability (i.e., intraclass kappa for stratified samples) and other recently developed measures to determine confidence intervals around kappa estimates. RESULTS: Diagnostic interviews using DSM-5 criteria were conducted by 279 clinicians of varied disciplines who received training comparable to what would be available to any clinician after publication of DSM-5.Overall, 2,246 patients with various diagnoses and levels of comorbidity were enrolled,of which over 86% were seen for two diagnostic interviews. A range of reliability coefficients were observed for the categorical diagnoses and dimensional measures. CONCLUSIONS: Multisite field trials and training comparable to what would be available to any clinician after publication of DSM-5 provided "real-world" testing of DSM-5 proposed diagnoses.

Are the available apathy measures reliable and valid? A review of the psychometric evidence.

OBJECTIVE: Apathy is highly prevalent among neuropsychiatric populations and is associated with greater morbidity and worse functional outcomes. Despite this, it remains understudied and poorly understood, primarily due to lack of consensus definition and clear diagnostic criteria for apathy. Without a gold standard for defining and measuring apathy, the availability of empirically sound measures is imperative. This paper provides a psychometric review of the most commonly used apathy measures and provides recommendations for use and further research. METHODS: Pertinent literature databases were searched to identify all available assessment tools for apathy in adults aged 18 and older. Evidence of the reliability and validity of the scales were examined. Alternate variations of scales (e.g., non-English versions) were also evaluated if the validating articles were written in English. RESULTS: Fifteen apathy scales or subscales were examined. The most psychometrically robust measures for assessing apathy across any disease population appear to be the Apathy Evaluation Scale and the apathy subscale of the Neuropsychiatric Inventory based on the criteria set in this review. For assessment in specific populations, the Dementia Apathy Interview and Rating for patients with Alzheimer's dementia, the Positive and Negative Symptom Scale for schizophrenia populations, and the Frontal System Behavior Scale for patients with frontotemporal deficits are reliable and valid measures. CONCLUSION: Clinicians and researchers have numerous apathy scales for use in broad and disease-specific neuropsychiatric populations. Our understanding of apathy would be advanced by research that helps build a consensus as to the definition and diagnosis of apathy and further refine the psychometric properties of all apathy assessment tools.