Empathy in family medicine postgraduate education: A mixed studies systematic review.

PURPOSE: Empathy is an important construct in patient-physician relationships, particularly critical in family physicians' daily practice. We aimed to understand how empathy has been conceived and integrated into family medicine postgraduate training. MATERIALS AND METHODS: Medline, PsyINFO, and Embase were searched in this systematic mixed studies systematic review. Two independent reviewers screened abstracts and full texts. Disagreements were solved through research team consensus-based discussion. Included studies were synthesized thematically. RESULTS: A total of 18 studies were included. Four themes were identified. (1) Empathy definition. Included studies stressed the cognitive component of empathy, paired either with a behavioural or an affective response. (2) Empathy modifiers. Starting residency right after medical school, having a role model, having high empathy levels before residency, having children, being married, and being exposed to patient involvement in education were found to have a positive impact on empathy. (3) Empathy-burnout relationship. Whereas greater burnout was related to lower empathy levels, excess empathy seems to favour burnout through 'compassion fatigue.' (4) Educational programs for empathy development. Five programs were identified: a communication workshop, a patient-led program, a mindfulness program, a family-oriented intervention, and an arts-based program. CONCLUSIONS: Studies mostly measured the cognitive component of empathy. The moral component of empathy was underrepresented in the conceptualization of empathy and the development of educational interventions. Conflicting evidence exists regarding the decline of empathy levels during the family medicine residency. Longitudinal designs should be privileged when exploring the evolution of empathy levels across the continuum of medical education.

Assessment of risk factors of treatment discontinuation among patients on paliperidone palmitate and risperidone microspheres in France, Germany and Belgium.

BACKGROUND: Long-acting antipsychotics (e.g. 1-monthly (PP1M) / 3-monthly (PP3M) injection forms of paliperidone palmitate) have been developed to improve treatment continuation in schizophrenia patients. We aim to assess risk factors of treatment discontinuation of patients on paliperidone palmitate and risperidone microsphere. Additionally, treatment discontinuation between patients with PP1M and PP3M was compared. METHODS: The IQVIA Longitudinal Prescription databases were used. Risk factors of treatment discontinuation were identified by a multilevel survival regression using Cox proportional hazards model. Kaplan Meier analyses were performed by identified significant risk factors. RESULTS: Twenty-five thousand three hundred sixty-one patients (France: 9,720; Germany: 14,461; Belgium: 1,180) were included. Over a one-year follow-up period, a significant lower treatment discontinuation was observed for patients newly initiated on paliperidone palmitate (53.8%) than those on risperidone microspheres (85.4%). Additionally, a significantly lower treatment discontinuation was found for 'stable' PP3M patients (19.2%) than 'stable' PP1M patients (37.1%). Patients were more likely to discontinue when drugs were prescribed by GP only (HR = 1.68, p < 0.001 vs. psychiatrist only) or if they were female (HR = 1.07, p < 0.001), whereas discontinuation decreased with age (31-50 years: HR = 0.95, p = 0.006 and > 50 years: HR = 0.91, p < 0.001 vs. 18-30 years). CONCLUSIONS: This study demonstrates that patients stay significantly longer on treatment when initiated on paliperidone palmitate as compared to risperidone microspheres. It also indicated a higher treatment continuation of PP3M over PP1M. Treatment continuation is likely to be improved by empowering GPs with mental health knowledge and managing patients by a collaborative primary care-mental health model. Further research is needed to understand why females and younger patients have more treatment discontinuation.

Use and misuse of prescription stimulants by university students: a cross-sectional survey in the french-speaking community of Belgium, 2018.

BACKGROUND: Misuse of prescription stimulants (PS) has been reported among students to enhance academic performance in Flanders (Belgium). However, PS misuse among students in the French-speaking community is unknown. The main purpose of the study was to estimate the prevalence of medical use and misuse of PS by university students in the French-speaking community (Belgium), and to investigate the reasons and sources associated with PS misuse. METHODS: A cross-sectional online survey was performed in 2018. All university students 18 years and older were invited to participate and asked about PS use, including medical (i.e., used for therapeutic purposes) and nonmedical reasons and sources of PS. RESULTS: In total, 12 144 students participated in the survey (median age = 21 years, 65.5% female). The estimated prevalence of PS use was 6.9% (ever use) and 5.5% (past-year). Among ever users, 34.7% were classified as medical users and 65.3% as misusers. Lifetime prevalence of misuse was estimated at 4.5%. The most common reason for medical use was treatment of attention disorder (85.9%). Reasons for misuse were mainly to improve concentration (76.1%) or to stay awake and study longer (50.7%). Friends or acquaintances inside the student community and general practitioners were the main sources of PS for misuse (41.5% and 23.5%, respectively). CONCLUSIONS: This study found that rates of misuse of PS in French-speaking universities in Belgium were in line with studies conducted in Flanders and Europe. Academic institutions can use these results to tailor their drug prevention campaigns.

The role of emotional competencies in predicting medical students' attitudes towards communication skills training.

OBJECTIVES: This study aims to investigate whether stress, depression and emotional competencies can help to predict medical students' attitudes towards communication skills training (CST). Anxiety and negative attitudes towards CST have been shown to be linked. Conversely, emotional competencies (EC) were associated with positive attitudes. Exploring these psycho(patho)logical variables therefore seems to be a promising approach to better understanding, or even modifying, attitudes towards CST. METHODS: 179 third year medical students were asked to complete the Communication Skills Attitude Scale (CSAS), the Perceived Stress Scale (PSS), the Montgomery-Asberg Depression Rating Scale Self-assessment (MADRS-S) and the Profile of Emotional Competence (PEC). RESULTS: 168 students completed the entire questionnaire. The stepwise regression model first revealed that, taken together, intrapersonal EC "Utilization" and interpersonal EC "Expression" account for 17% of the variance in positive attitudes. Secondly, taken together, intrapersonal EC "Utilization" and interpersonal EC "Expression" account for 16% of the variance in negative attitudes. CONCLUSION: The more competent a student is in "Utilization" and "Expression", the more positive attitudes and the less negative attitudes he/she has towards CST. In addition, measuring a large set of bio-psycho-social factors might be a way of capturing more variance in attitudes towards CST. PRACTICE IMPLICATIONS: In the study of variables influencing attitudes towards CST, emotional competencies cannot be ignored. The context of the medical consultation encourages the discussion of various emotions felt by the patient. As educationalists, we should prepare the student for this by integrating the notion of EC within the CST.

Longitudinal study: Impact of communication skills training and a traineeship on medical students' attitudes toward communication skills.

OBJECTIVES: To study longitudinally students' attitudes towards communication skills (CS) in order to examine whether CS training (CST) has an enduring impact on medical students' attitudes toward being a lifelong learner of CS. METHODS: 105 students completed the Communication Skills Attitude Scale at 4 times: before CST, after CST and before and after a traineeship. RESULTS: Our final sample size is 105 students. CST improved the attitudes of our students toward CS, and the traineeship stabilised those attitudes. However, while the improvement in positive attitudes was sustained over time, negative attitudes increased 6 months after CST. CONCLUSION: CST using experiential methods in a safe environment has the potential to improve students' attitudes towards CS. A short traineeship in general medicine allows students to quickly integrate CST into clinical practice, without deteriorating their attitudes toward CS. However, 6 months of medical lessons without CST reinforces students' negative attitudes. PRACTICE IMPLICATIONS: To avoid the deterioration of attitudes over time, CST should be continuous or at least spaced at intervals less than 6 months and supported by the institutional authorities. In addition, placing the CST close to an observation traineeship in general practice seems an interesting way to prevent further deterioration of attitudes.

Decline of Empathy after the First Internship: Towards a More Functional Empathy?

Research has shown a decline in empathy as medical studies progress. Among various hypotheses, an explanation track evoked is the first contact with the internship. Objectives This quasi-experimental study was designed to examine the impact of the first internship in medical students. Our research question was: "to what extent the first internship may decreased the empathy's scores of our 3d year medical students?" Methods We measured the empathy of 220 third year medical students before and after their first internship (3 weeks) in family medicine. Using online surveys methodology, we collected data about empathy ("Interpersonal Reactivity Index": IRI), epidemiology, professional orientation choices. Results Statistical analyses revealed a small but significant decrease in IRI's "fantasy," "empathic concern" and "personal distress" subscales. Conclusion These results suggest a potential impact of the first internship on empathic skills. The fact that the students' score for the "personal distress" subscale (which characterizes a difficulty in managing their emotions) decreases is actually a rather good thing. These data raise the question of the "function" of this loss of empathy. The fact that this score decreases after first internship, may indicate a positive change for these medical students: towards better emotional regulation and more functional affective empathy.

A mixed-approach to investigate what motivates Belgian students to study medicine.

This article was migrated. The article was marked as recommended. Aims - Our main objective was to explore the motivations that led our third year Belgian students to study medicine. Method - We used a mixed method as we collected both quantitative and qualitative measures at the same time through online surveys. Chi-Square tests were used to examine differences in motivation between gender of the participants. A thematic content analysis was then conducted on the open-ended question using a qualitative approach. Results and conclusions - The final sample consists of 243 third-year students (87 men and 156 women). Chi-square analyses revealed gender differences in motivations to study medicine. The motivation most often reported by our students in both qualitative and quantitative analyses is "altruistic motivation". The qualitative analysis identified, within this category, sometimes unrealistic beliefs about the practice of medicine, leading to the conclusion that it is necessary to put medical students in contact with the reality of the field as soon as possible. Furthermore, the lack of focus on the relationship with the patient within the formal curriculum and subsequent medical practice could be the cause of a form of disillusionment among these students. We believe that more lessons on relational aspects should be offered to them. Perspectives - Finally, in addition to identifying and classifying the motivations present among medical students, we believe that some perspectives are the analysis of the interactions between these motivations in 1) the determination of the choice of study and 2) the attitudes and behaviours that will result from it.

Happiness and Social Behavior.

It is often assumed that there is a robust positive symmetrical relationship between happiness and social behavior: Social relationships are viewed as essential to happiness, and happiness is thought to foster social relationships. However, empirical support for this widely held view is surprisingly mixed, and this view does little to clarify which social partner a person will be motivated to interact with when happy. To address these issues, we monitored the happiness and social interactions of more than 30,000 people for a month. We found that patterns of social interaction followed the hedonic-flexibility principle, whereby people tend to engage in happiness-enhancing social relationships when they feel bad and sustain happiness-decreasing periods of solitude and less pleasant types of social relationships that might promise long-term payoff when they feel good. These findings demonstrate that links between happiness and social behavior are more complex than often assumed in the positive-emotion literature.

Racing thoughts revisited: A key dimension of activation in bipolar disorder.

BACKGROUND: Racing and crowded thoughts are frequently reported respectively in manic and mixed episodes of bipolar disorder (BD). However, questionnaires assessing this symptom are lacking. Here we aimed to investigate racing thoughts across different mood episodes of BD through a self-report questionnaire that we developed, the 34-item Racing and Crowded Thoughts Questionnaire (RCTQ). In addition to assessing its factor structure and validity, we were interested in the RCTQ's ability to discriminate mixed and non-mixed depression. METHODS: 221 BD patients and 120 controls were clinically assessed via the YMRS (mania) and the QIDS-C16 (depression), then fulfilled the RCTQ, rumination, worry, and anxiety measures. Three depression groups were operationalized according to YMRS scores: YMRS scores 2 > 6 and YMRS scores = 1 or 2, for respectively mixed and non-pure depression, and YMRS = 0 for pure-depression. RESULTS: Confirmatory factor analysis showed that the three-factor model of the RCTQ yielded the best fit indices, which improved after the removal of redundant items, resulting in a 13-item questionnaire. Hypomanic and anxiety symptoms were the main predictors of scores; rumination was not a significant predictor. RCTQ results were similar between mixed groups and non-pure depression, and both were higher than in pure-depression. LIMITATIONS: Patients' pharmacological treatment might have influenced the results. CONCLUSIONS: The 13-item RCTQ captures different facets of racing thoughts heightened in hypomanic and mixed states, but also in depression with subclinical hypomanic/activation symptoms (e.g. non-pure depression characterized by enhanced subjective irritability), suggesting that it is particularly sensitive to activation symptoms in BD, and could become a valuable tool in the follow-up of patients.

Cortical reactivations during sleep spindles following declarative learning.

Increasing evidence suggests that sleep spindles are involved in memory consolidation, but few studies have investigated the effects of learning on brain responses associated with spindles in humans. Here we used simultaneous electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) during sleep to assess haemodynamic brain responses related to spindles after learning. Twenty young healthy participants were scanned with EEG/fMRI during (i) a declarative memory face sequence learning task, (ii) subsequent sleep, and (iii) recall after sleep (learning night). As a control condition an identical EEG/fMRI scanning protocol was performed after participants over-learned the face sequence task to complete mastery (control night). Results demonstrated increased responses in the fusiform gyrus both during encoding before sleep and during successful recall after sleep, in the learning night compared to the control night. During sleep, a larger response in the fusiform gyrus was observed in the presence of fast spindles during the learning as compared to the control night. Our findings support a cortical reactivation during fast spindles of brain regions previously involved in declarative learning and subsequently activated during memory recall, thereby promoting the cortical consolidation of memory traces.

Beyond reduction with the representation: The need for causality with full complexity to unravel mental health.

In this commentary on Borsboom et al.'s target article, we argue that researchers should be aware of the historical development of models in neuroscience. Considering the importance of causality in anatomo-clinical approach and stressing the complexity of mental phenomenon, we provide new insight on reductionism and representation limitation.

Increased Reactivity of the Mesolimbic Reward System after Ketamine Injection in Patients with Treatment-resistant Major Depressive Disorder.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: The antidepressant effect of ketamine is associated with increased activity in the reward circuitry of the brain and a suppression of circuitry that mediates perceptual processing of negative emotions. The duration of ketamine effect on these brain structures remains to be defined. WHAT THIS ARTICLE TELLS US THAT IS NEW: As expected, ketamine administration led to an improvement in mood and global vigilance. The improvement in mood was accompanied by an increased recruitment of the orbitofrontal cortex, ventral striatum, medial substantial nigra and ventral tegmental area, structures that are part of the reward circuitry.Responses in the mesolimbic structures (amygdala, medial substantial nigra and ventral tegmental area, orbitofrontal cortex) to negative stimuli were decreased after ketamine administration.The data are consistent with the premise that ketamine induces sustained changes in the mesolimbic neural circuits to reset pathological reward and emotional processing. BACKGROUND: Ketamine rapidly improves maladaptive mood states in major depressive disorder, and some of the neural substrates underlying this therapeutic effect have been identified. This study aimed to identify functional changes within neural networks that may underlie the impact of ketamine on both reward and emotional processing in patients with treatment-resistant major depression. METHODS: Ten adult patients with a Montgomery-Åsberg Depression Rating Scale score above 25 were enrolled to receive a single intravenous administration of ketamine (0.5 mg/kg). Patients' performance along with related neural network activations were analyzed in a game-like reward task and in an emotional judgment task using functional magnetic resonance imaging 1 day before and 1 and 7 days after ketamine administration. RESULTS: A significant correlation (R = 0.46, P = 0.03) between the improvement of depression scores and the enhanced reaction time for positive items was found in the game-like reward task 1 day after ketamine administration. This enhanced sensitivity for rewarded items was accompanied by increased activity of reward-related brain regions, including the orbitofrontal cortex, ventral striatum, and the ventral tegmental area, an effect that persisted up to 1 week after ketamine injection. In the emotional judgment task, it was found that ketamine rapidly modified local brain activities in response to emotionally negative, positive, or neutral stimuli in the amygdala, insula, anterior cingulate cortex, and in the ventral tegmental area. CONCLUSIONS: Single bolus ketamine administration rapidly triggers lasting changes in mesolimbic neural networks to improve pathologic reward and emotional processing in patients with major depressive disorder.

[Problematic Use of Internet and Video Games in Students in Medicine]. / Utilisation problématique d'Internet et des jeux vidéo chez des étudiants en médecine.

Dependence on the Internet and video games would have an impact on academic performance and mental health.Objective Highlight some of the interest factors in a first-year medical student population who will be subjected during their studies and future to the intensive use of these technologies.Method A self-questionnaire was proposed, from a free access link from February to March 2014, to all first-year medical students at the University of Namur in Belgium. It consisted of questions related to socio-demographic data, Perceived Stress Scale (PSS 14), the Internet Addiction Test (IAT), the Problem Video Game Playing (PVP) and the Montgomery and Asberg Depression Rating Scale (MADRS).Results According to the Internet Addiction Test (IAT), 1% of the students are addicted to the Internet and 24,4% have occasional problematic use. According to Problem Video Game Playing (PVP), 11,4% of the students playing video games are problem gamblers. The data also show significantly higher scores for problematic use of the Internet and video games among stressed students, depressed students and those with poor academic performance.Conclusion We draw attention to the necessary debate between the rational use and the problematic use of new technologies as well as the need for longitudinal prevention from the beginning of studies.

Subjective Distress Associated with Adult ADHD: evaluation of a new self-report.

The current study aims at documenting the psychometric properties of the Subjective Distress Associated with Adult ADHD-Self-Report (SDAAA-SR), a newly developed instrument for the assessment of psychological suffering in ADHD adults. The SDAAA-SR was administered to 247 students and 142 ADHD adults. Factor structure, internal consistency, test-retest reliability, convergent validity and discriminant validity were assessed. Sensitivity to change was examined in a subsample of 25 ADHD patients who participated in a 1-year therapy. The initial pool of 62 items was reduced to 33 items distributed in a three-component structure. Internal consistency was excellent for the "distress due to inattention/disorganization" subscale and good for the "distress due to hyperactivity/impulsivity" and "distress due to self-esteem deficit" subscales. Test-retest reliability in a subsample of 98 students was substantial for all three subscales. ADHD patients scored significantly higher than students on distress due to "inattention/disorganization" and "hyperactivity/impulsivity," but no difference was observed for "self-esteem deficit." The components "inattention/disorganization" and "hyperactivity/impulsivity" displayed moderate to large correlations with the corresponding dimensions of the Adult Self-Report Scale for ADHD (ASRS-V1.1). Distress due to "inattention/disorganization" and "self-esteem deficit" was significantly associated with lower satisfaction with social behaviors (QFS, social functioning questionnaire) and quality of life (WHOQOL-BREF). Distress due to "inattention/disorganization" and "self-esteem deficit" significantly decreased after a 1-year therapy. The SDAAA-SR represents a reliable and valid measure of adult ADHD-associated distress, an important but often undocumented parameter in the clinical setting. Its use as an outcome variable in psychological interventions deserves further investigation.

Beyond sensorimotor imitation in the neonate: Mentalization psychotherapy in adulthood.

Despite the persuasiveness of Keven & Akins' (K&A) review, we argue that mentalization, or the ability to interpret the mental states of oneself and others, is required to construct the neonate mind, going far beyond sensorimotor imitation. This concept, informed by certain psychoanalytic and attachment theories, has produced a form of therapy called mentalization-based psychotherapy, which aims to improve emotional regulation. Our aim here is to shed light on a form of neonatal imitation that goes beyond sensorimotor imitation.

Altered brain connectivity in patients with schizophrenia is consistent across cognitive contexts.

BACKGROUND: Schizophrenia has been defined as a dysconnection syndrome characterized by aberrant functional brain connectivity. Using task-based fMRI, we assessed to what extent the nature of the cognitive context may further modulate abnormal functional brain connectivity. METHODS: We analyzed data matched for motion in patients with schizophrenia and healthy controls who performed 3 different tasks. Tasks 1 and 2 both involved emotional processing and only slighlty differed (incidental encoding v. memory recognition), whereas task 3 was a much different mental rotation task. We conducted a connectome-wide general linear model analysis aimed at identifying context-dependent and independent functional brain connectivity alterations in patients with schizophrenia. RESULTS: After matching for motion, we included 30 patients with schizophrenia and 30 healthy controls in our study. Abnormal connectivity in patients with schizophrenia followed similar patterns regardless of the degree of similarity between cognitive tasks. Decreased connectivity was most notable in the medial prefrontal cortex, the anterior and posterior cingulate, the temporal lobe, the lobule IX of the cerebellum and the premotor cortex. LIMITATIONS: A more circumscribed yet significant context-dependent effect might be detected with larger sample sizes or cognitive domains other than emotional and visuomotor processing. CONCLUSION: The context-independence of functional brain dysconnectivity in patients with schizophrenia provides a good justification for pooling data from multiple experiments in order to identify connectivity biomarkers of this mental illness.

Cerebral Activity Associated with Transient Sleep-Facilitated Reduction in Motor Memory Vulnerability to Interference.

Motor memory consolidation is characterized, in part, by a sleep-facilitated decrease in susceptibility to subsequent interfering experiences. Surprisingly, the cerebral substrates supporting this phenomenon have never been examined. We used fMRI to investigate the neural correlates of the influence of sleep on interference to motor memory consolidation. Healthy young adults were trained on a sequential motor task, and subsequently practiced a second competing sequence after an interval including diurnal sleep or wakefulness. Participants were then retested on the initial sequence 8 h and 24 h (including nocturnal sleep) after training. Results demonstrated that a post-training nap significantly protected memory against interference at 8 h and modulated the link between cerebral activity and behavior, such that a smaller post-interference decrease in cortico-striatal activity was associated with better performance. Interestingly, the protective effect of a nap was only transitory, as both groups performed similarly at 24 h. Activity in cortico-striatal areas that was disrupted during the day, presumably due to interference and accentuated in the absence of a nap, was restored overnight. Altogether, our findings offer the first evidence that cortico-striatal areas play a critical role in the transient sleep-facilitated reduction in motor memory vulnerability and in the overnight restoration of previously degraded memories.