Prospective study of antidepressant treatment of psychiatric patients with depressive disorders: treatment adequacy and outcomes.

BACKGROUND: Despite numerous national depression care guidelines (DCGs), suboptimal antidepressant treatment may occur. We examined DCG concordance and depression treatment outcomes in psychiatric settings. METHODS: We evaluated treatment received and outcomes of 128 psychiatric out- and inpatients participating in the PEGAD (Pharmacoepidemiology and Pharmacogenetics of Antidepressant Treatment for Depressive Disorders) study at baseline, two weeks, and eight weeks using interviews and questionnaires. Inclusion criteria were ICD-10 diagnosis of a depressive disorder, a Patient Health Questionnaire-9 symptom (PHQ-9) score ≥ 10, and a new antidepressant prescribed. The primary outcome of the study was within-individual change in PHQ-9 scores. RESULTS: At baseline, patients had predominately recurrent (83%) and in 19% treatment-resistant depression (TRD). The median preceding duration of the current episode was 6.5 months. At eight weeks, 85% of the patients (n = 107) used a DCG-concordant antidepressant dose. However, due to the scarcity of antidepressant combinations and augmentations, fewer TRD than non-TRD patients (25% vs. 84%, p < 0.005) received adequate antidepressant treatment. Additionally, one-third of the patients received inadequate follow-up. Overall, only 53% received treatment compatible with DCG recommendations for adequate pharmacotherapy and follow-up. The mean decline in PHQ-9 scores (-3.8 ± SD 5.7) was significant (p < 0.0005). Nearly 40% of the patients reached a subthreshold level of depression (PHQ-9 < 10), predicted by a lower baseline PHQ-9 score, recurrent depression, and female sex. However, 45% experienced no significant clinical improvement (PHQ-9 score reduction < 20%). CONCLUSIONS: Our findings suggest that inadequate treatment continues to occur in psychiatric care settings, particularly for TRD patients.

When theory meets reality- a mismatch in communication: a qualitative study of clinical transition from communication skills training to the surgical ward.

BACKGROUND: Communication skills training in patient centered communication is an integral part of the medical undergraduate education and has been shown to improve various components of communication. While the effects of different educational interventions have been investigated, little is known about the transfer from theoretical settings to clinical practice in the context of communication skills courses not integrated in the clinical curriculum. Most studies focus on single factors affecting transfer without considering the comprehensive perspective of the students themselves. The aim of this study is to explore how the students experience the transition to clinical practice and what they perceive as challenges in using patient centered communication. METHODS: Fifteen 4th year medical students were interviewed 3 weeks after the transition from an advanced communication skills course to surgical internship using semi-structured interviews. Qualitative content analysis was used to analyze the interviews. RESULTS: The analysis resulted in a theme 'When theory meets reality- a mismatch in communication'. It was comprised of four categories that encompassed the transfer process, from theoretical education, practical communication training and surgical internship to students' wishes and perceived needs. CONCLUSIONS: We concluded that preparing the students through theoretical and practical training should reflect the reality they will face when entering clinical practice. When educating medical students as a group, their proclivity for perfectionism, high performance environment and achievement-related stress should be taken into consideration. The role of tutors being role models, offering guidance, giving feedback and providing support plays a major part in facilitating transfer of communication skills. To enable transfer to a larger extent, the environment needs to promote patient centeredness and students need more opportunities to practice communication with their patients.

Training for Awareness, Resilience and Action (TARA) for medical students: a single-arm mixed methods feasibility study to evaluate TARA as an indicated intervention to prevent mental disorders and stress-related symptoms.

BACKGROUND: Medical students have a higher risk for depression, anxiety, stress-related symptoms, burnout, and suicide, and more rarely seek professional help or treatment than the general population. Appeals are being made to address the mental health and resilience of physicians-to-be. The novel program Training for Awareness, Resilience, and Action (TARA) was originally developed to treat depressed adolescents, targeting specific neuroscientific findings in this population. TARA has shown feasibility and preliminary efficacy in clinically depressed adolescents and corresponding brain-changes in mixed community adolescent samples. The present study investigated the feasibility and acceptability of TARA as a potential indicated prevention program for symptoms of depression, anxiety, stress and burnout in Swedish medical students. METHODS: We conducted a single-arm trial with 23 self-selected students in their early semesters of medical school (mean age 25.38 years, 5 males and 18 females), with or without mental disorders. All participants received TARA. Self-reported symptoms of depression, anxiety, perceived stress and psychological inflexibility were collected before (T0) and after the intervention (T1). Qualitative data on the participants' experiences of TARA were collected in focus-group interviews conducted halfway through the program and upon completion of the program. Individual interviews were also conducted 2 years later. Qualitative content analysis was performed. RESULTS: The mean attendance rate was 61.22% and the dropout rate was 17.40%. The Child Session Rating Scale administered after every session reflected an overall acceptable content, mean total score 34.99 out of 40.00. Trends towards improvement were seen across all outcome measures, including the Hospital Anxiety and Depression Scale Anxiety (t = 1.13, p = 0.29) and Depression (t = 1.71, p = 0.11) subscales, Perceived Stress Scale (t = 0.67, p = 0.51) and Avoidance and Fusion Questionnaire for youth (t = 1.64, p = 0.10). None of the participants deteriorated markedly during the intervention. Qualitative content analysis resulted in a main theme labeled: "An uncommon meeting-ground for personal empowerment", with 4 themes; "Acknowledging unmet needs", "Entering a free zone", "Feeling connected to oneself and others" and "Expanding self-efficacy". CONCLUSION: TARA is feasible and acceptable in a mixed sample of Swedish medical students. The students' reports of entering an uncommon meeting-ground for personal empowerment supports effectiveness studies of TARA in this context.

"It is through body language and looks, but it is also a feeling" - a qualitative study on medical interns' experience of empathy.

BACKGROUND: Empathy has long been recognized as a fundamental part of the professionalism of doctors and is considered to be both necessary and beneficial to doctor-patient relationships, although empathy is notoriously difficult to define and measure. Previous research on empathy has mostly consisted of quantitative studies measuring and evaluating empathy levels in students or medical residents. The aim of our qualitative study was to explore the lived experience of empathy among medical interns in Sweden. METHOD: We interviewed 16 medical interns, using semi-structured interviews. Content analysis was used to analyse the interviews. RESULTS: The analysis led to the emergence of a main theme of empathy as being multifaceted and conflictual, consisting of descriptions (subthemes) of "being" and "doing"; of being uncontrollable and contextual; biased and situated and essential and conflictual. Since the components of empathy were also found to be interwoven, to provide a more holistic presentation of the results, we applied a socio-ecological model to the results inspired by Bronfenbrenner. CONCLUSIONS: We concluded that empathy is situated and contextual. By using the socioecological model empathy can be described as a systemic interaction between doctor and patient. Based on this we propose a more holistic approach to empathy in medical education to better prepare students for clinical practice.

Empathy as a silent art-A doctor´s daily balancing act: A qualitative study of senior doctors' experiences of empathy.

Empathy in the doctor-patient relationship is of great importance and has long been considered a true professional virtue for doctors. Despite the general agreement concerning the importance of empathy, there is no consensus regarding the definition of empathy in medical research. While several quantitative studies, measuring empathy as an individual trait, show a decline in empathy among medical students, other studies have shown that empathy is influenced by contextual factors as well as the availability of role models. Therefore, further studies about the transition from medical school to clinical work also including the perspective of senior doctors are needed. The study presented in this article aims to better understand the clinical conditions for empathy through interviews with senior doctors about their lived experience of empathy. Twelve senior doctors, from different specialities were interviewed using a semi-structured approach. The data was analysed using content analysis. The analysis resulted in the main theme: Empathy as a silent art-a doctor`s daily balancing act. This main theme comprised three categories: "A tacit, yet language-dependent process", "A daily balancing act" and "An unsupported path towards mastery". Doctors face many challenges in their daily balancing act between individual and structural conditions that may affect empathy. In order to maintain and further develop empathy, doctors need working conditions allowing for collegial reflection and conversations that promote empathy.