Use of Messaging Principles to Design a Facebook Ad Promoting Public Engagement in Serious Illness Care for National Healthcare Decisions Day.

Public hesitation to engage in advance care planning, consultation with palliative care, and admission to hospice is a significant barrier to improving patient outcomes. In previous study, we derived five empirically supported messaging principles, and in this project we used these messaging principles to design, place, and analyze a 60-second video for the Oregon Coalition for Living Well with Serious Illness. The video was scripted to emphasize a single message that had emerged from the empirical research: that "you should have a say in your care." We deliberately did not use the term "advance care planning" because our prior focus groups showed that most consumers did not use this term. The marketing plan for the resulting video on Facebook included a paid sponsorship of the full-length video through a Facebook boosted post, and three 10-second ads featuring key lines from the video that tested different elaborations of the central message. Facebook Analytics indicated that the 60-second video was viewed 67,650 times in the week it was promoted. The three 10-second ads, which showed selected moments from the full-length video, were viewed a total of 253,087 times. Of the three 10-second ads, the one emphasizing "What matters to me is being near my family" (65% of clicks) strongly outperformed "I don't want to go out on a machine" and "I've heard so many medical horror stories" (35% for both messages combined) as messages that persuaded viewers to click through the ad to the website. Use of the messaging principles to guide the design and marketing of this Facebook ad shows that (1) the public is interested in serious illness care, (2) that targeted social media can be used to reach a defined public audience, and that (3) this public messaging strategy can be implemented at relatively low cost.

Bereavement is different: A multinational bereavement symptom model validation.

Clinicians need to rule out an appropriate grief reaction when diagnosing major depression. This study identifies symptom differences by bereavement status and validates a symptom model of bereavement. Symptom features from six national cross-sectional epidemiological samples were analyzed and estimates pooled. Crying often, thinking of death, appetite loss, waking up early, trouble sleeping, and depending on others were significantly more likely in the bereaved. Symptoms of thinking of or attempting suicide, feeling one would be better off dead or wanting to die, worthlessness, social conflict, worthlessness with difficulty making decisions, being discouraged, feeling less than others, being troubled, not coping, feeling hopeless, sleeping more, being upset and history of an anxiety disorder were all significantly less likely among the bereaved. Moderate to good model discrimination effect sizes were found. Good model performance was found when narrowly defined complicated bereavement cases were excluded. On the whole the bereaved are more likely to report symptoms consistent with a normal grief reaction. As depression screening becomes the norm in primary care, normal grief that meets Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) symptom criteria for a MDE likely has a high risk of being diagnosed inappropriately as pathological depression.

Public Messaging for Serious Illness Care in the Age of Coronavirus Disease: Cutting through Misconceptions, Mixed Feelings, and Distrust.

A year ago, we began a project designed to align public messages from 10 organizations involved in advance care planning (ACP), palliative care (PC), and hospice to increase public engagement. By public messaging, we are referring to a well-established evidence-driven method of disseminating information at scale that enables the public to take action to protect their health. Our project plan was upended by the coronavirus disease 2019 (COVID-19) pandemic-but we used the opportunity to conduct focus groups during the pandemic that, compared with focus groups conducted before the pandemic, provide an important portrait of public perceptions of serious illness care that can be used to design for greater public engagement. Our findings can be summarized in three observations. First, misunderstanding of ACP, PC, and hospice is wide ranging and deep. Second, COVID-19 evokes its own brand of confusion and ambivalence that is distinct from other serious illnesses. And third, distrust of the health care system has become the new normal. Despite these findings, our focus group participants strongly endorsed five messaging principles (1) talk up the benefits, (2) present choices for every step, (3) use stories that are positive and aspirational, (4) invite dialogue-more than once, and (5) invoke a new team-of people who matter, clinicians, medical institutions, and community organizations who are ready to help. After listening to 100-word stories describing real patient experiences with ACP, PC, and hospice, our focus group participants expressed interest and appreciation. But to improve public engagement broadly, we need to explain our work to the general public in a way that makes them want to know more.

Sex differences in the circadian regulation of sleep and waking cognition in humans.

The sleep-wake cycle and circadian rhythmicity both contribute to brain function, but whether this contribution differs between men and women and how it varies across cognitive domains and subjective dimensions has not been established. We examined the circadian and sleep-wake-dependent regulation of cognition in 16 men and 18 women in a forced desynchrony protocol and quantified the separate contributions of circadian phase, prior sleep, and elapsed time awake on cognition and sleep. The largest circadian effects were observed for reported sleepiness, mood, and reported effort; the effects on working memory and temporal processing were smaller. Although these effects were seen in both men and women, there were quantitative differences. The amplitude of the circadian modulation was larger in women in 11 of 39 performance measures so that their performance was more impaired in the early morning hours. Principal components analysis of the performance measures yielded three factors, accuracy, effort, and speed, which reflect core performance characteristics in a range of cognitive tasks and therefore are likely to be important for everyday performance. The largest circadian modulation was observed for effort, whereas accuracy exhibited the largest sex difference in circadian modulation. The sex differences in the circadian modulation of cognition could not be explained by sex differences in the circadian amplitude of plasma melatonin and electroencephalographic slow-wave activity. These data establish the impact of circadian rhythmicity and sex on waking cognition and have implications for understanding the regulation of brain function, cognition, and affect in shift-work, jetlag, and aging.

SYMPTOM AND FUNCTIONAL TRAITS OF BRIEF MAJOR DEPRESSIVE EPISODES AND DISCRIMINATION OF BEREAVEMENT.

BACKGROUND: Despite the removal of the bereavement exclusion from DSM-5, clinicians may feel uncertain on how to proceed when caring for a patient who presents with depressive symptoms following the death of someone close. The ability to better distinguish, on a symptom and functional level, between patients who experience depression in the context of bereavement and those with nonbereavement-related depression, could help guide clinical decision making. METHOD: Individual and clustered depressive symptom and impairment measures were used for modeling bereavement status within a nationally representative longitudinal cohort. Deviance, linear shrinkage factor, and bias-corrected c-statistic were used for identifying a well-calibrated and discriminating final model. RESULTS: Of the 450 (1.2%) respondents with a single brief major depressive episode, 162 (38.4%) reported the episode as bereavement-related. The bereaved were less likely to endorse worthlessness (P < .001), social conflict (P < .001), distress (P < .001), thoughts of suicide (P = .001), wanting to die (P = .01), self-medicating (P = .01), and being withdrawn (P = .04). In a multivariate model, the bereaved were more likely to have thoughts of their own death (P = .003), guilt coupled with weight or appetite loss (P = .013), and were less likely to report social conflict (P < .001), worthlessness coupled with difficulty making decisions (P < .001), thoughts of suicide (P = .006), distress coupled with weight or appetite gain (P = .022), and self-medicating (P = .045). CONCLUSIONS: Traits and trait combinations differentiate individuals who experience brief depressive episodes following the death of a loved one from other brief episodes. These differences can help guide clinical care of patients who present with depressive symptoms shortly after a loved one's death.

Predictors of criminal justice involvement in severe mania.

BACKGROUND: Criminal justice problems among those with bipolar disorder lead to disruption in social functioning, treatment, and recovery. Understanding factors that contribute to arrest during episodes of illness can help inform approaches to risk management and improve clinical care. METHODS: Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey conducted in two waves were used to identify factors that predicted inter-wave criminal justice involvement during bipolar I manic episodes. RESULTS: Over 10% of respondents experienced legal involvement during their most severe manic episode. Risk was found in a range of historical, clinical, and contextual factors. Multivariate analyses suggest risk is particularly high for those who are unemployed, non-white, have past juvenile detention, have a prior arrest (while using substances or when manic), used an illicit drug in the past year, and whose mania is characterized by both social and occupational impairment. Legal problems were particularly elevated among those who lacked health insurance while experiencing both social and occupational impairment. LIMITATIONS: Respondents did not include prisoners and hospital inpatients; criminal justice problems were only assessed with regard to the most severe manic episode. CONCLUSIONS: The particular array of factors that elevate the risk of legal involvement during manic episodes offers guidance when identifying prevention strategies and evaluating patients in clinical and forensic settings. Reducing such involvement will require that these issues be dealt with in the broader context of mental health and other services, which in turn necessitates providing adequate access to healthcare.

Prevalence of involvement in the criminal justice system during severe mania and associated symptomatology.

OBJECTIVE: This study sought to determine the prevalence of criminal justice involvement during episodes of mania and to identify whether specific manic symptoms contribute to this risk. METHODS: Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of noninstitutionalized U.S. adults (N=43,093), were analyzed to determine the rate of legal involvement (being arrested, held at the police station, or jailed) of individuals with bipolar I disorder during the most severe lifetime manic episode. RESULTS: Among the 1,044 respondents (2.5%) who met criteria for having experienced a manic episode, 13.0% reported legal involvement during the most severe manic episode. Unadjusted analyses found legal involvement more likely among those with episode-specific symptoms of increased self-esteem or grandiosity, increased libido, excessive engagement in pleasurable activities with a high risk of painful consequences, having six or more criterion B manic symptoms, and having both social and occupational impairment. The risk was lower among those with hypertalkativeness or pressured speech. When analyses adjusted for other manic symptoms and static variables, males, those with a first episode at age 23 or younger, and persons with mania-associated social indiscretions, excessive spending or reckless driving, and both social and occupational impairment were at greater risk. CONCLUSIONS: A large percentage of persons experience legal involvement during a manic episode, and it is associated with specific symptoms of mania. Efforts to reduce such involvement among persons during manic episodes may be enhanced by focusing attention and resources on this high-risk group.

Arrest types and co-occurring disorders in persons with schizophrenia or related psychoses.

This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.