Association of physician burnout with perceived EHR work stress and potentially actionable factors.

OBJECTIVE: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout. MATERIALS AND METHODS: Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors. RESULTS: Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04-1.47), not feeling valued (OR, 3.38; 95% CI, 1.69-7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87-4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63-4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12-2.67). DISCUSSION: Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. CONCLUSION: A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being.

Formative, multimethod case studies of learn to quit, an acceptance and commitment therapy smoking cessation app designed for people with serious mental illness.

Despite public health efforts, individuals with serious mental illness (SMI) still have very high rates of tobacco smoking. Innovative approaches to reach this population are needed. These series of case studies aimed to descriptively evaluate the usability, user experience (UX), and user engagement (UE) of Learn to Quit (LTQ), an acceptance and commitment therapy smoking cessation app designed for people with SMI, and to compare it with an app designed for the general population, NCI (National Cancer Institute) QuitGuide (QG). Both apps were combined with nicotine replacement therapy and technical coaching. Inspired by the ORBIT model, we implemented two case studies with crossover AB interventions, two B-phase training designs, and three bi-phasic AB single-case designs with Start-Point and Order randomization (A = QG, B = LTQ). Study outcomes were measured using the System Usability Scale, UX interviews, and background analytics. LTQ's usability levels were above the standard cutoff and on average higher than QG. UX outcomes suggested the relative benefits of LTQ's visual design, gamification and simple design structure. LTQ's overall UE was high; the app was opened for an average of 14 min per day (vs. QG: 7 min). However, users showed low levels of UE with each of the app's tracking feature. Measures of psychiatric functioning suggested the safety of LTQ in people with SMI. LTQ appears to be a usable and engaging smoking cessation app in people with SMI. An optimized version of LTQ should be tested in a Phase II study.

Barriers and Facilitators to Deaf Trauma Survivors' Help-Seeking Behavior: Lessons for Behavioral Clinical Trials Research.

Deaf individuals experience significant obstacles to participating in behavioral health research when careful consideration is not given to accessibility during the design of study methodology. To inform such considerations, we conducted an exploratory secondary analysis of a mixed-methods study that originally explored 16 Deaf trauma survivors' help-seeking experiences. Our objective was to identify key findings and qualitative themes from consumers' own words that could be applied to the design of behavioral clinical trials methodology. In many ways, the themes that emerged were not wholly dissimilar from the general preferences of members of other sociolinguistic minority groups-a need for communication access, empathy, respect, strict confidentiality procedures, trust, and transparency of the research process. Yet, how these themes are applied to the inclusion of Deaf research participants is distinct from any other sociolinguistic minority population, given Deaf people's unique sensory and linguistic characteristics. We summarize our findings in a preliminary "Checklist for Designing Deaf Behavioral Clinical Trials" to operationalize the steps researchers can take to apply Deaf-friendly approaches in their empirical work.

Deaf people's help-seeking following trauma: Experiences with and recommendations for the Massachusetts behavioral health care system.

OBJECTIVE: Deaf trauma survivors are one of the more underserved populations in behavioral health care and experience significant obstacles to seeking help. Repeated encounters with these barriers fuel negative perceptions and avoidance of behavioral health treatment. The current study sought to explore Deaf trauma survivors' help-seeking experiences and elicit their recommendations for improving Deaf behavioral health services in Massachusetts. METHOD: We conducted semistructured American Sign Language interviews with 16 trauma-exposed Deaf individuals that included questions from the Life Events Checklist and the PTSD Symptom Scale Interview and questions about Deaf individuals' help-seeking behaviors. Qualitative responses regarding help-seeking experiences were analyzed using a grounded theory approach. RESULTS: In the aftermath of trauma, our participants emphasized a desire to work with a signing provider who is highly knowledgeable about Deaf culture, history, and experience and to interact with clinic staff who possess basic sign language skills and training in Deaf awareness. Most stressed the need for providers to better outreach into the Deaf community-to provide education about trauma, to describe available treatment resources, and to prove one's qualifications. Participants also provided suggestions for how behavioral health clinics can better protect Deaf survivors' confidentiality in a small-community context. CONCLUSIONS: Deaf-friendly trauma treatment should incorporate the components of trauma-informed care but also carefully consider key criteria expressed by our participants: direct signed communication, understanding of Deaf history and experience, stringent practices to protect confidentiality, provider visibility in the community, and reliance on peer support and Deaf role models in treatment interventions. (PsycINFO Database Record

A Pilot Study of Deaf Trauma Survivors' Experiences: Early Traumas Unique to Being Deaf in a Hearing World.

Conducting semi-structured American Sign Language interviews with 17 Deaf trauma survivors, this pilot study explored Deaf individuals' trauma experiences and whether these experiences generally align with trauma in the hearing population. Most commonly reported traumas were physical assault, sudden unexpected deaths, and "other" very stressful events. Although some "other" events overlap with traumas in the general population, many are unique to Deaf people (e.g., corporal punishment at oral/aural school if caught using sign language, utter lack of communication with hearing parents). These findings suggest that Deaf individuals may experience developmental traumas distinct to being raised in a hearing world. Such traumas are not captured by available trauma assessments, nor are they considered in evidence-based trauma treatments.

Implementation of Mindfulness Training for Mental Health Staff: Organizational Context and Stakeholder Perspectives.

Occupational stress and burnout adversely impacts mental health care staff well-being and patient outcomes. Mindfulness training reduces staff stress and may improve patient care. However, few studies explore mental health setting implementation. This qualitative study used focus groups to evaluate stakeholders' perceptions of organizational factors affecting implementation of an adapted version of Mindfulness-Based Stress Reduction (MBSR) for staff on adolescent mental health units. Common facilitators included leadership securing buy-in with staff, allocating staff time to participate, and quiet space for training and practice. Other facilitators were past staff knowledge of mindfulness, local champions, and acculturating staff with mindfulness through a non-mandatory training attendance policy. Common barriers were limited staff time to attend training sessions and insufficient training coverage for some staff. Staff also reported improved focus when interacting with adolescents and improved social cohesion on the units. We conclude that a mindfulness-based program for reducing occupational stress can be successfully implemented on adolescent mental health units. Implementation appeared to change the social context of the units, including staff and patient interactions. More broadly, our findings highlight the importance of environmental factors in shaping attitudes, diffusion of innovation, and acculturation of wellness program implementations.

Evaluation of tobacco use on Chinese population through ATTOC model: a cross-sectional survey on hospitalized psychiatric patients.

OBJECTIVES: To evaluate the feasibility of Addressing Tobaccos through Organizational Change (ATTOC) intervention to Chinese psychiatric patients, and to better address tobacco use through the ATTOC intervention model in the context of China. METHODS: The study was conducted in Mental Health Center of West China Hospital in 2010. A total of 100 hospitalized psychiatric patients were recruited to carry out ATTOC intervention. Subjects suffers from mental illness were diagnosed by professional psychiatrists according to the International Statistical Classification of Diseases (ICD-10) criteria. RESULTS: The prevalence of tobacco use in hospitalized psychiatric patients were closely correlated with the type of mental illness, family smoking history, sex, age, marital status, education status, etc. However, most psychiatric patients knew little about these, and tended to ignore the importance of smoking cessation. CONCLUSIONS: The ATTOC intervention program of the U.S. may be suitable for hospitalized Chinese psychiatric patients, and it could be applied for the tobacco smoking treatment in China. However, the health effects of tobacco use still did not draw amount attentions from both the clinicians and general public. It is urgently needed to raise people's awareness and carry out ATTOC intervention to control tobacco use, and ultimately terminate tobacco use.

Acceptance and commitment therapy smoking cessation treatment for veterans with posttraumatic stress disorder: a pilot study.

OBJECTIVE: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking. METHODS: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms. RESULTS: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at three-month follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up. CONCLUSIONS: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial.

Smoking topography in Korean American and white men: preliminary findings.

UNLABELLED: This is the first study of Korean Americans' smoking behavior using a topography device. Korean American men smoke at higher rates than the general U.S. POPULATION: Korean American and White men were compared based on standard tobacco assessment and smoking topography measures. They smoked their preferred brand of cigarettes ad libitum with a portable smoking topography device for 24 h. Compared to White men (N = 26), Korean American men (N = 27) were more likely to smoke low nicotine-yield cigarettes (p < 0.001) and have lower Fagerstrom nicotine dependence scores (p = 0.04). Koreans smoked fewer cigarettes with the device (p = 0.01) than Whites. Controlling for the number of cigarettes smoked, Koreans smoked with higher average puff flows (p = 0.05), greater peak puff flows (p = 0.02), and shorter interpuff intervals (p < 0.001) than Whites. Puff counts, puff volumes, and puff durations did not differ between the two groups. This study offers preliminary insight into unique smoking patterns among Korean American men who are likely to smoke low nicotine-yield cigarettes. We found that Korean American men compensated their lower number and low nicotine-yield cigarettes by smoking with greater puff flows and shorter interpuff intervals than White men, which may suggest exposures to similar amounts of nicotine and harmful tobacco toxins by both groups. Clinicians will need to consider in identifying and treating smokers in a mutually aggressive manner, irrespective of cigarette type and number of cigarette smoked per day.

Posttraumatic stress disorder and substance use disorder comorbidity among individuals with physical disabilities: findings from the National Comorbidity Survey Replication.

Co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) affects multiple domains of functioning and presents complex challenges to recovery. Using data from the National Comorbidity Study Replication, a national epidemiological study of mental disorders (weighted N = 4,883), the current study sought to determine the prevalence of PTSD and SUD, the symptom presentation of these disorders, and help-seeking behaviors in relation to PTSD and SUD among individuals with physical disabilities (weighted n = 491; nondisabled weighted n = 4,392). Results indicated that individuals with physical disabilities exhibited higher rates of PTSD, SUD, and comorbid PTSD/SUD than nondisabled individuals. For example, they were 2.6 times more likely to meet criteria for lifetime PTSD, 1.5 times more likely for lifetime SUD, and 3.6 times more likely for lifetime PTSD/SUD compared to their nondisabled peers. Additionally, individuals with physical disabilities endorsed more recent/severe PTSD symptoms and more lifetime trauma events than nondisabled individuals with an average of 5 different trauma events compared to 3 in the nondisabled group. No significant pattern of differences was noted for SUD symptom presentation, or for receipt of lifetime or past-year PTSD or SUD treatment. Implications of these findings and recommendations for future research are discussed.

Smoking among individuals with schizophrenia in Korea: gender differences.

OBJECTIVE: This study examined gender differences in smoking and quitting among individuals diagnosed with schizophrenia in Korea. In addition, the study investigated differences in caffeine use by gender and smoking status. METHOD: An anonymous self-report survey was conducted with psychiatric inpatients. RESULTS: Compared to males, females were less likely to be current smokers (P<.001) and more likely to be former smokers (P<.01). Females were also less likely to be daily caffeine users (P<.001). Having more years of education (P<.05) and higher nicotine dependence scores (P<.05) were associated with decreased odds of intending to quit smoking, whereas having more previous quit attempts (P<.01) was associated with increased odds. These findings were significant even after adjusting for gender. Smokers were more likely to be daily caffeine users (P<.001) than their non-smoking counterparts. CONCLUSION: Nurses in Korea should play an active role in tobacco control for patients with schizophrenia by providing cessation counseling and educating the effect of caffeine use on cigarette consumption, while tailoring the service to gender differences found in this study.

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings.

OBJECTIVE: To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment. METHOD: Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment. RESULTS: Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources. CONCLUSION: Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.

Gender Differences in the Fagerström Test for Nicotine Dependence in Korean Americans.

INTRODUCTION: This study was conducted to compare gender differences in the psychometric properties of the Fagerström Test for Nicotine Dependence (FTND). METHODS: The sample comprised 334 Korean immigrants (97 women and 237 men) who reported daily smoking for the past six months. Item-by-item responses and exploratory factor analyses (EFA) were compared by gender. Promax rotation was selected based on findings from previous studies suggesting correlated factors. RESULTS: Compared with men, women smoked fewer cigarettes per day, were more likely to smoke when ill in bed, and were less likely to smoke frequently in the morning. The entire sample and men within the sample had the same factor loading pattern, where three items (time to first cigarette, the cigarette most hate to give up, and smoke more frequently in the morning) were loaded on Factor 1 (morning smoking) and the remaining three items (difficult to refrain from smoking in public places, number of cigarettes smoked per day, and smoking even when ill in bed) on Factor 2 (daytime smoking). For women, however, neither the 1- nor 2-factor model fit the data well. CONCLUSIONS: For Korean American male smokers, the psychometric properties of the FTND were similar to those seen in other populations, but this was not the case with Korean American women. Clinicians may need to modify their interpretation of nicotine dependence severity if basing only on the FTND with Korean Women. The FTND assesses smoking patterns which has a cultural influence and other measures of nicotine dependence should be considered.

New systems of care for substance use disorders: treatment, finance, and technology under health care reform.

This article outlined ways in which persons with addiction are currently underserved by our current health care system. However, with the coming broad scale reforms to our health care system, the access to and availability of high-quality care for substance use disorders will increase. Addiction treatments will continue to be offered through traditional substance abuse care systems, but these will be more integrated with primary care, and less separated as treatment facilities leverage opportunities to blend services, financing mechanisms, and health information systems under federally driven incentive programs. To further these reforms, vigilance will be needed by consumers, clinicians, and policy makers to assure that the unmet treatment needs of individuals with addiction are addressed. Embedded in this article are essential recommendations to facilitate the improvement of care for substance use disorders under health care reform. Ultimately, as addiction care acquires more of the "look and feel" of mainstream medicine, it is important to be mindful of preexisting trends in health care delivery overall that are reflected in recent health reform legislation. Within the world of addiction care, clinicians must move beyond their self-imposed "stigmatization" and sequestration of specialty addiction treatment. The problem for addiction care, as it becomes more "mainstream," is to not comfortably feel that general slogans like "Treatment Works," as promoted by Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment during its annual Recovery Month celebrations, will meet the expectations of stakeholders outside the specialty addiction treatment community. Rather, the problem is to show exactly how addiction treatment works, and to what extent it works-there have to be metrics showing changes in symptom level or functional outcome, changes in health care utilization, improvements in workplace attendance and productivity, or other measures. At minimum, clinicians will be required to demonstrate that their new systems of care and future clinical activity are in conformance with overall standards of "best practice" in health care.

Intentions to quit smoking: causal attribution, perceived illness severity, and event-related fear during an acute health event.

BACKGROUND: Experiencing a serious consequence related to one's health behavior may motivate behavior change. PURPOSE: This study sought to examine how causal attribution, perceived illness severity, and fear secondary to an acute health event relate to intentions to quit smoking. METHODS: Using a cross-sectional survey design, adult emergency department patients who smoked provided demographic data and ratings of nicotine dependence, causal attribution, perceived illness severity, event-related fear, and intentions to quit smoking. RESULTS: A linear regression analysis was used to examine the relations between the independent variables and quit intentions. We enrolled 186 participants. After adjusting for nicotine dependence, smoking-related causal attribution and event-related fear were associated with intentions to quit (ß = 0.26, p < 0.01 and ß = 0.21, p < 0.01, respectively). Perceived illness severity was correlated with event-related fear (r = 0.46, p < 0.001) but was not associated with intentions to quit (ß = -0.08, p = 0.32). CONCLUSION: While causal attribution and event-related fear were modestly associated with quit intentions, perceived illness severity was not. Longitudinal studies are needed to better explicate the relation between these variables and behavior change milestones.

Introducing qigong meditation into residential addiction treatment: a pilot study where gender makes a difference.

OBJECTIVE: The objective of this study was to explore the feasibility and efficacy of adding integrative qigong meditation to residential treatment for substance abuse. METHODS: Qigong meditation, which blends relaxation, breathing, guided imagery, inward attention, and mindfulness to elicit a tranquil state, was introduced into a short-term residential treatment program. At first clients chose to participate in qigong meditation on a voluntary basis during their evening break. Later they chose to participate in either meditation or Stress Management and Relaxation Training (SMART) twice a day as part of the scheduled treatment. Weekly questionnaires were completed by 248 participants for up to 4 weeks to assess their changes in treatment outcomes. Participants in the meditation group were also assessed for quality of meditation to evaluate the association between quality and treatment outcome. RESULTS: Most clients were amenable to meditation as part of the treatment program, and two thirds chose to participate in daily meditation. While both groups reported significant improvement in treatment outcome, the meditation group reported a significantly higher treatment completion rate (92% versus 78%, p < 01) and more reduction in craving than did the SMART group. Participants whose meditation was of acceptable quality reported greater reductions in craving, anxiety, and withdrawal symptoms than did those whose meditation was of low quality. Female meditation participants reported significantly more reduction in anxiety and withdrawal symptoms than did any other group. CONCLUSIONS: Qigong meditation appears to contribute positively to addiction treatment outcomes, with results at least as good as those of an established stress management program. Results for those who meditate adequately are especially encouraging. Meditative therapy may be more effective or acceptable for female drug abusers than for males. Further study is needed to assess ways to improve substance abusers' engagement and proficiency in meditation.

Comparison of two intensities of tobacco dependence counseling in schizophrenia and schizoaffective disorder.

Compared to the general population, smokers with schizophrenia (SCZ) have reduced success in quitting smoking with usual approaches. This study tested two manualized behavioral counseling approaches-Treatment of Addiction to Nicotine in Schizophrenia (TANS) or Medication Management (MM)-for smokers who were motivated to quit. Individual counseling sessions were provided by mental health clinicians in mental health settings, along with nicotine patch. The two treatments varied in intensity and frequency of sessions. Eighty-seven subjects were randomized and attended at least one treatment session. Twenty-one percent (n = 18) of participants had continuous abstinence at 12 weeks after the target quit date, which was not significantly different between conditions (15.6% TANS vs. 26.2% MM, chi(2) = 1.50, p = .221). Smokers in both groups significantly reduced smoking as measured by cigarettes per day and expired carbon monoxide. Findings support that mental health clinicians can be trained to effectively help smokers with SCZ maintain tobacco abstinence.

Predictors of outcome for short-term medically supervised opioid withdrawal during a randomized, multicenter trial of buprenorphine-naloxone and clonidine in the NIDA clinical trials network drug and alcohol dependence.

Few studies in community settings have evaluated predictors, mediators, and moderators of treatment success for medically supervised opioid withdrawal treatment. This report presents new findings about these factors from a study of 344 opioid-dependent men and women prospectively randomized to either buprenorphine-naloxone or clonidine in an open-label 13-day medically supervised withdrawal study. Subjects were either inpatient or outpatient in community treatment settings; however not randomized by treatment setting. Medication type (buprenorphine-naloxone versus clonidine) was the single best predictor of treatment retention and treatment success, regardless of treatment setting. Compared to the outpatient setting, the inpatient setting was associated with higher abstinence rates but similar retention rates when adjusting for medication type. Early opioid withdrawal severity mediated the relationship between medication type and treatment outcome with buprenorphine-naloxone being superior to clonidine at relieving early withdrawal symptoms. Inpatient subjects on clonidine with lower withdrawal scores at baseline did better than those with higher withdrawal scores; inpatient subjects receiving buprenorphine-naloxone did better with higher withdrawal scores at baseline than those with lower withdrawal scores. No relationship was found between treatment outcome and age, gender, race, education, employment, marital status, legal problems, baseline depression, or length/severity of drug use. Tobacco use was associated with worse opioid treatment outcomes. Severe baseline anxiety symptoms doubled treatment success. Medication type (buprenorphine-naloxone) was the most important predictor of positive outcome; however the paper also considers other clinical and policy implications of other results, including that inpatient setting predicted better outcomes and moderated medication outcomes.

Using information technology to evaluate the detection of co-occurring substance use disorders amongst patients in a state mental health system: implications for co-occurring disorder state initiatives.

The current study describes a system-wide method of evaluating detection strategies for co-occurring disorders within a state mental health system. Information technology was used to merge administrative datasets from the New Jersey mental health and substance abuse systems and identify individuals treated in both systems. We measured a 53% detection rate of substance use disorders amongst adult patients in the mental health system with particularly low detection rates in acute settings (49.0%) and among female (43.7%), older (36.2%), and psychotic patients (43.6%). The methodology described here could help evaluate critical aspects of ongoing state co-occurring disorder quality improvement initiatives.