"Don't Just Study our Distress, Do Something": Implementing and Evaluating a Modified Stepped-Care Model for Health Care Worker Mental Health During the COVID-19 Pandemic.

OBJECTIVE: Throughout the COVID-19 pandemic, there have been concerns about the mental health of health care workers (HCW). Although numerous studies have investigated the level of distress among HCW, few studies have explored programs to improve their mental well-being. In this paper, we describe the implementation and evaluation of a program to support the mental health of HCW at University Health Network (UHN), Canada's largest healthcare network. METHODS: Using a quality improvement approach, we conducted a needs assessment and then created and evaluated a modified stepped-care model to address HCW mental health during the pandemic. This included: online resources focused on psychoeducation and self-management, access to online support and psychotherapeutic groups, and self-referral for individual care from a psychologist or psychiatrist. We used ongoing mixed-methods evaluation, combining quantitative and qualitative analysis, to improve program quality. RESULTS: The program is ongoing, running continuously throughout the pandemic. We present data up to November 30, 2021. There were over 12,000 hits to the UHN's COVID mental health intranet web page, which included self-management resources and information on group support. One hundred and sixty-six people self-referred for individual psychological or psychiatric care. The mean wait time from referral to initial appointment was 5.4 days, with an average of seven appointments for each service user. The majority had moderate to severe symptoms of depression and anxiety at referral, with over 20% expressing thoughts of self-harm or suicide. Post-care user feedback, collected through self-report surveys and semistructured interviews, indicated that the program is effective and valued. CONCLUSIONS: Development of a high-quality internal mental health support for HCW program is feasible, effective, and highly valued. By using early and frequent feedback from multiple perspectives and stakeholders to address demand and implement changes responsively, the program was adjusted to meet HCW mental health needs as the pandemic evolved.

Initial findings on RESTORE for healthcare workers: an internet-delivered intervention for COVID-19-related mental health symptoms.

Many healthcare workers on the frontlines of the COVID-19 pandemic are experiencing clinical levels of mental health symptoms. Evidence-based interventions to address these symptoms are urgently needed. RESTORE (Recovering from Extreme Stressors Through Online Resources and E-health) is an online guided transdiagnostic intervention including cognitive-behavioral interventions. It was specifically designed to improve symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) associated with COVID-19-related traumatic and extreme stressors. The aims of the present study were to assess the feasibility, acceptability, and initial efficacy of RESTORE in healthcare workers on the frontline of the COVID-19 pandemic. We conducted an initial uncontrolled trial of RESTORE in 21 healthcare workers who were exposed to COVID-19-related traumatic or extremely stressful experiences in the context of their work and who screened positive for clinical levels of anxiety, depression, and/or PTSD symptoms. RESTORE was found to be feasible and safe, and led to statistically significant and large effect size improvements in anxiety, depression, and PTSD symptoms over the course of the intervention through follow-up. RESTORE has the potential to become a widely disseminable evidence-based intervention to address mental health symptoms associated with mass traumas.Clinical Trials Registration: This trial was registered with ClinicalTrials.gov ID: NCT04873622.

Development of RESTORE: an online intervention to improve mental health symptoms associated with COVID-19-related traumatic and extreme stressors.

Background: Frontline healthcare workers, recovered COVID+ patients who had severe illness, and close others of COVID+ patients who have recovered or died are at risk for clinical levels of mental health symptoms in the context of the COVID-19 pandemic. RESTORE (Recovering from Extreme Stressors Through Online Resources and E-health) was specifically designed for this context. RESTORE is a transdiagnostic guided online intervention adapted from evidence-based cognitive-behavioural therapies. Objectives: RESTORE was designed to address depression, anxiety, and posttraumatic stress disorder symptoms associated with exposure to COVID-19-related traumatic and extreme stressors, and to overcome multiple barriers to accessing psychotherapies. Method: This paper describes the intervention components and platform, as well as the principles used to develop RESTORE. Current research and future directions in developing and testing RESTORE are outlined. Results: Preliminary data from an initial uncontrolled trial evaluating RESTORE in frontline healthcare workers is highly promising. Conclusion: We believe RESTORE has great potential to provide accessible, evidence-based psychological intervention to those in great need.

Antecedentes: Los trabajadores de salud de primera línea, los pacientes de COVID positivo recuperados que tenían una enfermedad grave y las personas cercanas a los pacientes de COVID positivo que se han recuperado o fallecido están en riesgo de presentar niveles clínicos de síntomas de salud mental en el contexto de la pandemia de COVID-19. RESTORE (por sus siglas en inglés: Recovering from Extreme Stressors Through Online Resources and E-health: Recuperación de estresores extremos a través de recursos en línea y salud electrónica) fue diseñada específicamente para este contexto. RESTORE es una intervención en línea guiada transdiagnóstica adaptada de terapias cognitivo-conductuales basadas en la evidencia.Objetivos: RESTORE fue diseñado para abordar la depresión, la ansiedad y los síntomas del trastorno de estrés postraumático asociados con la exposición a factores estresantes traumáticos y extremos relacionados con COVID-19, y para superar múltiples barreras para acceder a psicoterapias.Método: Este artículo describe los componentes y la plataforma de la intervención, así como los principios utilizados para desarrollar RESTORE. Se describen las investigaciones actuales y las direcciones futuras para desarrollar y testear RESTORE.Resultados: Los datos preliminares de un ensayo inicial no controlado que evalúa RESTORE en trabajadores de salud de primera línea son muy prometedores.Conclusión: Creemos que RESTORE tiene un gran potencial para brindar una intervención psicológica accesible y basada en la evidencia a quienes más lo necesitan.

Individual- and Institutional-level Concerns of Health Care Workers in Canada During the COVID-19 Pandemic: A Qualitative Analysis.

Importance: Mental health and coping difficulties among health care workers (HCWs) have been reported during pandemics and particularly during the COVID-19 pandemic. Objective: To examine sources of distress and concern for HCWs in Canada during the COVID-19 pandemic. Design, Setting, and Participants: In this qualitative study, a critical discourse analysis was performed of questions posed by HCWs to hospital senior leadership between March 16, 2020, and December 1, 2020, through an online employee forum as part of a larger mixed-methods evaluation of a stepped-care mental health support program for HCWs at 1 of Canada's largest health care institutions. Questions could be submitted online anonymously in advance of the virtual forums on COVID-19 by any of the University Health Network's 21 555 employees, and staff members were able to anonymously endorse questions by upvoting, indicating that an already posed question was of interest. Main Outcomes and Measures: Themes, text structure, and rhetorical devices used within the questions were analyzed, taking into consideration their larger institutional and societal context. Results: Unique individual views of the forums ranged from 2062 to 7213 during the study period. Major individual-level concerns related to risks of contamination and challenges coping with increased workloads as a result of the pandemic intersected with institutional-level challenges, such as feeling or being valued within the health care setting and long-standing stratifications between types of HCWs. Concerns were frequently reported in terms of calls for clarity or demands for transparency from the institutional leadership. Conclusions and Relevance: The findings of this qualitative study suggest that larger institutional-level and structural concerns need to be addressed if HCWs are to be engaged in support and coping programs. Potential service users may be dissuaded from seeing their needs as being met by workplace mental health interventions that solely relate to individual-level concerns.

Donor outcomes in anonymous live liver donation.

BACKGROUND & AIMS: Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD). METHODS: Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact. RESULTS: A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision. CONCLUSIONS: This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability. LAY SUMMARY: We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability.

The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

One-Year Outcomes in Caregivers of Critically Ill Patients.

BACKGROUND: Few resources are available to support caregivers of patients who have survived critical illness; consequently, the caregivers' own health may suffer. We studied caregiver and patient characteristics to determine which characteristics were associated with caregivers' health outcomes during the first year after patient discharge from an intensive care unit (ICU). METHODS: We prospectively enrolled 280 caregivers of patients who had received 7 or more days of mechanical ventilation in an ICU. Using hospital data and self-administered questionnaires, we collected information on caregiver and patient characteristics, including caregiver depressive symptoms, psychological well-being, health-related quality of life, sense of control over life, and effect of providing care on other activities. Assessments occurred 7 days and 3, 6, and 12 months after ICU discharge. RESULTS: The caregivers' mean age was 53 years, 70% were women, and 61% were caring for a spouse. A large percentage of caregivers (67% initially and 43% at 1 year) reported high levels of depressive symptoms. Depressive symptoms decreased at least partially with time in 84% of the caregivers but did not in 16%. Variables that were significantly associated with worse mental health outcomes in caregivers were younger age, greater effect of patient care on other activities, less social support, less sense of control over life, and less personal growth. No patient variables were consistently associated with caregiver outcomes over time. CONCLUSIONS: In this study, most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00896220.).

Time to Consultation-Liaison Psychiatry Service Referral as a Predictor of Length of Stay.

OBJECTIVES: The aim of this study was to determine the relationship between the time to referral (TTR) to psychiatric consultation and the length of stay (LOS) after adjusting for medical comorbity. METHODS: Using a naturalistic study design, we collected and analyzed inpatient consultation-liaison psychiatry service data over a 12-month period from 2 Canadian hospital sites. Data collected included demographic characteristics, referral characteristics, Charlson Comorbidity Index to measure medical comorbidity severity, psychiatric diagnoses, type of psychiatric intervention, and time variables, namely TTR and LOS. We modeled the relationship LOS and TTR after adjusting for Charlson Index using a 3-component finite mixture of exponential regression models. RESULTS: A total of 814 patients were included. The median LOS was 12 days (interquartile range : 4-28 days). Median TTR was 3 days (interquartile range: 1,9), and median Charlson Index was 5 (interquartile range 3,6). Bivariate analysis indicated a strong positive correlation among LOS and TTR (Spearman correlation: 0.77, p < 0.0001) and Charlson Index(Spearman correlation: 0.34, p < 0.0001), respectively. After controlling for Charlson Index, we observe that TTR was significantly associated with LOS in each of the 3 components of the mixture of exponential regression models. Persons with longer TTR have longer expected LOS. Graphical summaries suggest that the mixture of exponential regression model provides a good fit to these LOS response data. CONCLUSIONS: Patients with longer TTR had significantly longer LOS. The association between TTR and LOS holds after controlling for severity of medical comorbidity. Our results support the role of integrated and proactive consultation-liaison psychiatry programs aimed at reducing TTR to improve LOS outcomes.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation.

RATIONALE: Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES: To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS: We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS: The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS: ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

Heart transplants: Identity disruption, bodily integrity and interconnectedness.

Of heart transplant recipients, 30 per cent report ongoing or episodic emotional issues post-transplant, which are not attributable to medications or pathophysiological changes. To this end, our team theorized that cardiac transplantation introduces pressing new questions about how patients incorporate a transplanted heart into their sense of self and how this impacts their identity. The work of Merleau-Ponty provided the theoretical underpinning for this project as it rationalizes how corporeal changes affect one's self and offer an innovative framework to access these complex aspects of living with a transplanted heart. We used visual methodology and recorded 25 semi-structured interviews videographically. Both visual and verbal data were analyzed at the same time in an iterative process. The most common theme was that participants expressed a disruption to their own identity and bodily integrity. Additionally, participants reported interconnectedness with the donor, even when the transplanted heart was perceived as an intruder or stranger. Finally, transplant recipients were very vivid in their descriptions and speculation of how they imagined the donor. Receiving an anonymous donor organ from a stranger often leaves the recipient with questions about who they themselves are now. Our study provides a nuanced understanding of heart transplant recipients' embodied experiences of self and identity. Insights gained are valuable to educate transplant professionals to develop new supportive interventions both pre- and post-transplant, and to improve the process of informed consent. Ultimately, such insights could be used to enable heart transplant recipients to incorporate the graft optimally over time, easing distress and improving recovery.

(Dis)orientation of international medical graduates: an approach to foster teaching, learning, and collaboration (TLC).

OBJECTIVE: The Teaching for Learning and Collaboration (TLC) Program is a teaching-skills program focusing on methods to improve student learning. This program was adopted to address the professional and personal challenges faced by International Medical Graduates (IMGs) completing a fellowship in psychosomatic medicine. METHOD: The authors conducted a literature review on the educational challenges encountered by IMGs. Based on this review, an adapted TLC Program was piloted on four IMG fellows who completed a psychosomatic medicine fellowship between 2008 and 2011. RESULTS: Teachers using the adapted TLC Program reported the following as being significant in the IMG training process: a safe educational environment; having an extended period of time for assessment and fellow adjustment; and more direct, rather than "diplomatic," feedback. CONCLUSIONS: Although piloted in a psychosomatic medicine fellowship, the TLC program is intended to be generalizable to other medical training settings. Further evaluation of the effectiveness of this approach for IMGs is required.

The role of attachment style and depression in patients with hepatitis C.

Patients infected with chronic hepatitis C virus (HCV) commonly suffer from the triad of depression, pain and fatigue. This symptom triad in HCV is likely influenced by additional psychological and interpersonal factors, although the relationship is not clearly understood. This retrospective study aimed to characterize the relationship between attachment style and depressive and physical symptoms in the HCV-infected population. Over 18 months, 99 consecutively referred HCV infected patients were assessed with the Hamilton Depression Rating Scale (HDRS), Fatigue Severity Scale, Patient Health Questionnaire-15 for physical symptoms and the Relationship Questionnaire for attachment style. An ANOVA was used to identify differences between attachment styles and Pearson correlations were used to evaluate the association between depression, fatigue and physical symptoms. Approximately 15 % of patients in the sample had a fearful attachment style. Patients with fearful attachment style had significantly higher depressive symptoms compared to a secure attachment style (p = .025). No differences in physical and fatigue symptoms were observed between attachment styles. Further, HDRS scores were significantly associated with fatigue scores (p < .001) and physical symptoms (p < .001), reinforcing the relationship between these symptom domains in HCV-infected patients. Although depressive, physical and fatigue symptoms are inter-related in HCV-infected patients, our study results suggest that only depressive symptoms were influenced by the extremes of attachment style. Screening of relationship styles may identify at-risk HCV-infected individuals for depression who may have difficulty engaging in care and managing physical symptoms.

The influence of somatic symptoms on Beck Depression Inventory scores in hospitalized postmyocardial infarction patients.

OBJECTIVE: The Beck Depression Inventory (BDI) has been used more than any other self-report questionnaire in research on depression in cardiovascular disease. However, no studies have examined whether BDI scores may be influenced by somatic symptoms common after myocardial infarction (MI) that may overlap with symptoms of depression. The objective of this study was to examine whether BDI scores of post-MI patients may be influenced by somatic symptoms that commonly occur after MI, but may not be related to depression. METHOD: Post-MI patients and psychiatric outpatients were matched on BDI cognitive-affective symptom scores, sex, and age, and their BDI somatic symptom scores were compared using independent samples t tests. RESULTS: Somatic symptoms accounted for 57% of BDI total scores for 296 post-MI patients (mean total BDI = 8.8), compared with 50% for 296 matched psychiatric outpatients (mean total BDI = 7.6). Overall, BDI somatic scores of post-MI patients were 1.3 points higher than for psychiatric outpatients (95% CI 0.68 to 1.82; P < 0.001), equivalent to 14% of total scores of post-MI patients. CONCLUSIONS: The relative influence of somatic symptoms on BDI total scores was higher for post-MI patients than for psychiatric outpatients matched on cognitive-affective scores, sex, and age. This finding stands in contrast to that from a previous study that used similar methods and sample comparisons and found that post-MI and psychiatric outpatients did not differ in their endorsement of somatic symptoms on the BDI-II. The BDI-II may be preferable to the BDI in post-MI patients.

Preparation and Support of Patients through the Transplant Process: Understanding the Recipients' Perspectives.

Preparation for heart transplant commonly includes booklets, instructional videos, personalized teaching sessions, and mentorship. This paper explores heart transplant recipients' thoughts on their preparation and support through the transplant process. Twenty-five interviews were audio-/videotaped capturing voice and body language and transcribed verbatim. Coding addressed language, bodily gesture, volume, and tone in keeping with our visual methodology. Recipients reported that only someone who had a transplant truly understands the experience. As participants face illness and life-altering experiences, maintaining a positive attitude and hope is essential to coping well. Healthcare professionals provide ongoing care and reassurance about recipients' medical status. Mentors, family members, and close friends play vital roles in supporting recipients. Participants reported that only heart transplant recipients understood the experience, the hope, and ultimately the suffering associated with living with another persons' heart. Attention needs to be focused not solely on the use of teaching modalities, but also on the development of innovative support networks. This will promote patient and caregiver engagement in self-management. Enhancing clinicians' knowledge of the existential aspects of transplantation will provide them with a nuanced understanding of the patients' experience, which will ultimately enhance their ability to better prepare and support patients and their caregivers.

Symptom reporting on the Beck Depression Inventory among post-myocardial infarction patients: in-hospital versus follow-up assessments.

OBJECTIVE: Depressive symptoms following myocardial infarction (MI) are often assessed using self-report questionnaires, such as the Beck Depression Inventory (BDI). No studies have examined whether depressive symptom scores assessed by self-report questionnaires during hospitalization post-MI are influenced by factors related to the acute event or hospitalization compared to subsequent outpatient assessments of the same patients. The objective of this study was to compare BDI total scores, somatic scores, and cognitive/affective scores among post-MI patients in-hospital versus at post-discharge follow-up. METHODS: Secondary analysis of data from two existing cohorts of post-MI patients (Groningen, The Netherlands and Toronto, Canada). In-hospital BDI scores and follow-up scores were compared using paired samples t-tests. RESULTS: There were 1556 patients from the Groningen sample with BDI data in-hospital and at 3-months post-MI and 229 patients from Toronto with data in-hospital and at 6-months post-MI. BDI total, somatic, and cognitive/affective scores did not differ significantly between in-hospital and follow-up assessments in either sample. Similarly, there were no substantive differences in symptom composition in either sample. Somatic symptoms accounted for 66.3% of total BDI scores in-hospital versus 64.9% at 3-months post-MI for Groningen patients and for 62.1% of total scores in-hospital versus 64.3% at 6-months post-MI for Toronto patients. CONCLUSION: Overall BDI total scores, somatic scores, and cognitive/affective scores did not differ between in-hospital and subsequent outpatient assessments. The timing of when depressive symptoms are assessed post-MI does not appear to influence the overall level of BDI scores or the composition of symptoms that are reported.

Identifying opportunities to improve management of autoimmune hepatitis: evaluation of drug adherence and psychosocial factors.

BACKGROUND & AIMS: Recognizing the importance of adherence to therapy in autoimmune hepatitis (AIH) is critical for patient care and avoidance of unnecessary intervention. The influence of psychosocial factors on treatment adherence needs better understanding and prominence. We sought to determine the association between anxiety, depressive symptoms, and avoidant relationship style on self-reported immunosuppressant medication adherence and treatment response in patients with AIH. METHODS: Fifty two patients with AIH were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Experiences in Close Relationship Scale (ECR) and a visual analogue scale to measure self-reported adherence. Laboratory markers of adherence and immunosuppressant treatment response were recorded. Chi-square Fisher's exact or Wilcox rank sum tests were used for comparison between groups. RESULTS: Treatment responders compared to non-responders were older (p=0.035), had normal or mild score ranges for anxiety and depression (p=0.025) and were significantly more likely to report >80% treatment adherence (p=0.007). Non-responders had higher anxiety symptoms (p=0.025), and significantly higher ECR-avoidance scores (p=0.023), suggestive of a tendency towards a more avoidant relationship style. CONCLUSIONS: We formally document that patients with AIH who have higher depressive and anxiety symptoms and avoidant relationship styles are more likely to be non-adherent to AIH therapy. We reiterate the need for early recognition and treatment of anxiety and depression in patients with AIH, stress the need for treatment adherence and highlight the need for formal evaluation of these factors in trials of therapy targeting apparent treatment non-responders.

Preparing international medical graduates for psychiatry residency: a multi-site needs assessment.

OBJECTIVE: Despite the growing number of international medical graduates (IMGs) training in medicine in Canada and the United States, IMG-specific challenges early in psychiatry residency have not been fully explored. Therefore, the authors conducted a needs-assessment survey to determine the needs of IMGs transitioning into psychiatry residency. METHOD: Using a 15-item online questionnaire, authors conducted a needs-assessment of IMG residents in five Canadian psychiatry residency programs. The survey examined IMGs' perceived difficulties with the transition into psychiatry residency, educational needs, and demographic data. Data were analyzed with descriptive statistics and Mann-Whitney tests. RESULTS: IMGs identified the following difficulties with their transition into residency: understanding the healthcare system, medical documentation, and evidence-based medicine/mental health. Language barriers and social isolation were significant factors affecting the transition into residency for residents who did not speak English as their first language. Residents who lived in Canada 12 months or less had greater perceived difficulties in psychotherapy knowledge and adapting to the Canadian healthcare system; 88% of IMGs reported having little-or-no IMG-specific preparation for psychiatry residency from their psychiatry program; however, 69% reported that they would use IMG resources if offered; 63% felt that faculty in their program should undergo training to assist with IMG transition. CONCLUSION: Several perceived challenges, needs, and gaps in training were reported by IMGs in Canadian psychiatry residency programs. The results of this survey will be used to inform future curriculum development to facilitate IMG transition into psychiatry postgraduate training programs.

A genetic predisposition to produce low levels of IL-10 is related to depressive symptoms: a pilot study of patients with end stage renal disease.

OBJECTIVE: Heightened levels of inflammation may be associated with an increased risk of depression, particularly among those with inflammatory medical conditions. Although elevated rates of both systemic inflammation and depression have been documented among patients with end stage renal disease (ESRD), the link between these factors has received little empirical evaluation. The goal of this pilot study was to investigate the association between cytokine gene polymorphisms (that are known to influence pro- and anti-inflammatory cytokine production) and depressive symptoms among patients with ESRD. METHODS: Ninety-three patients with ESRD completed the Beck Depression Inventory-II and the disease-related symptom subscale of the Kidney Disease Quality of Life short form. Patients were genotyped for eight single nucleotide polymorphisms in genes coding for pro-inflammatory (TNF-α, IL-6, IFN-γ) and anti-inflammatory (IL-10, TGF-ß1) cytokines. RESULTS: Regression analyses indicated that patients with the A/A genotype for the IL-10 -1082 polymorphism (lower IL-10 producers) reported significantly greater depressive symptoms than G allele carriers (higher IL-10 producers; b = 0.22, P = 0.011), even after controlling for relevant covariates. CONCLUSION: These findings provide some support for cytokine theories of depression in the medically ill, and specifically for the protective role of anti-inflammatory processes. Further research is needed to confirm these preliminary results and to explore the possibility of identifying subtypes of depressed patients based on inflammatory profiles, and those who may benefit from anti-inflammatory therapies.