The Effectiveness of Internet-Based Cognitive Behavioral Therapy for the Treatment of Depression in a Large Real-World Primary Care Practice: A Randomized Trial.

PurposeThe purpose of this study was to compare the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression, to that of treatment as usual (TAU) alone. MethodsIn this study, 302 depressed adult Family Medicine outpatients were randomized to receive either TAU or additional access to Thrive, a fully automated iCBT program with three video-based modules, each containing 10 lessons using behavioral activation, cognitive restructuring, and social skills training. The primary outcome was the change in the score on an online patient health questionnaire (PHQ-9), measured at 0, 8, and 24 weeks. ResultsThe intervention group saw a relative improvement of 2.5 points in PHQ-9 scores at 8 weeks (p = 0.002, d = -0.48), was 6.0 times (p < 0.001) more likely to respond (defined as a ≥ 50% reduction in PHQ-9 score), and was 5.2 times (p = 0.04) more likely to have achieved remission (defined as a PHQ-9 score of < 5) at 8 weeks, but by 24 weeks, the control group had improved to a similar extent as the intervention group (d = -0.14). The intervention group improved in productivity at 8 weeks (p = 0.03), but by 24 weeks, the TAU group had also improved to a similar extent. No significant differences in anxiety, quality of life, or suicidal ideation were found. Patients reported high satisfaction with this iCBT tool, including ease of use, tailoring, and perceived helpfulness. However, only 43% of the intervention group and 58% of the TAU group had outcome measures at every time point. ConclusionsiCBT was associated with greater depression response and remission at 8 weeks, compared with the control group. Depression scores in the intervention group remained similar at 24 weeks, at which time the control group also showed similar rate of response and remission.

Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study.

CONTEXT: The high prevalence and negative implications of resident physicians' burnout is well documented, yet few effective interventions have been identified. OBJECTIVE: To document resident and faculty perspectives on resident burnout, including perceived contributing factors and their recommended strategies for attention and prevention. DESIGN: We conducted 14 focus groups with core faculty and residents in 5 specialties at a large integrated health care system in Southern California. Training programs sampled included family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. Discussions were recorded, transcribed, and analyzed using a matrix-based approach to identify common themes. MAIN OUTCOME MEASURES: Resident and faculty perspectives regarding causes of burnout, preventive factors, and potential intervention strategies. RESULTS: Five themes captured the range of factors participants identified as contributing or protective factors for resident burnout: 1) having or lacking a sense of meaning at work; 2) fatigue and exhaustion; 3) cultural norms in medicine; 4) the steep learning curve from medical school to residency; and 5) social relationships at and outside work. Recommended intervention strategies targeted individuals, residents' social networks, and the learning and work environment. CONCLUSION: We engaged residents and core faculty across specialties in the identification of factors contributing to burnout and possible targets for interventions. Our results highlight potential focus areas for future burnout interventions and point to the importance of interventions targeted at the social environments in which residents' work and learn.

Comparison of Atropine with Glycopyrrolate for Use in ECT.

The occurrence of undesirable events during the postictal electroconvulsive therapy (ECT) period was retrospectively compared between 29 patients who had received glycopyrrolate premedication 0.002 mg/lb i.v. and 25 patients who had received atropine 1.0 mg i.m. A separate comparison was made for 14 patients who had received ECTs with each of these premedications. A total of 952 ECTs were reviewed. In both comparisons supraventricular tachycardia was more common with atropine (p <.0001 with each), after approximately 13% of ECTs. Otherwise, postictal events with the two agents were indistinguishable; specifically, bradycardia and nausea were not more frequent with glycopyrrolate.