Dying in hospital: the residents' viewpoint

A survey of residents'' (junior house officers'') experiences and attitudes to the terminal care part of their work in four Glasgow teaching hospitals showed that even a month after starting work one-fifth of the respondents had not actively managed a dying patient. Sixty-four per cent thought that they had received inadequate teaching in terminal care. Depression and anxiety had been the most difficult symptoms encountered. The residents thought that the ward nursing staff contributed much more than their senior medical colleagues to both the medical and psychological aspects of terminal care. The results indicate a need for more undergraduate education in the most relevant areas, such as coping with the psychological problems of dying patients and their relatives. Newly qualified residents require more support from senior medical staff in looking after the terminally ill.     

To strike or not to strike? House-staff attitudes and behaviors during a hospital work action.

Work actions by house staff are an infrequent response to sometimes difficult working conditions, but they can have a notable effect on institutional cohesiveness and represent a challenge to traditional notions of medical ethics. To determine the extent of participation in a hospital-wide doctors'' strike and factors associated with participation, we surveyed 432 house officers at a university-affiliated public hospital where a contract dispute had recently led to a 4-day work action. Of 257 respondents, 69% approved of the strike and 50% participated in it. Both strikers and nonstrikers agreed that quality of care and specific contract issues were important precipitants of the event. By logistic regression, factors independently associated with strike participation (P less than .05) included being unmarried, training in internal medicine or psychiatry, being in earlier stages of training, being assigned to an outpatient service at the time of the strike, holding a favorable view of physician activism, and perceiving nurses, faculty, peers, and the public to have favored the strike. These associations may provide a basis for understanding the individual and social determinants of house-staff strike activity.     

House Calls in Utah

To learn the criteria Utah physicians use in making or not making house calls and their specialty, age and frequency of calls, a random sample of half of Utah''s physicians in family practice, general practice and general medicine was surveyed. Of 225 respondents, 70% reported making house calls at an average rate of 2.6 per month. More family practitioners made house calls than did internists; older physicians made more house calls than their younger counterparts. An estimated 82% of the calls were for patients aged 65 years and older. The most frequently stated reasons for making house calls were that patients were homebound and to assess the family or home situation. Reasons given for not making house calls were inefficient use of time and lack of equipment or necessary facilities.     

Behavioral phenotypes in males with XYY and possible role of increased NLGN4Y expression in autism features

The male sex chromosome disorder, 47,XYY syndrome (XYY), is associated with increased risk for social‐emotional difficulties, attention‐deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). We hypothesize that increased Y chromosome gene copy number in XYY leads to overexpression of Y‐linked genes related to brain development and function, thereby increasing risk for these phenotypes. We measured expression in blood of two Y genes NLGN4Y and RPS4Y in 26 boys with XYY and 11 male controls and evaluated whether NLGN4Y expression correlates with anxiety, ADHD, depression and autistic behaviors (from questionnaires) in boys with XYY. The XYY cohort had increased risk of ASD behaviors on the social responsiveness scale (SRS) and increased attention deficits on the Conners' DSM‐IV inattention and hyperactive scales. In contrast, there was no increase in reported symptoms of anxiety or depression by the XYY group. Peripheral expression of two Y genes in boys with XYY vs. typically developing controls was increased twofold in the XYY group. Results from the SRS total and autistic mannerisms scales, but not from the attention, anxiety or depression measures, correlated with peripheral expression of NLGN4Y in boys with XYY. Males with XYY have social phenotypes that include increased risk for autism‐related behaviors and ADHD. Expression of NLGN4Y, a gene that may be involved in synaptic function, is increased in boys with XYY, and the level of expression correlates with overall social responsiveness and autism symptoms. Thus, further investigation of NLGN4Y as a plausible ASD risk gene in XYY is warranted.     

A newly identified group of adolescents at “invisible” risk for psychopathology and suicidal behavior: findings from the SEYLE study

This study explored the prevalence of risk behaviors (excessive alcohol use, illegal drug use, heavy smoking, reduced sleep, overweight, underweight, sedentary behavior, high use of Internet/TV/videogames for reasons not related to school or work, and truancy), and their association with psychopathology and self‐destructive behaviors, in a sample of 12,395 adolescents recruited in randomly selected schools across 11 European countries. Latent class analysis identified three groups of adolescents: a low‐risk group (57.8%) including pupils with low or very low frequency of risk behaviors; a high‐risk group (13.2%) including pupils who scored high on all risk behaviors, and a third group (“invisible” risk, 29%) including pupils who were positive for high use of Internet/TV/videogames for reasons not related to school or work, sedentary behavior and reduced sleep. Pupils in the “invisible” risk group, compared with the high‐risk group, had a similar prevalence of suicidal thoughts (42.2% vs. 44%), anxiety (8% vs. 9.2%), subthreshold depression (33.2% vs. 34%) and depression (13.4% vs. 14.7%). The prevalence of suicide attempts was 5.9% in the “invisible” group, 10.1% in the high‐risk group and 1.7% in the low‐risk group. The prevalence of all risk behaviors increased with age and most of them were significantly more frequent among boys. Girls were significantly more likely to experience internalizing (emotional) psychiatric symptoms. The “invisible” group may represent an important new intervention target group for potentially reducing psychopathology and other untoward outcomes in adolescence, including suicidal behavior.     

Suicidal Ideation and Suicide Attempts in Anxious or Depressed Family Caregivers of Patients with Cancer: A Nationwide Survey in Korea

Purpose

To describe the prevalence of suicidal ideation and suicide attempts in family caregivers (FCs) of patients with cancer and to identify the factors associated with suicidal ideation and suicide attempts in FCs with anxiety or depression.

Methods

A national, multicenter survey administered to 897 FCs asked questions concerning suicidal ideation and suicide attempts during the previous year and assessed anxiety, depression, socio–demographic factors, caregiving burden, patient factors, and quality of life (QOL).

Results

A total of 17.7% FCs reported suicidal ideation, and 2.8% had attempted suicide during the previous year. Among FCs with anxiety, 31.9% had suicidal ideation and 4.7% attempted suicide; the corresponding values for FCs with depression were 20.4% and 3.3%, respectively. Compared with FCs without anxiety and depression, FCs with anxiety or depression showed a higher adjusted odds ratios (aOR) for suicidal ideation (aOR  = 4.07 and 1.93, respectively) and attempts (OR  = 3.00 and 2.43, respectively). Among FCs with anxiety or depression, being female, unmarried, unemployed during caregiving, and having a low QOL were associated with increased odds of suicidal ideation. FCs with anxiety who became unemployed during caregiving constituted a high-risk group for suicide. Being unmarried and having a low QOL with respect to financial matters were associated with increased suicide attempts among FCs with depression.

Conclusion

FCs with anxiety or depression were at high risk of suicide. Interventions to enhance social support and to improve perceived QOL may help prevent suicide and manage suicidal ideation in FCs with anxiety or depression.     

Impaired attribution of emotion to facial expressions in anxiety and major depression

Background

Recognition of others'' emotions is an important aspect of interpersonal communication. In major depression, a significant emotion recognition impairment has been reported. It remains unclear whether the ability to recognize emotion from facial expressions is also impaired in anxiety disorders. There is a need to review and integrate the published literature on emotional expression recognition in anxiety disorders and major depression.

Methodology/Principal Findings

A detailed literature search was used to identify studies on explicit emotion recognition in patients with anxiety disorders and major depression compared to healthy participants. Eighteen studies provided sufficient information to be included. The differences on emotion recognition impairment between patients and controls (Cohen''s d) with corresponding confidence intervals were computed for each study. Over all studies, adults with anxiety disorders had a significant impairment in emotion recognition (d = −0.35). In children with anxiety disorders no significant impairment of emotion recognition was found (d = −0.03). Major depression was associated with an even larger impairment in recognition of facial expressions of emotion (d = −0.58).

Conclusions/Significance

Results from the current analysis support the hypothesis that adults with anxiety disorders or major depression both have a deficit in recognizing facial expression of emotions, and that this deficit is more pronounced in major depression than in anxiety.     

The roles of DNA methylation of NR3C1 and 11β-HSD2 and exposure to maternal mood disorder in utero on newborn neurobehavior

Exposure to maternal mood disorder in utero may program infant neurobehavior via DNA methylation of the glucocorticoid receptor (NR3C1) and 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD-2), two placental genes that have been implicated in perturbations of the hypothalamic pituitary adrenocortical (HPA) axis. We tested the relations among prenatal exposure to maternal depression or anxiety, methylation of exon 1F of NR3C1 and 11β-HSD-2, and newborn neurobehavior. Controlling for relevant covariates, infants whose mothers reported depression during pregnancy and showed greater methylation of placental NR3C1 CpG2 had poorer self-regulation, more hypotonia, and more lethargy than infants whose mothers did not report depression. On the other hand, infants whose mothers reported anxiety during pregnancy and showed greater methylation of placental 11β-HSD-2 CpG4 were more hypotonic compared with infants of mothers who did not report anxiety during pregnancy. Our results support the fetal programming hypothesis and suggest that fetal adjustments to cues from the intrauterine environment, in this case an environment that could be characterized by increased exposure to maternal cortisol, may lead to poor neurodevelopmental outcomes.     

Influence of Psychosocial Factors on Postpartum Weight Retention

For some women, pregnancy may increase the risk of future obesity with consequences for health and well‐being. Psychosocial factors may be partly responsible for this. The aim of this study was to examine the association between psychosocial factors during pregnancy and postpartum weight retention (PPWR) at 6 and 18 months. A total of 37,127 women in The Danish National Birth Cohort (DNBC; 1996–2002) participated in four telephone interviews before and after delivery. They gave information about their experience of distress, depression and anxiety, social support, and psychosocial burdens during pregnancy. PPWR was defined as retention ≥5 kg at 6 and 18 months postpartum according to a woman's prepregnancy weight. The associations were examined by use of logistic regression and presented as odds radios with 95% confidence intervals. Women who were more likely to feel depressed/anxious or distressed during pregnancy had a higher risk of PPWR at 6 months (1.35 (1.27; 1.44) and 1.30 (1.22; 1.38)) and 18 months (1.34 (1.24; 1.45) and 1.32 (1.23; 1.42)). Likewise, women who felt burdened by their economy or working situation had a higher risk of PPWR as did women with the lowest incomes or less education. Women who reported a high level of distress or depression/anxiety both during pregnancy and in the first 6 months of motherhood had the highest risk of PPWR 18 months postpartum (1.54 (1.39; 1.71) and 1.49 (1.32; 1.69), respectively). Feeling distressed, depressed, or anxious during pregnancy was associated with higher PPWR as was personal and economical burdens. Adverse psychosocial characteristics may be a common determinant of weight retention after childbirth.     

Affective changes during the postpartum period: Influences of genetic and experiential factors

This article is part of a Special Issue “Parental Care”.The postpartum period involves some truly transformational changes in females' socioemotional behaviors. For most female laboratory rodents and women, these changes include an improvement in their affective state, which has positive consequences for their ability to sensitively care for their offspring. There is heterogeneity among females in the likelihood of this positive affective change, though, and some women experience elevated anxiety or depression (or in rodents anxiety- or depression-related behaviors) after giving birth. We aim to contribute to the understanding of this heterogeneity in maternal affectivity by reviewing selected components of the scientific literatures on laboratory rodents and humans examining how mothers' physical contact with her infants, genetics, history of anxiety and depression and early-life and recent-life experiences contribute to individual differences in postpartum affective states. These studies together indicate that multiple biological and environmental factors beyond female maternal state shape affective responses during the postpartum period, and probably do so in an interactive manner. Furthermore, the similar capacity of some of these factors to modulate anxiety and depression in human and rodent mothers suggests cross-species conservation of mechanisms regulating postpartum affectivity.     

Delivering interventions for depression by using the internet: randomised controlled trial

Objective To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression—a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy.Design Randomised controlled trial.Setting Internet users in the community, in Canberra, Australia.Participants 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178).Main outcome measures Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy.Results Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the “depression literacy” site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants'' understanding of effective evidence based treatments for depression (P < 0.05).Conclusions Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.     

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient''s age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient''s discharge and less than one third of patients had been given more than 24 hours'' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.     

Evaluation of a stroke family care worker: results of a randomised controlled trial.

OBJECTIVE: To examine the effect of contact with a stroke family care worker on the physical, social, and psychological status of stroke patients and their carers. DESIGN: Randomised controlled trial with broad entry criteria and blinded outcome assessment six months after randomisation. SETTING: A well organised stroke service in an Edinburgh teaching hospital. SUBJECTS: 417 patients with an acute stroke in the previous 30 days randomly allocated to be contacted by a stroke family care worker (210) or to receive standard care (207). The patients represented 67% of all stroke patients assessed at the hospital during the study period. MAIN OUTCOME MEASURES: Patient completed Barthel index, Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, mental adjustment to stroke scale, and patient satisfaction questionnaire; carer completed Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, caregiving bassles scale, and carer satisfaction questionnaire. RESULTS: The groups were balanced for all important baseline variables. There were no significant differences in physical outcomes in patients or carers, though patients in the treatment group were possibly more helpless less well adjusted socially, and more depressed, whereas carers in the treatment group were possibly less hassled and anxious. However, both patients and carers in the group contacted by the stroke family care worker expressed significantly greater satisfaction with certain aspects of their care, in particular those related to communication and support. CONCLUSIONS: The introduction of a stroke family care worker improved patients'' and their carers'' satisfaction with services and may have had some effect on psychological and social outcomes but did not improve measures of patients'' physical wellbeing.     

Psychological outcomes following maternal serum screening: a cohort study

BACKGROUND: Maternal serum screening is used to assist in the prenatal detection of congenital anomalies. Its use is controversial, and one concern that has been expressed is its psychological effects on women. The authors examined whether this test leads to an increase in anxiety and depression among women who have a false-positive result as compared with those who have a true-negative result or do not undergo testing. METHODS: A prospective cohort study with baseline assessment at 15 to 18 weeks'' gestation and follow-up at 24 weeks'' gestation was conducted. Pregnant women at 8 geographically diverse sites across Ontario were recruited. The main outcome measures were the state portion of the State--Trait Anxiety Inventory and the Center for Epidemiologic Studies Depression Scale. RESULTS: Of the 2418 potential subjects 2020 (83.5%) were enrolled and eligible; 1741 (86.2%) completed the follow-up. A total of 1177 women (67.6%) underwent maternal serum screening. No overall adverse psychological effects as a result of testing were found at 24 weeks'' gestation. Women with a false-positive result had a mean increase in anxiety score of 1.6 (95% confidence interval [CI] -1.7 to 4.9), whereas women with a true-negative result had a mean decrease of 1.1 (95% CI -1.8 to -0.3) and those not tested had a mean decrease of 0.4 (95% CI -1.3 to 0.5). The mean depression score increased by 0.5 (95% CI -0.9 to 2.0) in the false-positive group, was unchanged (95% CI -0.3 to 0.4) in the true-negative group and increased by 0.2 (95% CI -1.7 to 1.2) in the not tested group. Of the women who underwent testing, 87 (7.6%) were unsure of their result at the time of follow-up. INTERPRETATION: The results suggest that maternal screening in Ontario is not causing serious psychological harm to women. Communication regarding test results could be improved, since a substantial proportion of women were unsure of their test result.     

Emotional Reactions of Mothers Facing Premature Births: Study of 100 Mother-Infant Dyads 32 Gestational Weeks

Objectives

This current study has been conducted to clarify the relationship between the mother''s post-traumatic reaction triggered by premature birth and the mother-infant interactions. In this article, the precocious maternal feelings are described.

Methods

A multicenter prospective study was performed in three French hospitals. 100 dyads with 100 very premature infants and their mothers were recruited. Mothers completed, at two different times self-questionnaires of depression/anxiety, trauma and social support. The quality of interactions in the dyads was evaluated.

Results

Thirty-nine percent of the mothers obtained a score at HADS suggesting a high risk of depression at the first visit and approximately one-third at visit two. Seventy-five percent of the mothers were at risk of suffering from an anxiety disorder at visit one and half remained so at visit two. A “depressed” score at visits one and two correlated with a hospitalization for a threatened premature labor. We noted a high risk of trauma for 35% of the mothers and high interactional synchrony was observed for approximately two-thirds of the dyads. The mothers'' psychological reactions such as depression and anxiety or postnatal depression correlate strongly with the presence of an initial trauma. At visit one and visit two, a high score of satisfaction concerning social support correlates negatively with presence of a trauma. A maternal risk of trauma is more frequent with a C-section delivery.

Conclusions

Mothers'' psychological reactions such as depression and anxiety correlate greatly with the presence of an initial trauma. The maternal traumatic reaction linked to premature birth does not correlate with the term at birth, but rather with the weight of the baby. Social support perceived by the mother is correlated with the absence of maternal trauma before returning home, and also seems to inhibit from depressive symptoms from the time of the infant''s premature birth.     

Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects.

OBJECTIVE: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING--Obstetrics and gynaecology department of a large teaching hospital. SUBJECTS: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women). MAIN OUTCOME MEASURES: Mental state, martial relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. RESULTS: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. CONCLUSIONS: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness.     

Whom do dying patients tell?

Eighty married patients dying of cancer were assessed for their overt awareness of their condition. Of the 62 who discussed the possibility of dying, 22 had spoken of this to hospital staff, 43 to their husband or wife, and 53 to the interviewer. Those more certain of dying were more likely to speak about it. Patients previously considered "nervous" people more often showed their awareness, but current anxiety had no consistent effect. More overt sharing of awareness tended to happen in marriages considered average or poor by the spouse than in some closer marital partnerships. The patients'' communication of awareness to wife or husband was consistently better when the spouse favoured telling the patient. Patients also tended to disclose their awareness of dying more frequently to those staff prepared to discuss the matter. The findings have implications for the care of the dying.     

Effects of living with and looking after survivors of a stroke.

Information from a two year, longitudinal study on a community sample of patients with acute stroke was analysed to determine the effects of the stroke on the mood of the chief carer (the person living with the patient). Increased anxiety was the most commonly reported change six months after stroke. Significant depression was seen in 11-13% of carers over the first two years after stroke. The patient''s functional disability was associated with depression in the carer over the first year but not at two years. A perceived poor recovery by the patient, a low level of general activities by the patient, and depression in the patient were also associated with depression in the carer within the first year. At two years after stroke none of the measured factors were related to a carer''s level of depression. Carers of patients who have suffered stroke showed anxiety and emotional distress unrelated to the patient''s physical disability after two years. More help from stroke support groups for carers is perhaps needed.     

Exposure of expectant mothers to cytomegalovirus infections.

Soon after the return of the hostages from Iran, the staff of the Mental Health Clinic of the Veterans Administration Outpatient Clinic, Santa Barbara, California, began noting an unusual association between veterans'' feelings and the attention given the returning hostages. Of 100 veterans referred at random for diagnosis and treatment, not one had positive feelings about the reception given the returning hostages; 34 viewed the festivities and proclamations of welcome as excessive and unfair, and 12 expressed violent feelings toward the hostages, media people or members of the government. Of these 100 veterans, 52 expressed anxiety and excessive irritability, 41 were having psychic symptoms of depression and 38 reported sexual disturbances. This unusual form of stress had activated long-dormant feelings in veterans of four different wars and several generations.     

Biased belief priors versus biased belief updating: Differential correlates of depression and anxiety

Individuals prone to anxiety and depression often report beliefs and make judgements about themselves that are more negative than those reported by others. We use computational modeling of a richly naturalistic task to disentangle the role of negative priors versus negatively biased belief updating and to investigate their association with different dimensions of Internalizing psychopathology. Undergraduate participants first provided profiles for a hypothetical tech internship. They then viewed pairs of other profiles and selected the individual they would prefer to work alongside out of each pair. In a subsequent phase of the experiment, participants made judgments about their relative popularity as hypothetical internship partners both before any feedback and after each of 20 items of feedback revealing whether or not they had been selected as the preferred teammate from a given pairing. Scores on latent factors of general negative affect, anxiety-specific affect and depression-specific affect were estimated using participants’ self-report scores on standardized measures of anxiety and depression together with factor loadings from a bifactor analysis conducted previously. Higher scores on the depression-specific factor were linked to more negative prior beliefs but were not associated with differences in belief updating. In contrast, higher scores on the anxiety-specific factor were associated with a negative bias in belief updating but no difference in prior beliefs. These findings indicate that, to at least some extent, distinct processes may impact the formation of belief priors and in-the-moment belief updating and that these processes may be differentially disrupted in depression and anxiety. Future directions for enquiry include examination of the possibility that prior beliefs biases in depression might reflect generalization from prior experiences or global schema whereas belief updating biases in anxiety might be more situationally specific.