Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses

Background@#Healthcare professionals often experience moral distress while providing endof-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea. @*Methods@#This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory. @*Results@#Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation. @*Conclusion@#Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Benzodiazepine Use and Long-Term Mortality in South Korean Adult Population: A Cohort Study

Purpose@#Studies have reported mixed results on the association between benzodiazepine use and mortality. Here, we investigated whether benzodiazepine use is associated with a higher risk of 5-year all-cause mortality, and examined the association between benzodiazepine use and 5-year disease-specific mortality. @*Materials and Methods@#In this population-based cohort study, a nationally representative sample cohort in South Korea was examined. In 2010, benzodiazepine users were defined as individuals prescribed benzodiazepine continuously over 30 days for regular administration, and all other subjects were included in the control group. The primary endpoint was 5-year all-cause mortality, evaluated from 2011 to 2015. Propensity score (PS) matching and time-dependent Cox regression were performed for statistical analysis, which included benzodiazepine use during 2011–2015 as a time-dependent variable. @*Results@#A total of 822414 adult individuals were included in the final analysis, and the all-cause 5-year mortality was recorded in 20991 individuals (2.7%). The benzodiazepine group included 30837 patients and the control group comprised 791377 patients.After PS matching, 61672 individuals (30836 in each group) were included in the final analysis. After PS matching, the 5-year allcause mortality in the benzodiazepine group was 10.0% (3082/30836), whereas that in the control group was 9.4% (2893/30836).In time-dependent Cox regression analysis of the PS-matched cohort, the benzodiazepine group showed 1.15-fold higher 5-year all-cause mortality (hazard ratio: 1.15, 95% confidence interval: 1.09–1.22; p<0.001) compared to the control group. @*Conclusion@#Benzodiazepine use was associated with increased 5-year all-cause mortality in the South Korean adult population.Further studies are needed to confirm these findings.

Benzodiazepine Use and Long-Term Mortality in South Korean Adult Population: A Cohort Study

Purpose@#Studies have reported mixed results on the association between benzodiazepine use and mortality. Here, we investigated whether benzodiazepine use is associated with a higher risk of 5-year all-cause mortality, and examined the association between benzodiazepine use and 5-year disease-specific mortality. @*Materials and Methods@#In this population-based cohort study, a nationally representative sample cohort in South Korea was examined. In 2010, benzodiazepine users were defined as individuals prescribed benzodiazepine continuously over 30 days for regular administration, and all other subjects were included in the control group. The primary endpoint was 5-year all-cause mortality, evaluated from 2011 to 2015. Propensity score (PS) matching and time-dependent Cox regression were performed for statistical analysis, which included benzodiazepine use during 2011–2015 as a time-dependent variable. @*Results@#A total of 822414 adult individuals were included in the final analysis, and the all-cause 5-year mortality was recorded in 20991 individuals (2.7%). The benzodiazepine group included 30837 patients and the control group comprised 791377 patients.After PS matching, 61672 individuals (30836 in each group) were included in the final analysis. After PS matching, the 5-year allcause mortality in the benzodiazepine group was 10.0% (3082/30836), whereas that in the control group was 9.4% (2893/30836).In time-dependent Cox regression analysis of the PS-matched cohort, the benzodiazepine group showed 1.15-fold higher 5-year all-cause mortality (hazard ratio: 1.15, 95% confidence interval: 1.09–1.22; p<0.001) compared to the control group. @*Conclusion@#Benzodiazepine use was associated with increased 5-year all-cause mortality in the South Korean adult population.Further studies are needed to confirm these findings.

Brief Communication

As the coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, there are growing concerns about patients' mental health. We investigated psychological problems in COVID-19 patients assessed with self-reported questionnaires including the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 scale, and Impact of Event ScaleRevised Korean version. Ten patients who recovered from COVID-19 pneumonia without complications underwent self-reported questionnaires about 1 month after discharge. Of them, 10% reported depression and posttraumatic stress disorder (PTSD) while 50% had depression during the treatment. Perceived stigma and history of psychiatric treatment affected PTSD symptom severity, consistent with previous emerging infectious diseases. Survivors also reported that they were concerned about infecting others and being discriminated and that they chose to avoid others after discharge. Further support and strategy to minimize their psychosocial difficulties after discharge should be considered.

Brief Communication

As the coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, there are growing concerns about patients' mental health. We investigated psychological problems in COVID-19 patients assessed with self-reported questionnaires including the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 scale, and Impact of Event ScaleRevised Korean version. Ten patients who recovered from COVID-19 pneumonia without complications underwent self-reported questionnaires about 1 month after discharge. Of them, 10% reported depression and posttraumatic stress disorder (PTSD) while 50% had depression during the treatment. Perceived stigma and history of psychiatric treatment affected PTSD symptom severity, consistent with previous emerging infectious diseases. Survivors also reported that they were concerned about infecting others and being discriminated and that they chose to avoid others after discharge. Further support and strategy to minimize their psychosocial difficulties after discharge should be considered.

Reduced Heart Rate Variability in Somatic Symptom Disorder: Associations with Alexithymia / 정신신체의학

Objectives@#：We investigated heart rate variability (HRV) patterns in patients with somatic symptom disorder (SSD) and the relationships of these patterns with alexithymia. @*Methods@#：In total, 42 patients with SSD and 33 healthy controls were enrolled in this study. Demographic, psychological, and HRV data were assessed at baseline, and 24 patients with SSD were reassessed after 6 months of treatment. The psychological data included somatic symptoms and levels of depression, anxiety, and alexithymia as indicated by the somatic symptom subscale of the Symptom Checklist 90-Revision (SCL-12), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and the Toronto Alexithymia Scale 20 (TAS-20), respectively. @*Results@#：Patients with SSD had a lower standard deviation of normal-to-normal R-R intervals (SDNN) and lower proportions of adjacent R-R intervals greater than 50 milliseconds (pNN50) compared with controls. These HRV parameters were negatively correlated with alexithymia severity. After treatment, patients exhibited significantly decreased levels of somatic symptoms and reduced anxiety and depression, but there were no significant differences in the HRV parameters. In patients with alexithymia, a high baseline SDNN and pNN50 were associated with a decrease in somatic symptoms. @*Conclusions@#：Patients with SSD have different HRV patterns, and several HRV parameters are associated with alexithymia severity. These findings suggest that ANS regulation is involved in the pathophysiology of SSD, mediated by alexithymia. Furthermore, these results suggest that certain HRV parameters may be associated with clinical outcomes of SSD.

Multidimensional Comparison of Cancer-Related Fatigue and Chronic Fatigue Syndrome: The Role of Psychophysiological Markers

OBJECTIVE: The present study compared cancer-related fatigue (CRF) and chronic fatigue syndrome (CFS) using multidimensional measurements with the aim of better understanding characteristics and exploring markers of two similar fatigue syndromes. METHODS: Twenty-five patients with CRF and twenty patients with CFS completed questionnaires, including the Fatigue Severity Scale (FSS), Hospital Anxiety Depression Scale (HADS), Perceived Stress Scale (PSS), and Pittsburgh Sleep Quality Index (PSQI). Additionally, levels of high sensitivity C-reactive protein (hs-CRP), heart rate variability (HRV), and electroencephalography (EEG) were obtained. Neurocognitive functioning was also evaluated. RESULTS: Both groups showed comparable levels of psychological variables, including fatigue. Compared to CFS subjects, CRF patients had significantly higher hs-CRP levels and a reduced HRV-index. The within-group analyses revealed that the FSS score of the CRF group was significantly related to scores on the HADS-anxiety, HADS-depression, and PSQI scales. In the CFS group, FSS scores were significantly associated with scores on the PSS and the absolute delta, theta, and alpha powers in frontal EEG. CONCLUSION: Findings indicate that different pathophysiological mechanisms underlie CFS and CRF. Inflammatory marker and HRV may be potential biomarkers for distinguishing two fatigue syndromes and frontal EEG parameters may be quantitative biomarkers for CFS.

Emotional Support and Palliative Care for Distressed Patients Suffering from Pancreatic Cancer / 대한소화기학회지

Pancreatic cancer is associated with a poor prognosis and high mortality. Thus, distress that includes depression and anxiety is a relatively common comorbidity for patients suffering from pancreatic cancer. However, these psychological symptoms are likely to be under-detected and undertreated. Regarding high levels of unmet needs of psychological support for patients with pancreatic cancer, early screening for distress and adequate interventions should be considered in palliative care settings. Suicide, a common but preventable cause of mortality for patients with pancreatic cancer, also deserves the further attention of care providers. Still, there have been limited studies that have documented psychological support for this population. Future research is needed to elucidate appropriate psychological care and models of services for patients suffering from pancreatic cancer.

Diagnostic Neuroimaging in Headache Patients: A Systematic Review and Meta-Analysis

OBJECTIVE: Neuroimaging in headache patients identifies clinically significant neurological abnormalities and plays an important role in excluding secondary headache diagnoses. We performed a systematic review and meta-analysis of the existing guidelines and studies surrounding neuroimaging in headache patients. METHODS: The research question involved determining the prevalence of detecting clinically significant neurological abnormalities using neuroimaging in patients suspected of primary headache. Searches of the PubMed and Embase databases were conducted on English-language studies published from 1991 to 2016, and the reference lists of the retrieved articles were also checked manually. All headache subtypes and patients aged ≥15 years were included in the analysis. RESULTS: Ten studies met the selection criteria. The pooled prevalence of detecting clinically significant abnormalities in the neuroimaging of headache patients was 8.86% (95% confidence interval: 5.12–15.33%). Subsequently, diverse subgroup analyses were performed based on the detection method, headache type, study type, study region, age group, and disease type. CONCLUSION: The present findings indicate that limited neuroimaging methods should be carefully considered for headache diagnostic purposes when there are red flag symptoms. Limitations and suggested directions for future studies on neuroimaging in headache patients are described.

The Development of Evidence-Based Guideline for Diagnosis and Management of Headache in Korea

OBJECTIVE: We aimed to develop the clinical guideline for headache by the systematic review and synthesis of existing evidence-based guidelines. The purpose of developing the guideline was to improve the appropriateness of diagnosis and treatment of headache disorder, and consequently, to improve patients’ pain control and quality of life. The guideline broadly covers the differential diagnosis and treatment of tension-type headache, migraine, cluster headache, and medication-overuse headache. METHODS: This is a methodological study based on the ADAPTE methodology, including a systematic review of the literature, quality assessment of the guidelines using the Appraisal of Clinical Guidelines for REsearch & Evaluation II (AGREE II) Instrument, as well as an external review using a Delphi technique. The inclusion criteria for systematic search were as follows: topic-relevant, up-to-date guidelines including evidence from within 5 years, evidence-based guidelines, guidelines written in English or Korean, and guidelines issued by academic institutions or government agencies. RESULTS: We selected five guidelines and conducted their quality assessment using the AGREE II Instrument. As a result, one guideline was found to be eligible for adaptation. For 13 key questions, a total of 39 recommendations were proposed with the grading system and revised using the nominal group technique. CONCLUSION: Recommendations should be applied to actual clinical sites to achieve the ultimate goal of this guideline; therefore, follow-up activities, such as monitoring of guideline usage and assessment of applicability of the recommendations, should be performed in the future. Further assessment of the effectiveness of the guideline in Korea is needed.

Emotional Support and Palliative Care for Distressed Patients Suffering from Pancreatic Cancer / 대한소화기학회지

Pancreatic cancer is associated with a poor prognosis and high mortality. Thus, distress that includes depression and anxiety is a relatively common comorbidity for patients suffering from pancreatic cancer. However, these psychological symptoms are likely to be under-detected and undertreated. Regarding high levels of unmet needs of psychological support for patients with pancreatic cancer, early screening for distress and adequate interventions should be considered in palliative care settings. Suicide, a common but preventable cause of mortality for patients with pancreatic cancer, also deserves the further attention of care providers. Still, there have been limited studies that have documented psychological support for this population. Future research is needed to elucidate appropriate psychological care and models of services for patients suffering from pancreatic cancer.

Symptom Persistence after Iron Normalization in Women with Restless Legs Syndrome

OBJECTIVE: The aim of this study was to determine the clinical course of restless legs syndrome (RLS) and potential risk factors for the persistence of RLS symptoms after iron normalization in women with RLS and low serum ferritin (<50 μg/L). METHODS: We reviewed 39 women with RLS and iron deficiency, who achieved iron normalization after oral iron replacement for three months. Risk factors contributing to symptom persistence were estimated by logistic regression analyses. Remission was defined as no RLS symptoms for at least 6 months after the iron normalization. RESULTS: Over the observation period of 2.5±1.4 years, 15 patients reported no RLS symptom whereas 24 patients still complained of RLS symptoms. The remission rate of RLS with iron replacement was 38.5%. The relative risk of symptom persistence was increased by the duration of RLS symptoms (OR: 1.88, 95% CI: 1.01–3.49) or by the age at RLS diagnosis (OR: 1.25, 95% CI: 1.01–1.56). CONCLUSION: Almost two-third of RLS patients with iron deficiency showed persistence of the symptom even after iron normalization. Considering that longer duration of RLS symptoms and older age at RLS diagnosis were risk factors for symptom persistence, early intervention of iron deficiency in RLS is warranted.

Modest Improvement of Untreated Severe Sleep-Disordered Breathing in the Middle-Aged and Elderly

OBJECTIVE: It has been reported that untreated sleep-disordered breathing (SDB) deteriorates over time, however this remains contentious. The aim of the present study is to evaluate the clinical course of SDB in middle-aged and older SDB patients, and to identify how relevant factors contribute to the change in SDB severity. METHODS: Baseline and follow-up polysomnographic data of 56 untreated SDB patients (mean age, 61.2±5.71) were obtained retrospectively and the mean interval was 62.4±22.0 months. Subgroup analysis was performed based on the baseline severity, and the factors associated with the course of SDB were analyzed. RESULTS: At the baseline, 13 subjects were simple snorers, 15 had mild to moderate SDB, and 28 were severe SDB patients. While there was no significant change in apnea-hypopnea index (AHI) as a whole, subgroup analysis showed decrease of AHI in severe SDB patients (43.9±10.6 to 35.6±20.0, p=0.009). The change in supine time percent and baseline AHI were associated with the change in AHI (β=0.387, p=0.003; β=-0.272, p=0.037). CONCLUSION: Untreated SDB did not deteriorate over time with modest improvement in severe SDB. A proportion of severe SDB patients might expect decrease in SDB severity irrespective of changes in sleep position or body weight.

Do Patients Want to Listen to a Diagnosis of Dementia in Korea? Preferences on Disclosing a Diagnosis of Dementia and Discussing Advance Care Planning in Elderly Patients with Memory Concerns and Their Families

OBJECTIVE: In this study, we aimed to investigate preferences regarding the disclosure of a dementia diagnosis and advance care planning (ACP) in patients with memory complaints and their families. METHODS: A total of 98 patients who visited the department of psychiatry at a tertiary hospital with memory complaints and 62 family members completed a structured questionnaire. The questionnaire included preferences on disclosure of dementia and cancer diagnosis, awareness and preferences on ACP. RESULTS: In total, 96.9% of patients were willing to know their dementia diagnosis. There were no significant differences in preferences between the diagnosis of cancer and dementia. Only 24.7% of patients and 45.8% of family members have heard of ACP. However, 82.8% of patients agreed on the necessity of ACP under the current condition. Multivariate analysis revealed that younger patients were more likely to agree with necessity for ACP under the current condition. CONCLUSION: In Korea, patients with memory complaints and their family members strongly favored a disclosure of dementia diagnosis. The majority of participants also agreed on the necessity of ACP. More active involvement of patients is needed in treatment decisions and care planning in cases of dementia as well as other life-threatening illnesses.

Factors Associated with the Compliance of Cognitive Behavioral Therapy for Obsessive Compulsive Disorder / 신경정신의학

OBJECTIVES: Non-completion rate of cognitive behavioral therapy (CBT) for Obsessive Compulsive Disorder (OCD) was reported to be higher than expected and it could interfere with the effectiveness of treatment. The aim of this study was to investigate predictors of treatment non-completion and to compare the effectiveness of CBT for OCD between completers and non-completers. METHODS: We studied 107 patients with a principal diagnosis of OCD who initiated a 13-week CBT for OCD from June 2004 to June 2011. Demographic and clinical characteristics, psychiatric co-morbidity, and medication of 20 participants who did not complete therapy were compared with those of treatment completers (n=87). Clinical Global Impression scores were also compared between the two groups in order to evaluate the effect of CBT for OCD at the 13th week. RESULTS: The results showed a difference in marital status between treatment completers and non-completers : more non-completers were not married (p=0.04). Patients with aggressive obsessions at baseline showed a trend (p=0.06) toward lower treatment completion than those with only non-aggressive obsession. In addition, the non-completer group showed a trend of not being medicated (p=0.08). No other differences were observed between completers and non-completers. The 13th week Clinical Global Impression-Improvement scores were significantly different ; completers (2.5+/-0.8) and non-completers (3.2+/-0.8) (p<0.001). CONCLUSION: In this study, we confirmed that CBT could affect symptom improvement of OCD and treatment non-completion interfered with effectiveness of CBT. However, in the current state of our knowledge, no factor is clinically applicable as a predictor of treatment non-completion. Therefore, these results suggest that clinicians should monitor compliance during CBT for OCD patients.

Mild Impairments in Cognitive Function in the Elderly with Restless Legs Syndrome / 수면정신생리

OBJECTIVES: Cognitive impairment in restless legs syndrome (RLS) patients can be affected by sleep deprivation, anxiety and depression, which are common in RLS. The objective of this study is to investigate relationship between cognitive impairment and RLS in the non-medicated Korean elderly with controlling for psychiatric conditions. METHOD: The study sample for this study comprised 25 non-medicated Korean elderly RLS patients and 50 age-, sex-, and education-matched controls. All subjects were evaluated with comprehensive cognitive function assessment tools-including the Korean version of Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet (CERAD-K), severe cognitive impairment rating scale (SCIRS), frontal assessment battery (FAB), and clock drawing test (CLOX). Sleep quality and depression were also assessed with Pittsburgh sleep quality index (PSQI) and geriatric depression scale (GDS). RESULTS: PSQI and GDS score showed no difference between RLS and control group. There was no significant difference between two groups in nearly all the cognitive function except in constructional recognition test, in which subjects with RLS showed lower performance than control group (t=-2.384, p=0.02). Subjects with depression (GDS> or =10) showed significant cognitive impairment compared to control in verbal fluency, Korean version of Mini Mental Status Examination in the CERAD-K (MMSE-KC), word list memory, trail making test, and frontal assessment battery (FAB). In contrast, no difference was observed between subjects who have low sleep quality (PSQI>5) and control group. CONCLUSIONS: At the exclusion of the impact of insomnia and depression, cognitive function was found to be relatively preserved in RLS patients compared to control. Impairment of visual recognition in RLS patients can be explained in terms of dopaminergic dysfunction in RLS.

Predictors of Clinical Response to Escitalopram in Obsessive-Compulsive Disorder / 대한정신약물학회지

OBJECTIVE: In this study, we aimed to investigate the predictors of clinical response to escitalopram (ESC) in obsessive-compulsive disorder (OCD) from the baseline clinical characteristics. In addition, we aimed to search the differences of prescription pattern between responders and non-responders to ESC. METHODS: Two hundred and twenty-three patients who met the DSM-IV criteria for OCD and visited at least once after the initiation of ESC prescription were included in this study. A primary outcome measure was the Clinical Global Impression-Improvement scale (CGI-I), which was scored at the time of retrospective chart review. Responders were defined as those with a CGI-I score of 1 or 2 at the final point of evaluation. Baseline clinical characteristics, prescription patterns, and adverse events were compared between responders and non-responders. We also examined the validity of the prediction model regarding treatment response to ESC. RESULTS: The OCD patients having aggressive obsessions and related compulsions showed significantly decreased response rate to ESC (odd ratio=0.285) in comparison with the OCD patients not having aggressive symptom dimension (p=0.002). The maximum dose of ESC prescription and rate of antipsychotics combination were higher in responders in comparison to the nonresponders. Among the adverse effects, sedation and constipation showed significantly different occurrence rate between responders versus non-responders. CONCLUSION: Aggressive obsessions and related compulsions seem to be associated with poor clinical response to ESC in OCD. Obsessive-compulsive symptom dimension should be considered when choosing a serotonin reuptake inhibitor for OCD.

Vulnerability Factors of Obsessive-Compulsive Disorder on the Temperamental and Affective Aspects and the Effect of Pharmacotherapy / 대한정신약물학회지

OBJECTIVE: Recently some behavioral features and affective traits are considered important for the phenotype of obsessive-compulsive disorder (OCD). The purpose of this study was to assess some specific behavioral, temperamental, emotional features of OCD patients and to investigate if there is any change in patterns of temperament-character after 4-month pharmacotherapy. METHODS: Fifty-six patients with OCD and 70 normal controls were enrolled in this study. Four self-report questionnaires were employed to assess temperamental characteristics and affective traits: The behavioral inhibition system and behavioral activation system scale, the Baratt impulsiveness scale, state-trait anger expression inventory, emotional intelligence inventory. Among 56 OCD patients, 21 subjects started pharmacotherapy and 4 months later, they repeated 4 self-report tests as the same above and Yale-Brown obsessive compulsive scale (Y-BOCS). And then we investigated the changes from initial results. RESULTS: Patients with OCD showed significantly greater expression of behavioral inhibition system (p<0.0001), more cognitive impulsiveness (p<0.0001), motor impulsiveness (p=0.0067) and increased level of state anger (p<0.0001), trait anger (p<0.0001) than healthy controls. Compared to the controls, the OCD patients also expressed significantly lower level of emotional intelligence for using to facilitate thinking (p<0.0001) and managing emotions (p<0.0001). After 4-month pharmacotherapy for 21 OCD patients, Y-BOCS scores significantly decreased while self-report tests showed no meaningful differences from baseline assessments. CONCLUSION: Our results suggest that patients with OCD may have some differences in behavioral and affective tendencies including behavioral inhibition, impulsiveness, anger experiences, and emotional patterns. And short term pharmacotherapy during 4 months improved the severity of obsessive-compulsive symptoms but didn't influence these traits. These results provide some perspectives about possible vulnerability or trait markers of OCD. Further research is needed to examine the effects of long term treatment and other investigation might be helpful to assess the relationships between these behavioral and affective aspects and clinical phenotypes of OCD.