Telephone interpersonal counseling treatment for frequent attenders to primary care: Development and piloting.

BACKGROUND: Frequent attenders in primary care (FAs) consume a disproportionate amount of healthcare resources and often have depression, anxiety, chronic health issues, and interpersonal problems. Despite extensive medical care, they remain dissatisfied with the care and report no improvement in quality of life. OBJECTIVE: To pilot a Telephone-based Interpersonal Counseling intervention for Frequent Attenders (TIPC-FA) and assess its feasibility and efficacy in reducing symptoms and healthcare utilization. METHOD: Top 10% of primary care visitors were randomly assigned to TIPC-FA, Telephone Supportive Contact (Support), or Treatment as Usual (TAU). TIPC-FA and Support groups received six telephone sessions over twelve weeks, while the TAU group was interviewed twice. Multilevel regression tested for changes over time, considering patient and counselor variance. RESULTS: TIPC-FA and Support groups demonstrated reduced depressive symptoms, and the TIPC-FA group showed decreased somatization and anxiety. The TIPC-FA group demonstrated a trend towards less healthcare utilization than the TAU group. CONCLUSION: This pilot study suggests that IPC via telephone outreach is a feasible approach to treating FAs, achieving a reduction in symptoms not seen in other groups. Promising reduction in healthcare utilization in the TIPC-FA group warrants further exploration in larger-scale trials.

Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study.

BACKGROUND: Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT). OBJECTIVE: The aim of this study was to examine whether (1) the training protocol would increase clinicians' knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings. METHODS: A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time. RESULTS: Trainees' knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied). CONCLUSIONS: Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation.

A 10-year prospective study of respiratory disease and depression and anxiety in adulthood.

BACKGROUND: Several cross-sectional studies have found an association between respiratory disease and increased mood or anxiety disorders among adults. Little is known about the nature of these associations over time or the role of potential confounders in these links. OBJECTIVES: To investigate the association between respiratory disease and incident and persistent depression or anxiety disorders 10 years later and to examine potential pathways of these associations. METHODS: Data were drawn from the Midlife Development in the United States survey, a representative sample of adults in the United States ages 18 to 74 years. Participants (N = 2,101) were interviewed on a range of health domains at baseline at wave 1 (1994) and again at wave 2 (2005). RESULTS: Respiratory disease was associated with increased odds of depression and anxiety disorders cross-sectionally at both time points. Respiratory disease at wave 1 was not associated with incident depression or anxiety disorders at wave 2. Respiratory disease at wave 1 was associated with increased odds of persistent depression or anxiety disorders 10 years later among those with depression or anxiety disorders at wave 1. Associations were not explained by differences in demographic characteristics, secondhand smoke exposure, cigarette smoking, or history of exposure to childhood maltreatment. CONCLUSION: Findings shed new light on the association between respiratory disease and depression or anxiety disorders. Individuals with respiratory disease appear to have higher prevalence of concurrent depression or anxiety disorders and persistent depression or anxiety disorders compared with those without respiratory disease. However, a history of respiratory disease does not appear to confer increased risk of new onset of depression or anxiety disorders.

Anxiety disorders and risk of self-reported ulcer: a 10-year longitudinal study among US adults.

OBJECTIVE: Previous epidemiologic studies have documented a link between anxiety disorders and ulcer among adults. Few studies have examined these associations over time and little is understood about the pathways underlying these relationships. METHOD: Data were drawn from n = 2101 adult participants in the Midlife Development in the United States I and II. Data on ulcer diagnoses were collected through self-report: among participants in the current sample, 38 reported ulcer at Waves 1 and 2 (prevalent ulcer), and 18 reported ulcer at Wave 2 but not at Wave 1 (incident ulcer). Panic attacks and generalized anxiety disorder at Wave 1 (1994) were examined in relation to prevalent (past 12 months) and incident ulcer approximately 10 years later at Wave 2 (2005). RESULTS: Anxiety disorders at Wave 1 were associated with increased prevalence of ulcer [odds ratio (OR) = 4.1, 95% confidence interval (CI) = 2.0-8.4], increased risk of incident ulcer at Wave 2 (OR = 4.1, 95% CI = 1.4-11.7) and increased risk of treated ulcer at Wave 2 (OR = 4.7, 95% CI = 2.3-9.9) compared with those without anxiety. CONCLUSIONS: In this large population sample of adults, anxiety disorders were associated with an increased risk of ulcer over a 10-year period. These relationships do not appear to be explained by confounding or mediation by a wide range of factors. Future studies should address potential mechanisms underlying the relationship between anxiety and ulcer.

Does parental response to children's pain moderate the association between pain severity and functional disability? An examination of noncardiac chest pain.

OBJECTIVE: We sought to examine whether parental responses to children's noncardiac chest pain moderate the relationship between child's pain severity and functional disability. METHODS: 77 children (ages 8-18 years) with noncardiac chest pain and their parents were recruited from pediatric cardiology clinics in Israel. Children completed measures assessing pain (intensity/frequency) and functioning. Parents and children completed measures assessing parental responses to children's pain. RESULTS: Parental protective responses (parent and child report) moderated the relationship between child's pain intensity and frequency and functional disability. Parental encouraging/monitoring responses (child report only) moderated the relationship between child's pain intensity and functional disability. As expected, the association between pain and disability was greater for children and adolescents whose parents were higher in these behaviors. CONCLUSIONS: Parental protective and encouraging/monitoring behavior may exacerbate the impact of pain on functioning. Interventions that promote more adaptive responses to children's pain may help reduce disability in youth with pain.

Mechanisms of change in interpersonal therapy (IPT).

Although interpersonal therapy (IPT) has demonstrated efficacy for mood and other disorders, little is known about how IPT works. We present interpersonal change mechanisms that we hypothesize account for symptom change in IPT. Integrating relational theory and insights based on research findings regarding stress, social support, and illness, IPT highlights contextual factors thought to precipitate and maintain psychiatric disorders. It frames therapy around a central interpersonal problem in the patient's life, a current crisis or relational predicament that is disrupting social support and increasing interpersonal stress. By mobilizing and working collaboratively with the patient to resolve this problem, IPT seeks to activate several interpersonal change mechanisms. These include: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills. We hope that articulating these mechanisms will help therapists to formulate cases and better maintain focus within an IPT framework. Here we propose interpersonal mechanisms that might explain how IPT's interpersonal focus leads to symptom change. Future work needs to specify and test candidate mediators in clinical trials. We anticipate that pursuing this more systematic strategy will lead to important refinements and improvements in IPT and enhance its application in a range of clinical populations.

Panic disorder in children and adolescents with noncardiac chest pain.

Adults with panic disorder (PD) often present to medical settings with noncardiac chest pain (NCCP), but less is known about children and adolescents with this complaint. We sought to characterize PD in youth with NCCP and compare features with PD in youth in psychiatric outpatient settings. Using a semi-structured diagnostic interview we evaluated 132 youth (ages 8-17) with NCCP recruited from two medical settings. Twenty-seven (20.5 %) met full DSM-IV criteria for PD, eleven of which were children (<13 years). Most frequent panic symptoms were somatic complaints, although cognitive symptoms were also common. Only 14.8 % had clinically significant agoraphobia. Comorbid anxiety disorders and major depression were common. Overall, clinical features of PD among youth with NCCP are similar to PD in psychiatric settings. Interventions for PD may benefit youth who present initially with NCCP. Systematic psychiatric screening could increase detection of PD and improve care for this population.

Do mindfulness-based interventions reduce pain intensity? A critical review of the literature.

BACKGROUND: Mindfulness-based interventions (MBIs) emphasizing a nonjudgmental attitude toward present moment experience are widely used for chronic pain patients. Although changing or controlling pain is not an explicit aim of MBIs, recent experimental studies suggest that mindfulness practice may lead to changes in pain tolerance and pain intensity ratings. OBJECTIVE: The objective of this review is to investigate the specific effect of MBIs on pain intensity. METHODS: A literature search was conducted using the databases PUBMED and PsycINFO for relevant articles published from 1960 to December 2010. We additionally conducted a manual search of references from the retrieved articles. Only studies providing detailed results on change in pain intensity ratings were included. RESULTS: Sixteen studies were included in this review (eight uncontrolled and eight controlled trials). In most studies (10 of 16), there was significantly decreased pain intensity in the MBI group. Findings were more consistently positive for samples limited to clinical pain (9 of 11). In addition, most controlled trials (6 of 8) reveal higher reductions in pain intensity for MBIs compared with control groups. Results from follow-up assessments reveal that reductions in pain intensity were generally well maintained. CONCLUSIONS: Findings suggest that MBIs decrease the intensity of pain for chronic pain patients. We discuss implications for understanding mechanisms of change in MBIs.

Haven't we met somewhere before? The effects of a brief Internet introduction on social anxiety in a subsequent face to face interaction.

Social anxiety occurs in a range of social situations, the salience of which is influenced by prevailing modes of social contact. The emergence of computer mediated communication (CMC), buoyed by the recent explosion of social networks, has changed the way many people make and maintain social contacts. We randomly assigned 30 socially anxious and 30 low social anxiety participants to a brief internet chat introduction or a control internet surfing condition followed by a standardized face to face (FTF) interaction. We hypothesized that for socially anxious participants the chat introduction would reduce anxiety of and preference to avoid the subsequent FTF interaction. Results supported hypotheses for most indices. Findings suggest that, at least for the common situation in which internet chat precedes FTF interaction with the same person, such contact may reduce social anxiety. It is not known whether this decrease would generalize to FTF contact in other contexts. It is suggested that CMC might be construed as a particularly useful form of safety behavior that may help in the allocation of attentional resources to process new information relevant for disconfirmation of negative beliefs maintaining social anxiety. Potential clinical implications are discussed.

Therapist adherence to interpersonal vs. supportive therapy for social anxiety disorder.

We assessed therapist adherence to interpersonal therapy (IPT) and supportive therapy (ST) in a controlled trial for social anxiety disorder. Raters blindly scored n = 133 videotapes from 53 participants using the Collaborative Study Psychotherapy Rating Scale (CSPRS). Results reveal statistical differences across groups, but higher than expected overlap. Greater use of IPT in beginning sessions predicted better outcome in both therapies. Suboptimal adherence may be due to the crossed design in which the same therapists delivered both IPT and ST. Since switching between different approaches is a clinical reality for integrative psychotherapists, these findings may have important clinical implications.

Psychiatric disorders in youth with medically unexplained chest pain versus innocent heart murmur.

OBJECTIVE: To examine the prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders in youth with chest pain compared with a control sample with innocent heart murmur. STUDY DESIGN: We assessed youth ages 8 to 17 years who were examined in cardiology settings for medically unexplained chest pain (n=100) or innocent heart murmur (n=80). We conducted semi-structured interviews and assessed medical history, quality of life, and disability. RESULTS: Youth with chest pain had a higher prevalence of psychiatric disorders compared with youth with murmur (74% versus 47%, χ(2)=13.3; P<.001). Anxiety disorders predominated, although major depression was also more common in the chest pain group (9% versus 0%; Fisher exact tests; P<.01). Onset of psychiatric disorders generally preceded chest pain. Patterns were similar for boys and girls and for children and adolescents. Chest pain was associated with poorer quality of life and with pain-related disability for youth with co-morbid psychiatric disorder. CONCLUSIONS: In childhood and adolescence, medically unexplained chest pain is associated with a high prevalence of psychiatric disorders. Systematic mental health screening may improve detection and enhance treatment of these patients.

Depressive symptoms, risk factors and sleep in asthma: results from a national Israeli health survey.

OBJECTIVE: The objective was to assess the association between asthma and depressive symptoms (DS) and to evaluate the relationship between DS and risk factors [smoking, physical inactivity, body mass index (BMI) and sleep duration] in asthmatic individuals. METHODS: We analyzed data from the Israeli National Health Interview Survey, conducted among 9509 participants aged ≥21 years in 2003-2004. Data on sociodemographic factors, chronic respiratory disorders, DS and risk factors were obtained through telephone interviews. DS were measured using Short Form 36 mental health items. Analyses were performed using multivariate logistic regression models. RESULTS: A total of 393 participants (4.2%) reported chronic asthma in the 12 months previous to the interview. Of those, 37.4% had DS, compared with 21.8% of nonasthmatic participants [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.47-2.30; P<.001]. DS in asthmatic individuals were significantly associated with physical inactivity [adjusted OR (AOR), 2.01; 95% CI, 1.12-3.61; P=.02], with smoking (AOR 1.80; 95% CI, 1.04-3.12; P=.04) and with less sleep (AOR, 1.81; 95% CI, 1.03-3.19; P=.04). DS in asthmatic participants were not associated with BMI. CONCLUSIONS: DS are common in asthmatic individuals and are significantly associated with physical inactivity, with smoking and with less hours of sleep. Such health-related risk factors may impact on the course of asthma and on overall health.

[Chronic asthma, depressive symptoms and risk behaviors: results from a national health survey].

BACKGROUND: Previous research suggests that depression is common in individuals with asthma. Research on the association between depressive symptoms and health-related risk behaviors in persons with respiratory disorders is scarce. OBJECTIVE: To assess the association between asthma and depressive symptoms; and to evaluate the relationship between depressive symptoms and risk behaviors (smoking, physical inactivity and obesity) in individuals with asthma. METHODS: We analyzed data from the Israeli National Health Interview Survey [INHIS-1), conducted on a large sample (N = 9,509) of the adult Israeli population (age > or = 21 years) in 2003-4. Data on socio-demographic factors, chronic respiratory conditions, depressive symptoms and risk behaviors were obtained through telephone interviews. Analyses were performed using adjusted Logistic regression models. RESULTS: A total of 381 participants (4.0%) reported chronic asthma in the year previous to the interview. Of those, 15.5% had moderate depressive symptoms compared with 7.2% of participants with no respiratory conditions (odds ratio, 1.95; 95% CI, 1.40-2.72; P < .0001). Depressive symptoms in individuals with asthma were significantly associated with smoking (adjusted odds ratio (AOR) 3.31; 95% CI, 1.58-6.91; P = .001 for moderate depressive symptoms; AOR 1.91; 95% CI, 1.05-3.45; P = .03 for mild depressive symptoms); moderate but not mild depressive symptoms were significantly associated with physical inactivity (AOR, 3.05; 95% CI, 1.52-6.12; P = .002). These associations were stronger in females. Depressive symptoms were not associated with obesity. CONCLUSIONS: Among Israelis with chronic asthma, depressive symptoms are associated with important differences in health behaviors (higher rates of smoking and lack of physical activity) which may impact on the course of respiratory illness and on overall health.

The challenge of estimating PTSD prevalence in the context of ongoing trauma: the example of Israel during the Second Intifada.

Many studies attempt to gauge population prevalence of post traumatic stress disorder (PTSD) following a major catastrophe. However, little is known about the validity of these estimates in the increasingly common situation of ongoing trauma. During the period of the Second Intifada in Israel, which involved frequent and widespread terrorist attacks, several studies generated estimates of PTSD prevalence in the Israeli population, but yielded widely discrepant findings. A number of focused surveys using symptom checklists estimated population prevalence of PTSD or probable PTSD diagnosis at about 9%. However a large population health study conducted during this same time period using a structured diagnostic interview yielded a very low estimated prevalence of PTSD (0.5%). We examine methodological differences that might account for these striking discrepancies. Inherent limitations of both checklist and structured interview methods may be especially problematic in the context of ongoing trauma. Findings regarding PTSD and associated factors obtained during ongoing trauma should be interpreted with caution.

Family history of alcohol use disorders among adults with panic disorder in the community.

OBJECTIVE: Clinical studies suggest a familial association between panic disorder and alcohol use disorders but this relationship has not been examined in a representative community sample. The objective of this study is to examine the familial association between panic disorder and alcohol use disorders among adults in the community. METHOD: Data were drawn from the NESARC, a nationally representative sample of over 43,000 adults in the United States. Rates of alcohol use disorders were examined using the family history method in first-degree relatives (FDRs) of adults with panic disorder. Analyses were adjusted for demographics, alcohol use disorders in the proband, and anxiety disorders in the FDRs. RESULTS: First-degree relatives of adults with panic disorder have significantly higher odds of alcohol use disorders, compared with FDRs of adults without panic disorder. These associations persist after adjusting for demographic characteristics, alcohol use disorders in the proband, and anxiety disorders in the FDR's. CONCLUSIONS: Consistent with findings from clinical studies, this is the first population-based study to show a familial link between panic disorder and alcohol use disorders. This association appears independent of the influence of comorbidity of alcohol use disorders and anxiety disorders, suggesting a potential familial and/or genetic pathway. Future longitudinal studies will be needed to further understand the mechanism of this observed association.

A psychological intervention for pediatric chest pain: development and open trial.

OBJECTIVE: Noncardiac chest pain (NCCP) is a common and persistent problem for children and adolescents; typically there is no clear medical cause. To date, no psychological intervention has been studied for chest pain in a pediatric sample. METHODS: (a) We developed a brief psychological treatment for chest pain and associated worry in children and adolescents with NCCP. This program includes psychoeducation, breathing retraining, cognitive coping strategies, and 1 session of parent education and coaching regarding the impact of reinforcement on pain and coping behaviors. (b) We treated 9 youngsters with chronic NCCP, assessing pain, somatization, disability, anxiety and depressive symptoms, and coping. Assessments were conducted before, after, and 6 months following treatment. RESULTS: After treatment, there was a significant decrease in chest pain and somatization. Benefits were maintained at 6-month follow-up. There was no decrease in associated psychological symptoms. CONCLUSIONS: A brief psychological treatment for pediatric NCCP is feasible to administer and may help alleviate symptoms of pediatric NCCP. Further study in a randomized trial is needed.

Chief complaints and diagnoses of displaced Israelis seeking medical treatment during the 2006 Israel-Lebanon War.

OBJECTIVE: To examine patterns of visits by residents of northern Israel displaced during the Israel-Lebanon War of 2006 to an urgent care system in central Israel and to compare these patterns with those of local patients. DESIGN: Retrospective analysis of electronic medical records. SETTING: Urgent care clinic system in and around Jerusalem, Israel. PARTICIPANTS: Patients residing in northern Israel who presented from July 12 to August 21, 2006. Local patients who presented during the same time period were used for comparison. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Chief complaints, discharge diagnoses, demographics, and visit characteristics. RESULTS: There were a total of 1,175 visits for 938 northern patients, reflecting 6.7 percent of total visits to this system. Overall age distribution of northerners was generally similar. As a proportion of visits, adult northerners were less likely to visit for chief complaints of injury or laceration and more likely to visit for complaint of back pain. They were more likely to have a discharge diagnosis of chest pain, anxiety, or hypertension. Northern children and adolescents were less likely to visit due to injury or fall or to have a discharge diagnosis of fracture. They were more likely to have a discharge diagnosis of gastroenteritis or tonsillitis. CONCLUSIONS: Patterns of common discharge diagnoses were generally similar between northern and local residents, with the exception of fewer injury-related visits and more anxiety-related visits. Urgent care appears to have served an important function for displaced individuals during this war, mostly for routine medical needs.

The relationship of chronic pain with and without comorbid psychiatric disorder to sleep disturbance and health care utilization: results from the Israel National Health Survey.

OBJECTIVE: Chronic pain is associated with health problems including sleep difficulties and increased medical utilization. Because chronic pain is frequently comorbid with psychiatric disorders, it is unclear to what degree chronic pain itself is associated with these problems. In a large population sample, we examined the relationship between chronic pain, both alone and comorbid with psychiatric disorders, with sleep disturbance and increased medical utilization. METHODS: We analyzed data from the Israel National Health Survey (INHS) conducted in 2003-2004 on a representative sample (N=4859) of the adult Israeli population. Data were collected in face-to-face interviews using the Composite International Diagnostic Interview. Statistical analyses were performed using multinomial logistic regression models. RESULTS: Past year chronic pain was reported by 29.9% of all study participants (n=1453). Psychiatric disorders were more common among participants with chronic pain; adjusted odds ratios were 2.23 (95% CI 1.49-3.36) for depressive disorders and 2.94 (95% CI 2.08-4.17) for anxiety disorders. Associations of chronic pain and psychiatric disorders were stronger in men. Chronic pain was associated with both sleep problems and increased health care utilization even for individuals with no psychiatric comorbidity. Sleep difficulties but not health care utilization rates were more pronounced in the comorbid group compared to the chronic pain only group. CONCLUSION: Chronic pain was associated with sleep problems and increased health care utilization in this sample, independent of psychiatric comorbidity. Sleep problems were significantly greater in the comorbid vs. non-comorbid group. In contrast, associations of pain with health care utilization were largely independent of psychiatric comorbidity.

Psychopathology and disability in children with unexplained chest pain presenting to the pediatric emergency department.

OBJECTIVE: Chest pain is a common presentation in the pediatric emergency department (PED). In the majority of cases, no clear medical cause is found. Among adults with noncardiac chest pain, psychopathology including panic disorder is common. We assessed the likelihood and type of psychopathology as well as the health status of children and adolescents with unexplained chest pain who presented to the PED. METHODS: We performed a semistructured diagnostic interview of children 8 to 17 years old who presented to an urban, tertiary-care PED with a primary complaint of chest pain for which no medical cause was found. We used Diagnostic Statistical Manual of Mental Disorders, Fourth Edition criteria to diagnose psychopathology. We also assessed pain severity, extent of other somatic complaints, quality of life, and functional disability using standard, validated instruments. RESULTS: We enrolled 32 children with a mean age of 12.8 (SD, 2.9) years (range, 8-17 years); 47% were female. Twenty-six (81%) were diagnosed with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition anxiety disorder; 9 (28%) had full-criteria panic disorder. Quality of life was compromised in multiple domains, and children reported a range of functional disabilities due to chest pain. Other somatic symptoms, including other pain complaints, were commonly reported in this sample. CONCLUSION: Unexplained chest pain in the PED is frequently associated with potentially treatable anxiety disorders. Emergency physicians should consider the possibility of anxiety disorders in patients with medically unexplained chest pain.