Real-Time Virtual Support as an Emergency Department Strategy for Rural, Remote, and Indigenous Communities in British Columbia: Descriptive Case Study.

BACKGROUND: British Columbia has over 200 rural, remote, and Indigenous communities that have limited health care resources due to physician isolation, sparsity in clinical resources, the lack of collegial support, and provider burnout. Real-time virtual support (RTVS) peer-to-peer pathways provide support to patients and providers. Amid the COVID-19 pandemic exacerbating existing health care disparities and equitable access to timely care, RTVS presents a portable and additional opportunity to be deployed in a hospital or patient home setting in rural communities. We highlight the story of the Rural Urgent Doctor in-aid (RUDi) pathway within RTVS that successfully supported the Dawson Creek District Hospital (DCDH) emergency department (ED) in 2021. OBJECTIVE: This study aims to describe the rapid implementation process and identify facilitators and barriers to successful implementation. METHODS: This case study is grounded in the Quadruple Aim and Social Accountability frameworks for health systems learning. The entire study period was approximately 6 months. After 1 week of implementation, we interviewed RUDi physicians, DCDH staff, health authority leadership, and RTVS staff to gather their experiences. Content analysis was used to identify themes that emerged from the interviews. RESULTS: RUDi physicians covered 39 overnight shifts and were the most responsible providers (MRPs) for 245 patients who presented to the DCDH ED. A total of 17 interviews with key informants revealed important themes related to leadership and relationships as facilitators of the coverage's success, the experience of remote physician support, providing a "safety net," finding new ways of interprofessional collaboration, and the need for extensive IT support throughout. Quality improvement findings identified barriers and demonstrated tangible recommendations for how this model of support can be improved in future cases. CONCLUSIONS: By acting as the MRP during overnight ED shifts, RUDi prevented the closure of the DCDH ED and the diversion of patients to another rural hospital. Rapid codevelopment and implementation of digital health solutions can be leveraged with existing partnerships and mutual trust between RTVS and rural EDs to ease the pressures of a physician shortage, particularly during COVID-19. By establishing new and modified clinical workflows, RTVS provides a safety net for rural patients and providers challenged by burnout. This case study provides learnings to be implemented to serve future rural, remote, and Indigenous communities in crisis.

Concordance between 8-1-1 HealthLink BC Emergency iDoctor-in-assistance (HEiDi) virtual physician advice and subsequent health service utilization for callers to a nurse-managed provincial health information telephone service.

BACKGROUND: British Columbia 8-1-1 callers who are advised by a nurse to seek urgent medical care can be referred to virtual physicians (VPs) for supplemental assessment and advice. Prior research indicates callers' subsequent health service use may diverge from VP advice. We sought to 1) estimate concordance between VP advice and subsequent health service use, and 2) identify factors associated with concordance to understand potential drivers of discordant cases. METHODS: We linked relevant provincial administrative databases to obtain inpatient, outpatient, and emergency service use by callers. We developed operational definitions of concordance collaboratively with researcher, patient, VP, and management perspectives. We used Kaplan-Meier curves to describe health service use post-VP consultation and Cox regression to estimate the association of caller factors (rurality, demography, attachment to primary care) and call factors (reason, triage level, time of day) with concordance as hazard ratios. RESULTS: We analyzed 17,188 calls from November 16, 2020 to April 30, 2021. Callers advised to attend an emergency department (ED) immediately were the most concordant (73%) while concordance was lowest for those advised to seek Family Physician (FP) care either immediately (41%) or within 7 days (47%). Callers unattached to FPs were less likely to schedule an FP visit (hazard ratio = 0.76 [95%CI: 0.68-0.85]). Rural callers were less likely to attend an ED within 48 h when advised to go immediately (0.53 [95%CI:0.46-0.61]) compared to urban callers. Rural callers advised to see an FP, either immediately (1.28 [95%CI:1.01-1.62]) or within 7 days (1.23 [95%CI: 1.11-1.37]), were more likely to do so than urban callers. INTERPRETATION: Concordance between VP advice and subsequent caller health service use varies substantially by category of advice and caller rurality. Concordance with advice to "Go to ED" is high overall but to access primary care is below 50%, suggesting potential issues with timely access to FP care. Future research from a patient/caller centered perspective may reveal additional barriers and facilitators to concordance.

Real-time virtual supports improving health equity and access in British Columbia.

In British Columbia (BC) and across the territories of over 200 First Nations and 39 Métis Nation Chartered communities, the COVID-19 pandemic catalyzed a group of partner organizations to rapidly establish seven virtual care pathways under the Real-Time Virtual Support (RTVS) network. They aimed to address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities, and provide pan-provincial services. Mixed-method evaluation assessed implementation, patient and provider experience, quality improvement, cultural safety, and sustainability. Pathways supported 38,905 patient encounters and offered 29,544 hours of peer-to-peer support from April 2020 to March 2021. Mean monthly encounter growth was 178.0% (standard deviation = 252.1%). Ninety percent of patients were satisfied with the care experience; 94% of providers enjoyed delivering virtual care. Consistent growth suggests that the virtual pathways met the needs of providers and patients in rural, remote, and Indigenous communities, and supported virtual access to care in BC.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Barriers and Facilitators to Accessing Digital Health Tools Faced by South Asian Canadians in Surrey, British Columbia: Community-Based Participatory Action Exploration Using Photovoice.

BACKGROUND: South Asian community members in Canada experience a higher burden of chronic disease than the general population. Digital health innovations provide a significant opportunity to address various health care challenges such as supporting patients in their disease self-management. However, South Asian community members are less likely to use digital tools for their health and face significant barriers in accessing them because of language or cultural factors. OBJECTIVE: The aim of this study is to understand the barriers to and facilitators of digital health tool uptake experienced by South Asian community members residing in Canada. METHODS: This study used a qualitative community-based participatory action research approach. Residents from Surrey, British Columbia, Canada, who spoke 1 of 4 South Asian languages (Hindi, Punjabi, Urdu, or Tamil) were invited to participate in focus group discussions. A subsample of the participants were invited to use photovoice methods in greater depth to explore the research topics. RESULTS: A total of 197 participants consented to the focus group discussions, with 12 (6.1%) participating in the photovoice phase. The findings revealed several key obstacles (older age, lack of education, and poor digital health literacy) and facilitators (social support from family or community members and positive attitudes toward technology) to using digital health tools. CONCLUSIONS: The results support the value of using a community-based participatory action research approach and photovoice methods to engage the South Asian community in Canada to better understand digital health competencies and needs. There were several important implications for policy makers and future research, such as continued engagement of community leaders by health care providers and administrators to learn about attitudes and preferences.

Integration of virtual physician visits into a provincial 8-1-1 health information telephone service during the COVID-19 pandemic: a descriptive study of HealthLink BC Emergency iDoctor-in-assistance (HEiDi).

BACKGROUND: British Columbia, like many jurisdictions, has a health information telephone service (8-1-1) to provide callers with information by registered nurses and help them decide whether to attend an emergency department or primary care clinic, or manage their concern at home. We describe a new service, HealthLink BC Emergency iDoctor-in-assistance (HEiDi), that partnered physicians available by videoconferencing with 8-1-1 registered nurses to support callers. METHODS: From Apr. 6 to Aug. 2, 2020, all callers to the 8-1-1 telephone service (available to anyone in BC) categorized as "seek care within 24 hours" by registered nurses were eligible for referral to HEiDi. HEiDi physicians ("virtual physicians") connected directly with callers via desktop videoconferencing software, assessed their health complaint, provided advice and suggested care disposition. We conducted a descriptive study and collected demographic characteristics, health concern and disposition determined by the virtual physician. RESULTS: HEiDi virtual physicians provided 7687 consultations. Most patients (n = 4439, 57.8%) were in the 20-64 age range, and 4814 (62.9%) were female. Common health concerns were related to gastroenterology (n = 1275, 16.6%), respiratory (n = 877, 11.4%) and dermatology (n = 874, 11.4%). From the 7531 calls with available data, 2548 (33.8%) callers were advised to attempt home treatment, 2885 (38.3%) to contact a primary care physician within 1 week, 1131 (15.0%) to attend an emergency department immediately and 538 (7.1%) to attend their primary provider now. INTERPRETATION: We found that virtual physicians were able to advise nearly 3 out of 4 (72.1%) patients away from in-person emergency or clinic assessment and 1 in 7 (15.0%) to seek immediate emergency department care. Virtual physicians can provide an effective complement to a provincial health telephone system.

Testing a school-based program to promote digital health literacy and healthy lifestyle behaviours in intermediate elementary students: The Learning for Life program.

Promoting digital health literacy and healthy lifestyle behaviours in children can lead to positive long-term health outcomes and prevent chronic diseases. However, there are few school-based interventions promoting this education to intermediate elementary students. The objective of this study was to test the effectiveness of a novel intervention to increase students' digital health literacy and health knowledge. Learning for Life is a classroom-based education program, developed for grade 4-7 students and delivered by teachers over six weeks. Three Canadian schools were recruited to deliver the intervention in 2018. This study had a pre-post design and no control group. Students' self-reported digital health literacy and healthy lifestyle behaviours were measured at pre-intervention (n = 126), post-intervention (n = 119), and two-month follow-up (n = 104). Students at pre-intervention had a mean (SD) age of 10.98 (0.56) years (57.1% females). Almost all (97%) students had unsupervised access to the Internet through a computer or smartphone. From pre- to post-intervention, students' digital health literacy increased (p = 0.009), but decreased from post-intervention to follow-up (p < 0.001). Post-intervention, the majority of students could identify at least one healthy behaviour (e.g., exercising one hour/day) and reported making at least one healthy change in their lives (e.g., eating more fruits/vegetables). This study demonstrated that the Learning for Life intervention can improve intermediate elementary students' digital health literacy over the short-term and help them learn and retain healthy lifestyle knowledge and behaviours. These findings affirm the need for interventions promoting digital healthy literacy and healthy lifestyle behaviours for this age group.

A Wearable Technology Delivering a Web-Based Diabetes Prevention Program to People at High Risk of Type 2 Diabetes: Randomized Controlled Trial.

BACKGROUND: Intensive lifestyle interventions are effective in reducing the risk of type 2 diabetes, but the implementation of learnings from landmark studies is expensive and time consuming. The availability of digital lifestyle interventions is increasing, but evidence of their effectiveness is limited. OBJECTIVE: This randomized controlled trial (RCT) aimed to test the feasibility of a web-based diabetes prevention program (DPP) with step-dependent feedback messages versus a standard web-based DPP in people with prediabetes. METHODS: We employed a two-arm, parallel, single-blind RCT for people at high risk of developing diabetes. Patients with a hemoglobin A1c (HbA1c) level of 39-47 mmol/mol were recruited from 21 general practices in London. The intervention integrated a smartphone app delivering a web-based DPP course with SMS texts incorporating motivational interviewing techniques and step-dependent feedback messages delivered via a wearable device over 12 months. The control group received the wearable technology and access to the web-based DDP but not the SMS texts. As this was a feasibility study, the primary aim was to estimate potential sample size at different stages of the study, including the size of the target study population and the proportion of participants who consented, were randomized, and completed follow-up. We also measured the main outcomes for a full-scale RCT, namely, change in weight and physical activity at 6- and 12-month follow-ups, and secondary outcomes, including changes in the HbA1c level, blood pressure, waist circumference, waist-to-hip ratio, and lipid levels. RESULTS: We enrolled 200 participants: 98 were randomized to the intervention and 102 were randomized to the control group. The follow-up rate was higher in the control group (87/102, 85.3%) than in the intervention group (69/98, 70%) at 12 months. There was no treatment effect on weight at 6 months (mean difference 0.15; 95% CI -0.93 to 1.23) or 12 months (mean difference 0.07 kg; 95% CI -1.29 to 1.44) or for physical activity levels at 6 months (mean difference -382.90 steps; 95% CI -860.65 to 94.85) or 12 months (mean difference 92.64 steps; 95% CI -380.92 to 566.20). We did not observe a treatment effect on the secondary outcomes measured at the 6-month or 12-month follow-up. For the intervention group, the mean weight was 92.33 (SD 15.67) kg at baseline, 91.34 (SD 16.04) kg at 6 months, and 89.41 (SD 14.93) kg at 12 months. For the control group, the mean weight was 92.59 (SD 17.43) kg at baseline, 91.71 (SD 16.48) kg at 6 months, and 91.10 (SD 15.82) kg at 12 months. In the intervention group, the mean physical activity was 7308.40 (SD 4911.93) steps at baseline, 5008.76 (SD 2733.22) steps at 6 months, and 4814.66 (SD 3419.65) steps at 12 months. In the control group, the mean physical activity was 7599.28 (SD 3881.04) steps at baseline, 6148.83 (SD 3433.77) steps at 6 months, and 5006.30 (SD 3681.1) steps at 12 months. CONCLUSIONS: This study demonstrates that it is feasible to successfully recruit and retain patients in an RCT of a web-based DPP. TRIAL REGISTRATION: ClinicalTrials.gov NCT02919397; http://clinicaltrials.gov/ct2/show/NCT02919397.

Reducing weight and increasing physical activity in people at high risk of cardiovascular disease: a randomised controlled trial comparing the effectiveness of enhanced motivational interviewing intervention with usual care.

OBJECTIVE: The epidemic of obesity is contributing to the increasing prevalence of people at high risk of cardiovascular disease (CVD), negating the medical advances in reducing CVD mortality. We compared the clinical and cost-effectiveness of an intensive lifestyle intervention consisting of enhanced motivational interviewing in reducing weight and increasing physical activity for patients at high risk of CVD. METHODS: A three-arm, single-blind, parallel-group randomised controlled trial was conducted in consenting primary care centres in south London. We recruited patients aged 40-74 years with a QRisk2 score ≥20.0%, which indicates the probability of having a CVD event in the next 10 years. The intervention was enhanced motivational interviewing which included additional behaviour change techniques and was delivered by health trainers in 10 sessions over 1 year, in either group (n=697) or individual (n=523) format. The third arm received usual care (UC; n=522). The primary outcomes were physical activity (mean steps/day) and weight (kg). Secondary outcomes were changes in low-density lipoprotein cholesterol and CVD risk score. We estimated the relative cost-effectiveness of each intervention. RESULTS: At 24 months, the group and individual interventions were not more effective than UC in increasing physical activity (mean difference=70.05 steps, 95% CI -288.00 to 147.90 and mean difference=7.24 steps, 95% CI -224.01 to 238.50, respectively), reducing weight (mean difference=-0.03 kg, 95% CI -0.49 to 0.44 and mean difference=-0.42 kg, 95% CI -0.93 to 0.09, respectively) or improving any secondary outcomes. The group and individual interventions were not cost-effective at conventional thresholds. CONCLUSIONS: Enhancing motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in those at high CVD risk.

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT.

BACKGROUND: Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor. OBJECTIVES: The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested. DESIGN: This was a three-arm, single-blind, parallel randomised controlled trial. SETTING: A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited. PARTICIPANTS: A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised. INTERVENTIONS: The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC. RANDOMISATION: Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation. MAIN OUTCOME MEASURES: The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. RESULTS: The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective. CONCLUSIONS: Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84864870. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.

People who have a high risk of heart disease can reduce this risk by changing their lifestyles, such as by improving their diets and increasing their physical activity levels. However, there is no good evidence on how best to support people to change and then maintain healthier lifestyles. It is thought that support from others might be helpful. An intervention based on two talking therapies, called motivational interviewing and cognitive­behavioural therapy, to help people make a commitment to living healthier lives was developed. People from the local community with a health-related background were recruited and trained in these skills. Then general practitioners invited patients on their register who were at high risk of heart disease to participate. Those patients who replied and met the study criteria were randomly allocated to one of three arms. Participants received either group- or individual-based intensive lifestyle sessions or usual care. Those who were randomised to the lifestyle course were offered 10 sessions of therapy over 12 months by lifestyle trainers. Two years later, it was found that there were no differences in weight or physical activity levels between the three arms. The lifestyle interventions were not cost-effective compared with usual care. When the possible explanations were studied, it was found that those who could have benefited the most from the therapy (such as those who were most overweight, those from poorer backgrounds and those who were of African Caribbean ethnicity) were less likely to participate. Whether or not the skills of the therapists made a difference could not be properly assessed. Sometimes, patients and their doctors were not sure why they were invited. Future research should focus on people who have lifestyles that can be changed (e.g. more overweight individuals with unhealthy diets), on finding ways of improving the quality of the intervention and on ensuring that patients have more information.

Diabetes and TelecommunicationS (DATES) study to support self-management for people with type 2 diabetes: a randomized controlled trial.

BACKGROUND: The increasing prevalence of type 2 diabetes and suboptimal glycaemic control in Kuwait requires novel, wide-reaching, low-cost interventions to motivate and mobilise individuals towards more effective self-management. More than 2 million people in Kuwait own mobile phones. We will test whether automated personalised health text messages based on principles of motivational interviewing and are responsive to biodata delivered remotely is potentially effective in improving glycaemic control compared to usual care. METHODS: This is a two-arm parallel single-blind randomised controlled trial of 572 individuals with type 2 diabetes in Kuwait. We will develop a culturally appropriate database of text messages supporting positive lifestyle changes in type 2 diabetes. A computer programme will deliver over 400 text messages over a 12-month period using algorithms which provide participants with information on diet and physical activity as well as personalised messages regarding motivators to change behaviours. Individuals aged 18-75 years with established type 2 diabetes who are fluent in Arabic or English and officially resident in Kuwait will be identified via screening of hospital diabetes clinic and primary care practices and invited to participate. A sample of 572 participants will be randomised to usual care or usual care plus the DATES text message intervention. Randomisation will be conducted by an independent Clinical Trials Unit and researchers collecting baseline and outcome data will be blinded to treatment allocation. The primary outcome is change in HbA1c and weight at 12 months in both study arms. Secondary outcomes will include changes in physical activity, fasting lipids and quality of life in both study arms. DISCUSSION: The potential of mobile phones in improving diabetes self-care in settings with a high prevalence of diabetes and widespread mobile phone usage has face validity. Mobile phones and text messaging are an understudied virtual communication media which can deliver discrete focused psychological support to motivate and enable diabetes self-care changes. TRIAL REGISTRATION: ISRCTN10342151 . 11/03/2015.

Parent and Child ADHD Symptoms in Relation to Parental Attitudes and Parenting: Testing the Similarity-Fit Hypothesis.

OBJECTIVE: We tested the similarity-fit hypothesis that predicts more positive parenting when both parent and child have high levels of ADHD symptoms compared to when only one does. METHOD: Mothers and fathers of 156, 5 to 13 year old sons participated (110 boys with ADHD, 46 without). Parent inattentive and hyperactive-impulsive symptoms were examined, in interaction with child ADHD, as predictors of parental tolerance, empathy, encouragement of child autonomy, and positive parenting. RESULTS: Several interactions of parent ADHD symptoms and child ADHD were detected which suggested that for parents with low levels of symptoms, the presence of child ADHD was associated with less positive parenting attitudes and behavior, but this negative relation between positive parenting and child ADHD was dampened among parents with more ADHD symptoms. CONCLUSIONS: Considered alongside the well documented parenting difficulties associated with parental ADHD, our findings suggest that parental ADHD symptoms also may help to mitigate some of the challenges facing families of children with ADHD.

Attention-Deficit/Hyperactivity Disorder Symptoms in Mothers and Fathers: Family Level Interactions in Relation to Parenting.

Previous studies linking parent ADHD symptoms to parenting have typically focused on each parent individually. To provide a broader understanding of family context, in this study, levels of inattention and hyperactivity-impulsivity in mothers and fathers were examined, both individually and in combination, in relation to negative parenting and child-rearing disagreements. Two-parent families of 5 to 13 year old boys (126 with ADHD and 53 typically developing) participated. Parents reported their own ADHD symptoms and their perceptions of child-rearing disagreements. Parenting was measured using self-, partner-, and child-reports as well as observations. Controlling for child ADHD symptoms, inattention symptoms in fathers predicted parenting difficulties. For mothers, inattention symptoms were linked to parenting problems only when fathers also had high levels of inattention. In contrast, parenting was most problematic for both mothers and fathers in families in which fathers had higher and mothers had lower levels hyperactivity-impulsivity symptoms. These results remained essentially unchanged when child externalizing behavior and mother depression and hostility were controlled, but father depression reduced the significance of some interactions. The results highlight the importance of the match between father and mother levels of symptoms, and point to differential relations of parenting to inattention and hyperactivity-impulsivity symptoms in parents.

The effect of remission status on work functioning in employed patients treated for major depressive disorder.

BACKGROUND: The ability to function at work is impaired in patients with major depressive disorder (MDD) but few clinical trials include occupational outcome assessments. This study examined whether symptom remission following treatment for MDD is associated with work functioning improvement. METHODS: We conducted a secondary analysis of a 12-week randomized clinical trial comparing escitalopram with or without telephone-administered cognitive therapy in employed patients with MDD (N = 86). Outcomes included the Montgomery-Åsberg Depression Rating Scale (MADRS) and validated, self-rated work functioning scales including the Lam Employment Absence and Productivity Scale (LEAPS), Work Performance Questionnaire (HPQ), and Sheehan Disability Scale (SDS). Remission was defined as MADRS score ≤10 at 12 weeks. Data were evaluated using analysis of covariance with baseline score as covariates. RESULTS: Remission status was associated with significant improvement in work performance as assessed by the LEAPS productivity subscale, HPQ overall performance, and the SDS work/school item; a trend (P = .08) was observed with the HPQ productivity subscale. The effect sizes (d = 0.23, 0.51, 0.36, and 0.43, respectively) indicate small to medium effects that are likely clinically significant. CONCLUSIONS: The results of our study confirm that symptom remission following treatment is associated significantly with improvement in work performance and productivity, as measured by validated work functioning scales. Measurement-based care for MDD should include both symptom and functional outcome assessments.

The effects of desvenlafaxine on neurocognitive and work functioning in employed outpatients with major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) is associated with staggering personal and economic costs, a major proportion of which stem from impaired psychosocial and occupational functioning. Few studies have examined the impact of depression-related cognitive dysfunction on work functioning. We examined the association between neurocognitive and work functioning in employed patients with MDD. METHODS: Employed adult outpatients (n=36) with MDD of at least moderate severity (≥23 on the Montgomery Asberg Depression Rating Scale, MADRS) and subjective cognitive complaints completed neurocognitive tests (CNS Vital Signs computerized battery) and validated self-reports of their work functioning (LEAPS, HPQ) before and after 8 weeks of open-label treatment with flexibly-dosed desvenlafaxine 50-100mg/day. Relationships between neurocognitive tests and functional measures were examined using bivariate correlational and multiple regression analyses, as appropriate. An ANCOVA model examined whether significant change in neurocognitive performance, defined as improvement of ≥1SD in the Neurocognition Index (NCI) from baseline to post-treatment, was associated with improved outcomes. RESULTS: Patients showed significant improvements in depressive symptom, neurocognitive, and work functioning measures following treatment with desvenlafaxine (e.g., MADRS response=77% and MADRS remission=49%). There were no significant correlations between changes in NCI or cognitive domain subscales and changes in MADRS, LEAPS, or HPQ scores. However, patients demonstrating significant improvement in NCI scores (n=11, 29%) had significantly greater improvement in clinical and work functioning outcomes compared to those without NCI improvement. LIMITATIONS: The limitations of this study include small sample size, lack of a placebo control group, and lack of a healthy comparison group. Our sample also had more years of education and higher premorbid intelligence than the general population. CONCLUSIONS: There were no significant correlations between changes in neurocognitive and work functioning measures in this study. However, meaningful improvement in neurocognitive functioning with desvenlafaxine was associated with greater improvement in both mood and occupational outcomes. This suggests that addressing cognitive dysfunction may improve clinical and occupational outcomes in employed patients with MDD. However, the relationship between neurocognitive and work functioning in MDD is complex and requires further study.

The relationship between burnout and depressive symptoms in patients with depressive disorders.

BACKGROUND: Burnout - physical or psychological fatigue in the personal, work and client-related work domains - appears to share numerous overlapping characteristics with major depressive episodes. However, whether burnout and depression are in fact separate conditions is still ambiguous. Our aim was to examine burnout in a clinically depressed patient sample. METHODS: Outpatients with a DSM-IV depressive episode (major depressive episode and dysthymic disorder) completed the Copenhagen Burnout Inventory (CBI) and the Quick Inventory for Depressive Symptomatology, Self-Rated (QIDS-SR). The relationship between CBI-defined burnout and depressive symptoms was examined using correlation and hierarchical multiple regression analyses. RESULTS: Depressed patients had high rates of CBI-defined burnout as well as significant correlations between burnout scores and overall depression severity scores. Individual depressive symptoms were significantly higher between patients with and without burnout, and significantly correlated with burnout scores, with the exception of guilt/worthlessness. Multiple regression analysis identified changes in sleep and fatigue as significant predictors of burnout. LIMITATIONS: The main limitations of the study were the sample size, the broad definition of depression, and the cross-sectional design. CONCLUSIONS: The high burnout scores and correlations between burnout and depression severity observed in this study highlight the importance of understanding burnout in depressed patients. Despite the significant overlap between burnout and depression, the relationship between these two concepts still requires further clarification.