Designing High-Fidelity Mobile Health for Depression in Indonesian Adolescents Using Design Science Research: Mixed Method Approaches.

BACKGROUND: COVID-19 mitigation protocols, enacted to control the pandemic, have also been shown to have a negative impact on mental health, including the mental health of adolescents. The threat of being infected by SARS-CoV-2 and substantial changes in lifestyle, including limited social interaction due to stay-at-home orders, led to loneliness as well as depressive symptoms. However, offline psychological assistance is restricted, as psychologists are bounded by mitigation protocols. Further, not all adolescents' guardians are open to their children attending or have the means to pay for psychological service; thus, adolescents remain untreated. Having a mobile health (mHealth) app for mental health that uses monitoring, provides social networks, and delivers psychoeducation may provide a solution, especially in countries that have limited health facilities and mental health workers. OBJECTIVE: This study aimed to design an mHealth app to help prevent and monitor depression in adolescents. The design of this mHealth app was carried out as a high-fidelity prototype. METHODS: We used a design science research (DSR) methodology with 3 iterations and 8 golden rule guidelines. The first iteration used interviews, and the second and third iterations used mixed method approaches. The DSR stages include the following: (1) identify the problem; (2) define the solution; (3) define the solution objective; (4) develop, demonstrate, and evaluate the solution; and (5) communicate the solution. This study involved students and medical experts. RESULTS: The first iteration resulted in a wireframe and prototype for the next iteration. The second iteration resulted in a System Usability Scale score of 67.27, indicating a good fit. In the third iteration, the system usefulness, information quality, interface quality, and overall values were 2.416, 2.341, 2.597, and 2.261, respectively, indicating a good design. Key features of this mHealth app include a mood tracker, community, activity target, and meditation, and supporting features that complement the design include education articles and early detection features. CONCLUSIONS: Our findings provide guidance for health facilities and to design and implement future mHealth apps to help treat adolescent depression.

The effectiveness of self-empowerment-based patient-centered care for obese students in primary services: A randomized controlled trial.

BACKGROUND: Self-empowerment-based patient-centered services with a coaching approach are imperative in the management of students with obesity. This study evaluated the applicability and effectiveness of self-empowerment-based patient-centered coaching for the weight loss program model for obese students. MATERIALS AND METHODS: This randomized control trial recruited 60 obese students aged 17-22 years in Universitas Indonesia from August to December 2021. Intervention group subjects were coached by a health coach. Each health coach assisted four subjects with SMART model coaching in six meetings every 2 weeks through a zoom platform. Both groups had instructions on obesity, nutrition, and physical activity from specialist doctors online. Paired t-test or Mann-Whitney test, as appropriate, to compare the measurements of anthropometry, body composition (bioelectrical impedance analysis), food intake (food record form), physical activity (physical activity form), subjective well-being (subjective well-being questionnaire), and healthy behavior habits (satisfaction scale) between the two groups before and after the intervention. RESULTS: A total of 41 obese students completed the study, 23 from intervention group and 18 from the control group. The change in total body fat (-0.9 [-12.9, 0.70] vs. 0.0 [-6.9, 3.50], P = 0.02) and healthy behavior habit (13.5 ± 11.85 vs. 7.5 ± 8.08, P = 0.04) in the intervention group was significantly greater than in the control group. The change in satisfaction scale of hobby/passion (2 [-4.6] vs. 1 [-2.2], P = 0.02), movement exercise (2.3 ± 2.11 vs. 1.2 ± 1.93, P = 0.03), sleep rest (2 [-6.5] vs. 1 [-3.2], P = 0.01), and spiritual (1 [0.6] vs. 0 [-1.3], P = 0.00) was significantly higher in the coached group. CONCLUSION: A weight loss program for obese students was tested through self-empowerment-based patient-centered care with a coaching approach and has proven to effect changes in anthropometric indicators, body composition, self-empowerment, food intake, and physical activity.

Social curiosity as a way to overcome death anxiety: perspective of terror management theory.

Social curiosity has been found to have great benefits in human life, especially in fostering interpersonal relationships. Nevertheless there is indication of other benefit of social curiosity that have not yet been explored, namely overcoming the anxiety of death. This indication is based on previous research which found a positive relationship between anxiety and social curiosity. In this study, social curiosity is framed as representation of symbolic immortality, which people use to overcome the terror of death. To support this conjecture, two studies were conducted using the Terror Management Theory (TMT) framework. Study 1 (N = 352, M age = 19.39) found a positive relationship between death anxiety and social curiosity. In Study 2 (N = 507, M age = 20.68) it was found that intolerance of uncertainty and desire for self-verification mediated the relationship between death anxiety and social curiosity. The results of this study indicate that increasing interest in obtaining information about how other people think, feel, or act is a form of mechanism used by people to control anxiety related to death.

Does the Length of Disability between Injury and Functional Restoration Program Entry Affect Treatment Outcomes for Patients with Chronic Disabling Occupational Musculoskeletal Disorders?

Purpose Functional restoration programs (FRPs), for patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), have consistently demonstrated positive socioeconomic treatment outcomes, including decreased psychosocial distress and increased work return. The pre-treatment length of disability (LOD), or time between injury and treatment admission, has been shown to influence FRP work outcomes. Some studies have found that shorter LOD is associated with better work outcomes. However, few studies have actually examined cohorts with LOD duration longer than 18 months. This present study evaluated the effects of extended LOD (beyond 18 months) on important treatment outcomes. Methods A total cohort of 1413 CDOMD patients entered an FRP. Of those, 312 did not complete the program, so they were eliminated from outcome analyses. The 1101 patients who completed the FRP were classified based on LOD: Late Rehabilitation (LR, 3-6 months, n = 190); Chronic Disability (CD, 7-17 months, n = 494); and Late Chronic Disability (LCD). The LCD, in turn, consisted of four separate subgroups: 18-23 months (LCD-18, n = 110); 24-35 months (LCD-24, n = 123); 36-71 months (LCD-36, n = 74); and 72+ months (LCD-72, n = 110). Patients were evaluated upon admission and were reassessed at discharge. Those patients who chose to pursue work goals post-treatment (n = 912) were assessed 1-year later. Results Longer LOD was associated with less likelihood of completing the FRP (p < .001). Compared to the other LOD groups, a relatively large percentage of patients (47%) in the longest- disability group were receiving social security disability benefits. Associations were found between longer LOD and more severe patient-reported pain, disability, and depressive symptoms at treatment admission. At discharge, symptom severity decreased for these patient-reported variables in all LOD groups (p < .001). Using binary logistic regressions, it was found that LOD significantly predicted work-return (Wald = 11.672, p = .04) and work-retention (Wald = 11.811, p = .04) after controlling for covariates. Based on the LOD groups, the percentage of patients returning to, and retaining work, ranged from 75.6 to 94.1%, and from 66.7 to 86.3%, respectively. The odds of LCD-24 and LCD-72 patients returning to work were 2.9, and 7.4, respectfully, less likely, compared to LR patients. Furthermore, the odds of LCD-24 and LCD-72 patients retaining work were 3.3 and 3.8 times, respectively, less likely, compared to LR patients. Conclusions Long LOD was a risk factor for FRP non-completion, and was associated with more severe patient-reported variables, including pain intensity and perceived disability. Furthermore, long LOD was a significant predictor for work outcomes at 1 year following FRP discharge. Nevertheless, a large percentage of longer LOD (>24 months) patients had returned to work within the year after discharge (above 85%), and had retained at least part-time work 1-year later (above 66%). These results support the effectiveness of the FRP in mitigating the effects of extended LOD in a large percentage of long-term LOD patients.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population.

OBJECTIVES: To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure. MATERIALS AND METHODS: In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later. RESULTS: Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution. DISCUSSION: Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

The Potential Utility of the Patient Health Questionnaire as a Screener for Psychiatric Comorbidity in a Chronic Disabling Occupational Musculoskeletal Disorder Population.

OBJECTIVES: The patient health questionnaire (PHQ) is designed for screening psychopathology in primary care settings. However, little is known about its clinical utility in other chronic pain populations, which usually have high psychiatric comorbidities. DESIGN: A consecutive cohort of 546 patients with chronic disabling occupational musculoskeletal disorder (CDOMD) was administered and compared upon psychosocial assessments, including the PHQ and a structured clinical interview for DSM-IV (SCID). Four PHQ modules were assessed: major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and alcohol use disorders (AUD) [including both alcohol abuse and dependence]. Based on the SCID diagnosis, sensitivity and specificity were determined. RESULTS: The specificity of the PHQ ranged from moderate to high for all 4 PHQ modules (MDD, 0.79; GAD, 0.67; PD, 0.89; AUD, 0.97). However, the sensitivity was relatively low: MDD (0.58); GAD (0.61); PD (0.49); and AUD (0.24). The PHQ was also associated with psychosocial variables. Patients whose PHQ showed MDD, GAD, or PD reported significantly more depressive symptoms and perceived disability than patients who did not (Ps < 0.001). Patients with MDD or GAD reported significantly higher pain than those without (Ps < 0.001). CONCLUSIONS: The strong specificity of the PHQ appears to be its primary strength for this cohort. Due to its high specificity, the PHQ could be employed as an additional screening tool to help rule out potential psychiatric comorbidity in patients with CDOMD. The low sensitivity of the PHQ in this population, however, remains a weakness of the PHQ.

Does Classification of Chronic Musculoskeletal Disorder Patients Into Psychosocial Subgroups Predict Differential Treatment Responsiveness and 1-Year Outcomes After a Functional Restoration Program?

OBJECTIVES: The objectives of this study: (1) to assess whether Multidimensional Pain Inventory (MPI) profiles predicted differential responses to a functional restoration program (FRP) in chronic disabling occupational musculoskeletal disorder (CDOMD) patients; (2) to examine whether coping style improves following FRP; and (3) to determine whether discharge MPI profiles predict discharge psychosocial and 1-year socioeconomic outcomes. METHODS: Consecutive CDOMD patients (N=716) were classified into Adaptive Coper (AC, n=209), Interpersonally Distressed (ID, n=154), Dysfunctional (DYS, n=310), and Anomalous (n=43) using the MPI, and reclassified at discharge. Profiles were compared on psychosocial measures and 1-year socioeconomic outcomes. An intent-to-treat sample analyzed the effect of drop-outs on treatment responsiveness. RESULTS: The MPI classification significantly predicted program completion (P=0.001), although the intent-to-treat analyses found no significant effects of drop-out on treatment responsiveness. There was a significant increase in the number of patients who became AC or Anomalous at FRP discharge and a decrease in those who were ID or DYS. Patients who changed or remained as DYS at FRP discharge reported the highest levels of pain, disability, and depression. No significant interaction effect was found between MPI group and time for pain intensity or disability. All groups improved on psychosocial measures at discharge. DYS patients had decreased work retention and a greater health care utilization at 1 year. CONCLUSIONS: An FRP was clinically effective for CDOMD patients regardless of initial MPI profiles. The FRP modified profiles, with patients changing from negative to positive profiles. Discharge DYS were more likely to have poor 1-year outcomes. Those classified as Anomalous had a good prognosis for functional recovery similar to ACs.

Improved functional capacity evaluation performance predicts successful return to work one year after completing a functional restoration rehabilitation program.

OBJECTIVE: To evaluate whether functional capacity evaluation (FCE) scores are responsive to functional restoration treatment, and to assess the ability of FCEs at program discharge to predict work outcomes. DESIGN: An interdisciplinary cohort study of prospectively collected data. SETTING: A functional restoration center. PATIENTS: A consecutive sample of 354 patients with chronic disabling occupational musculoskeletal disorders (CDOMDs) completed a functional restoration program consisting of quantitatively directed exercise progression and multi-modal disability management with interdisciplinary medical supervision. METHODS: Each patient participated in an FCE at admission and discharge from treatment. The results of each FCE yielded the physical demand level (PDL) at which patients were functioning. Patients were initially divided into 5 PDL groups, based on job-of-injury lifting, carrying, and pushing/pulling requirements, for the pre- to posttreatment responsiveness analyses. Patients were subsequently divided into 5 PDL groups, based on their performance on the FCE upon program completion. MAIN OUTCOME MEASURES: Outcome measures included admission-to-discharge changes in PDLs and 2 specific FCE lifting tasks: isokinetic lifting; and the Progressive Isoinertial Lifting Evaluation (PILE). Socioeconomic outcomes were also evaluated, including post-discharge work return and work retention 1-year after treatment completion. RESULTS: Overall, 96% of the patients demonstrated improvement in their PDLs from admission to discharge. A majority of patients (56%) were able to achieve a discharge PDL that was comparable to their estimated job-of-injury lifting requirement or higher (P < .001). Lifting ability improved from admission to discharge by approximately 50% (all P < .001). Discharge PDLs predicted both work return (P < .001) and work retention (P < .001) 1 year later. CONCLUSIONS: FCE scores were responsive to functional restoration treatment, and the associated discharge PDLs predicted work return after treatment completion and work retention 1 year later.

Evaluation of functional restoration outcomes for chronic disabling occupational cervical disorders.

OBJECTIVE: To systematically evaluate the effectiveness of an interdisciplinary functional restoration program (FRP) for treating chronic cervical disorders. METHODS: Consecutive chronic occupational lumbar disorder patients (n = 898) and chronic occupational cervical disorder patients (n = 215) were admitted to an FRP from 2001 to 2011. Patients were compared on demographics, work-related and psychosocial factors, and socioeconomic outcomes 1 year after discharge. RESULTS: Compared with lumbar patients, cervical patients were more likely to be female, have preadmission surgery, perform white-collar work, and have a longer time between injury and treatment admission. Cervical patients were similar to lumbar patients on most psychosocial self-report outcome measures. In addition, both groups exhibited high work return and work retention rates 1 year after FRP discharge. CONCLUSIONS: An FRP seems to be equally efficacious for treating both chronic occupational cervical and lumbar disorders.

Does patient-reported insomnia improve in response to interdisciplinary functional restoration for chronic disabling occupational musculoskeletal disorders?

STUDY DESIGN: An analysis of prospectively collected data. OBJECTIVE: To evaluate how patient-reported insomnia, in patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), responds to a functional restoration program (FRP), and to investigate the relationships among insomnia, psychosocial factors, medication use, and post-FRP socioeconomic outcomes. SUMMARY OF BACKGROUND DATA: Insomnia is commonly reported by patients with chronic pain. METHODS: A consecutive sample of 262 patients with predominant chronic spinal pain was assessed with the insomnia severity index (ISI) at program admission and discharge. Groups were formed on the basis of the ISI total scores, from no clinically significant insomnia to severe clinical insomnia (SCI). Patient-reported psychosocial measures were administered, medication information was collected, and ISI discharge score categories were compared with 1-year post-FRP socioeconomic outcomes. The Wilcoxon signed rank, repeated measures ANOVAs, ANOVAs and χ tests were performed. RESULTS: The degree of clinical insomnia at admission significantly predicted program completion, P < 0.001. Mean ISI scores improved from admission (M = 17.2) to discharge (M = 10.6, P < 0.001), but a relatively high percentage of patients (36.6%) still reported moderate to severe insomnia symptoms at discharge. The prevalence of SCI decreased by 18.4%, but this remaining group still reported more pain, disability, and depressive symptoms, and demonstrated more use of opioids, sedatives, and antidepressants (P ≤ 0.01), compared with the other insomnia groups at discharge. One year later, only 56% of the patients with severe insomnia at discharge had retained work, whereas 71% to 93% of those with lesser sleep disturbance were still working (P < 0.001). Those with SCI at discharge were 10.4 times less likely to be working than those without clinically significant insomnia. CONCLUSION: Although insomnia improved for the majority of patients with chronic disabling occupational musculoskeletal disorder, a relatively high percentage continued to report clinically significant insomnia at FRP discharge. Patients with SCI reported more pain, depression, and disability, used more medication, and had poorer work outcomes 1-year post-FRP. LEVEL OF EVIDENCE: 2.

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression.

BACKGROUND CONTEXT: Insomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population. PURPOSES: This study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population. STUDY DESIGN/SETTING: This was a retrospective study of prospectively captured data. PATIENT SAMPLE: A consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol. OUTCOME MEASURES: Insomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0-7); subthreshold insomnia (score, 8-14); moderate clinical insomnia (score, 15-21); and severe clinical insomnia (score, 22-28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire. METHODS: Patients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses. RESULTS: The presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia. CONCLUSION: This research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.