Conversations Regarding Personhood: Use of the Patient Dignity Question in an Outpatient Psycho-Oncology Clinic.

Background: The Patient Dignity Question (PDQ) is a single question, which directly asks the patient, "What should I know about you as a person to help me take the best care of you that I can?" Research has demonstrated that the PDQ enhances quality health care within an inpatient palliative care setting; however, no research to date has examined the PDQ in an outpatient setting, particularly a psycho-oncology setting. Objective: The PDQ was administered as part of routine clinical care in an outpatient psycho-oncology clinic to enhance patient-centered care. Methods: Individuals diagnosed with cancer (n = 66) were referred for individual psychotherapy primarily for anxiety and/or depression. After gathering a thorough patient history during the initial psychology consult, patients were asked the PDQ as it was worded without further prompting. Patient responses were then qualitatively analyzed to measure the most common themes. Results: The themes expressed by patients in response to the PDQ included Who I Am (59.7%), which referenced individual characteristics and core personality traits, What My Cancer Journey Has Been (21.7%) described how patients' lives have been impacted since receiving a cancer diagnosis, and What I Want to Achieve (18.4%) in which patients described what goals they wanted to achieve in their lives (both general and specific to psychotherapy). Conclusions: Data from this small pilot study show promise that this brief assessment tool can be readily added to a psychological intake assessment and patients appreciated being asked about their personhood. Incorporating the PDQ into standard psychological care allows patients to be "seen" and helps us to acknowledge the person in the patient.

Mixed-methods quantitative-qualitative study of 29 nonagenarians and centenarians in rural Southern Italy: focus on positive psychological traits.

OBJECTIVE: This was a study of positive psychological traits in a group of rural Italians aged 90 to 101 years, and their children or other family members. DESIGN: Mixed-methods quantitative (standardized rating scales) and qualitative (semi-structured interviews) study. SETTING: Study participants' homes in nine villages in the Cilento region of southern Italy. PARTICIPANTS: Twenty-nine nonagenarians and centenarians and 51 family members aged 51-75 years, selected by their general practitioners as a part of a larger study called CIAO (Cilento Initiative on Aging Outcomes). METHODS: We used published rating scales of mental and physical well-being, resilience, optimism, anxiety, depression, and perceived stress. Qualitative interviews gathered personal narratives of the oldest-old individuals, including migrations, traumatic events, and beliefs. Family members described their impressions about the personality traits of their older relative. RESULTS: Participants age ≥90 years had worse physical health but better mental well-being than their younger family members. Mental well-being correlated negatively with levels of depression and anxiety in both the groups. The main themes that emerged from qualitative interviews included positivity (resilience and optimism), working hard, and bond with family and religion, as described in previously published studies of the oldest old, but also a need for control and love of the land, which appeared to be unique features of this rural population. CONCLUSIONS: Exceptional longevity was characterized by a balance between acceptance of and grit to overcome adversities along with a positive attitude and close ties to family, religion, and land, providing purpose in life.

Hospice staff perspectives on Dignity Therapy.

BACKGROUND: Dignity Therapy is a brief psychotherapy performed with patients at the end of life. Previous research has examined the effects of Dignity Therapy with patients and family, but none has examined hospice staff perceptions of the treatment. OBJECTIVE: The study objective was to investigate hospice staff perspectives regarding the impact and value of Dignity Therapy when provided as a clinical service. METHODS: Eighteen hospice staff members who referred patients for Dignity Therapy were asked to rate the value of the treatment. The staff also completed qualitative interviews to gather more detailed information about their most common reasons for referral; their perspectives regarding the therapy's impact on patients; and their beliefs about the costs, benefits, and barriers to treatment. The staff interview responses were qualitatively analyzed to measure the most common emergent themes. RESULTS: Hospice staff members rated Dignity Therapy as worthwhile, and somewhat able to reduce patients' pain and suffering. The vast majority (92%) of hospice staff members believed the treatment would help patients' families in the future, and 100% reported a desire to recommend the treatment to others. Qualitative analyses revealed that staff commonly viewed Dignity Therapy as a positive, affirming experience for patients and felt the emotional or time requirements of the treatment were justified. As a result of offering the service, the staff noted an increased connection with patients and related increases in job satisfaction. CONCLUSIONS: Hospice staff believe Dignity Therapy is a worthwhile service that offers a positive, quality-enhancing experience for patients at the end of life. The addition of this clinical service may further enhance staff members' job satisfaction and connection with patients. These findings provide useful information for clinicians or organizational leaders who consider offering Dignity Therapy in their setting.

Comparison of international medical graduates with US medical students and residents after a four-week course in palliative medicine: a pilot study.

BACKGROUND: The need for doctors who have skills in pain management and palliative medicine is greatest in low and moderate resource countries where patients most frequently present to their health care system with advanced illness and greater than 80% of the global deaths occur. While medical students trained in the United States are required to have training in palliative medicine, international medical graduates (IMGs), who have completed medical school outside North America, may not have the same exposure to palliative medicine training as U.S. physicians. The goal of this study was to evaluate whether a four-week course in palliative medicine could bring IMG attitudes, concerns, competence, and knowledge to the level of U.S. trainees. METHODS: As part of a prospective cohort study, 21 IMGs from 14 countries participated in a four-week course in palliative medicine. Attitudes, concerns, self-reported competence, and knowledge were assessed pre-course and post-course. The course was evaluated weekly and at the end of the four-week program. The data from the IMGs was compared to data from U.S. medical students and residents using the same assessment tools. RESULTS: After the course, IMGs had significantly decreased concern about ethical and legal issues in palliative medicine to the level of U.S.-trained residents and a significant increase in knowledge and self-rated competence equivalent to the level of U.S. trainees. CONCLUSIONS: A four-week course in palliative medicine can improve the levels of concern, knowledge and self-assessed competence in IMGs to the level of US trainees.

Psychiatry resident education in palliative care: opportunities, desired training, and outcomes of a targeted educational intervention.

OBJECTIVES: To assess the educational offerings provided to psychiatry residents in palliative care as well as their concomitant interest in learning more about this subspecialty. To measure the pre- and post-levels of competence, concern, and knowledge exhibited by psychiatry residents when completing a formalized clinical rotation in hospice and palliative care, with additional comparisons to family and internal medicine residents completing the same clinical rotation. METHODS: Fifty-two Psychiatry Program Directors and 98 psychiatry residents completed an online survey assessing the current course offerings and level of interest in palliative care. Thirty psychiatry residents were additionally evaluated before and after completion of a clinical rotation in hospice and palliative care. RESULTS: Few programs offered any formalized training in palliative care, although nearly all psychiatry residents reported interest in this area. A clinical rotation in palliative care significantly increased psychiatry residents' competence and knowledge while simultaneously decreasing their concerns about practice in this area; most were at levels comparable to family and internal medicine residents completing the same rotation. Psychiatry residents' knowledge of pain assessment, pain management, and generalized non-pain management were also enhanced during the rotation. CONCLUSIONS: Results indicate that training opportunities in palliative care are lacking for psychiatry residents in the United States although residents report strong interest in this area. This study finds psychiatry residents can benefit as much as other disciplines from receiving palliative care training. The need to offer such training within psychiatry residencies is highlighted and the welcoming of psychiatrists into palliative care is suggested.

Suicidal ideation and suicide attempts among middle-aged and older patients with schizophrenia spectrum disorders and concurrent subsyndromal depression.

This study examines the prevalence and correlates of current suicidal ideation and past suicide attempts among patients aged 40 and older with schizophrenia spectrum disorders and concurrent depressive symptoms. Nearly half the sample (n = 132) reported having attempted suicide once or more in their lifetime; those who had attempted, exhibited greater depression and psychopathology. A regression analysis revealed that only past suicide attempts and hopelessness significantly accounted for the presence of current suicidal ideation. Surprisingly, current suicidal ideation did not differ by diagnosis, race/ethnicity, marital status, living situation, age, education, or severity of medical illness. Overall, suicidal ideation and the presence of past suicide attempts were remarkably prevalent, highlighting the need for continued clinical vigilance with this patient population. The impact of hopelessness and general psychopathology, as well as the insignificance of demographic characteristics and medical illness severity warrant further investigation.

Suicide risk in schizophrenia: learning from the past to change the future.

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5-13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the result of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophrenia patients.

Self-administered cognitive screening for a study of successful aging among community-dwelling seniors: a preliminary study.

BACKGROUND: Cognitive functioning is a central component of successful aging. Yet, there are few published instruments for brief and reliable self-administered cognitive assessment that could be used in large population-based studies of community-dwelling elderly people. OBJECTIVE: We examined the utility of a self-administered cognitive screening instrument in a group of community-dwelling older adults, and we evaluated correlations of the performance on this measure with demographic variables and specific indicators of self-rated successful aging. METHOD: We assessed 182 well-educated adults ages 58 to 99 with a modified version of a previously published cognitive screening instrument (Cognitive Assessment Screening Test--Revised; CAST-R), a measure of cognitive complaints (Cognitive Failures Questionnaire; CFQ), and a self-rating of successful aging. We used the SF-36 Physical and Mental Composite Scores as measures of physical and mental health-related functioning. RESULTS: As expected, most individuals performed well on the CAST-R; only 7% of participants fell below a previously established cut score for cognitive impairment. CAST-R scores were positively correlated with level of education, income, SF-36 Mental Composite Scores, and a self-rating of successful aging, and negatively correlated with chronological age. Scores on the CAST-R were not correlated with cognitive complaints (CFQ total score) or SF-36 Physical Composite Scores. CONCLUSIONS: A self-administered cognitive screening tool may be a useful, albeit limited, way of screening for cognitive disabilities among well-educated, community-dwelling older adults. Although preliminary, significant associations with several successful aging-related variables in expected directions represent the first step in establishing the validity of the CAST-R.

Diagnostic variability for schizophrenia and major depression in a large public mental health care system dataset.

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.

Correlates of self-rated successful aging among community-dwelling older adults.

OBJECTIVE: There is no consensus on how to define successful aging. The authors sought to determine the correlates of self-rated successful aging as well as its correspondence with major researcher-defined criteria. METHODS: Participants were 205 community-dwelling adults over age 60. A questionnaire survey asked the participants to rate their own degree of successful aging and inquired about demographic characteristics, medical history, activity levels, resilience, daily functioning, and health-related quality of life (Medical Outcomes study 36-item Short-Form [MOS-SF-36]). Participants' subjective ratings of successful aging were contrasted with sets of researcher-defined criteria, and correlates of subjectively rated successful aging were examined. RESULTS: Ninety-two percent of the participants rated themselves as aging successfully. A majority of them also met other research criteria for successful aging such as independent living, mastery/growth, and positive adaptation but not those requiring an absence of chronic medical illness or physical disability. Higher SF-36 scores as compared with a published sample indirectly corroborated participants' subjectively rated successful aging. Subjective ratings of successful aging were significantly correlated with higher scores on health-related quality of life as well as resilience, greater activity, and number of close friends but not with several demographic characteristics. CONCLUSION: Most community-dwelling older adults viewed themselves as aging successfully despite having chronic physical illnesses and some disability. Longitudinal studies of the reliability and validity of subjective ratings of successful aging are warranted.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia.

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.

Suicide among patients with schizophrenia: a consideration of risk and protective factors.

BACKGROUND: The elevated rate of suicide among patients with schizophrenia is well documented and thus frequently researched. The majority of research has focused solely on the identification of risk factors that predispose patients to attempt or commit suicide. This review serves to expand on the literature pertaining to suicide risk factors by additionally outlining how protective factors may shield against suicide within this unique patient population. METHODS: A literature review of English-language publications pertaining to suicide among people with schizophrenia was completed using PsychINFO and MEDLINE databases between the years of 1960-2004 and 1950-2004 respectively. Special emphasis was given to studies of risk factors and protective factors for suicide. RESULTS: Commonly supported risk factors for suicide were identified: previous attempts, severity of illness, comorbidity, social isolation, temporal relationships, and demographic characteristics. Risk factors such as a history of violence, the presence of command hallucinations, and recent tragic loss were found to warrant future study. Social support, positive coping skills, life satisfaction, and resiliency emerged as protective factors that may mitigate suicide. CONCLUSIONS: Understanding why some patients wish to end their lives but also why some desire to live allows for more comprehensive suicide prevention.