Moderators of psychological recovery from benign cancer screening results.

OBJECTIVE: The sudden confrontation of a potential health threat such as cancer, even after the diagnosis turns out to be benign, can have enduring adverse psychological consequences, including persistent anxiety, cancer fears, and other manifestations of psychological distress. The present study examines factors that potentially moderate psychological recovery among women who face a breast cancer threat. DESIGN: Participants were adult women had just received a benign outcome from a breast cancer diagnostic procedure that had been conducted because of suspicion of breast cancer (a non-conclusive mammography or ultrasonography result, a referral from their doctor because of pain or family history, detection of a lump, a 6-month follow-up appointment after a breast abnormality from a previous screening or diagnostic procedure, or a fluid leak from one or both breasts). We measured several psychological traits at Time 1 (right after receipt of the "no cancer" feedback) and then each month for the next 3 months. Analyses examined the factors that hindered or facilitated psychological recovery from the cancer threat. RESULTS: Results showed that trait anxiety and family history of cancer hindered recovery and that older age and optimism facilitated recovery and lessened adverse psychological consequences. Self-regulatory strategies such as planful problem-solving, positive reappraisal, and mastery facilitated recovery. CONCLUSIONS: Our findings shed light on the factors that are implicated in psychological recovery from a benign breast cancer outcome after a diagnostic procedure (ultrasonography, repeat or initial mammography, stereotactic biopsy, fine-needle aspiration, or ultrasound-guided biopsy). Those factors could be used to identify women who may experience prolonged psychological distress, so as to assist them when they face stressful diagnostic concerns.

Adverse events associated with prescription drug cost-sharing among poor and elderly persons.

CONTEXT: Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups. OBJECTIVES: To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation. DESIGN AND SETTING: Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events. PARTICIPANTS: A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients. MAIN OUTCOME MEASURES: Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction. RESULTS: After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits. CONCLUSIONS: In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.

The Office of the Future Project: the integration of new technology into office practice. Academic detailing through the super highway. Quebec Research Group on Medication Use in the Elderly.

Effective management of drug therapy in the elderly is a challenge for primary-care physicians. There are 20,400 drugs approved for marketing in Canada. Most elderly patients will fill 33 prescriptions per year and take 5 different medications. To be a safe prescriber in the 1990s, physicians need to be aware that 33,000 drug interactions, 6,500 drug-disease contraindications, and 3,500 drug-allergy contraindications have been documented. Inappropriate prescribing is a problem in the elderly. At least one inappropriate prescription is given to 12% to 46% of seniors, and 25% of drug-related hospital admissions are due to prescribing errors. Half of all physicians will write at least one inappropriate prescription for an elderly patient each year, and one quarter of inappropriate prescriptions will be created by the presence of multiple prescribing physicians. Academic detailing is the most effective approach to improve physician prescribing. However, it is an expensive intervention that must be limited to a small number of drugs and conditions, and it must be continued to retain its effectiveness. Furthermore, it fails to address the problems created by multiple prescribers. In this project, we developed a prototype of the future office practice. Physicians are equipped with personal computers and expert prescribing-system software. This electronic academic detailer reviews all current medications for a patient, identifies therapeutic duplications, generates alerts for 50 prescribing problems that have been identified as clinically relevant by a Canadian expert panel, suggests suitable alternatives, and reviews all new prescriptions for potential problems. Information on all prescriptions received by the physicians' elderly patients is downloaded weekly from the provincial prescription claims database, so that the primary physician is able to coordinate and manage all drugs prescribed to their patients by all physicians. The effectiveness of this intervention is being evaluated in a randomized controlled trial of 110 physicians and approximately 16,000 elderly patients in Montreal. We will test whether the intervention reduces the rate of inappropriate prescribing, as well as the rate of drug-related injuries and hospitalizations among patients treated by physicians in the experimental group.

Parental support: effects of a mass-media intervention.

Although face-to-face parental support programs have been shown to improve parents' knowledge, attitudes and behaviour, such interventions are relatively costly to administer. This article reports the findings of a quasi-experimental evaluation of a relatively less costly, mass-media intervention: an age-paced newsletter for new parents. Readership and effectiveness of the newsletter were assessed after three years of distribution. Evaluation participants were 453 randomly selected fathers and mothers of three-year-olds, of which 193 were newsletter recipients and 260 were nonrecipients. Results showed that readership and satisfaction were high. Modest effects were found among mothers in the experimental group on knowledge and perception of existing community resources. Experimental mothers also tended to display greater knowledge of child development. No significant effects of the newsletter were found for fathers. The discussion centres on the potential for this type of intervention strategy to optimize existing investment in public family support programs.

[Health promotion: application of the Ottawa Charter]. / Promotion de la santé: un exercice de mise en application de la Charte d'Ottawa.

One of the greatest challenges for community health today is to translate the health promotion framework into specific actions. An essential step toward integration of the strategies suggested by the Ottawa Charter for Health Promotion lies in a close scrutiny of community health practice by health professionals. In the context of our own organization, we have set up a series of policy development seminars designed to bring together staff involved in different areas of community health and to have them work through clear institutional positions regarding current public health issues. We examined the policy positions in the light of the Ottawa Charter. Some of the Charter's suggested strategies were not well covered by the seminar participants. This could be partly attributed to the traditional mix of disciplines in community health. In order to approach health as defined in the Charter, a novel mix of disciplines should be invited to collaborate with the already existing professionals. The Charter is a useful tool for better focusing community health practice onto the health promotion paradigm.

Evaluation of an early, mass media parental support intervention.

This article reports on the evaluation of Parents Magazine, an age-paced newsletter distributed to parents starting with the birth of their children. The evaluation was carried out after the newsletter's first year of circulation. Measures were taken of reader satisfaction as well as impact on parents' knowledge, attitudes and behavior toward education and use of community resources. Findings indicated that the newsletter's penetration of families and their natural milieu was strong but that it had a limited impact. However, the parents who received the newsletter developed more positive attitudes toward community resources. The articles discusses the implication of these findings for future research.

[Psychotherapy : pleasure without principle.]. / Les psychothérapies : le plaisir sans le principe.

Is the current marketing of psychotherapy going to be its end ? The growing confusion induced by the commercialization of psychotherapy does not seem to worry the psychotherapists who think they profit from it as much as does the public. This paper argues that it is high time for psychotherapists to adopt a consumer perspective if they are to fully grasp the extent of the problem engendered by the commercialization of contemporary psychotherapy. The rules of the therapeutic relationship are not aimed only at serving the patient's objectives but are subject to other pressures such as institutional contexts, ideological and sociopolitical position of the therapists. The author analyses the constraints governing the practice of psychotherapy and points to various ways in which psychotherapists contribute to the decay of psychotherapy. On this critical basis, five areas are identified wherein concerted action by psychotherapists may help pull psychotherapy out of its present crisis.

The directive sex therapies in psychiatric outpatient settings.

The treatment techniques and associated outcome studies of the directive sex therapies (DST) are briefly reviewed and data on the treatment of 12 couples are presented. The directive sex therapies have achieved rather impressive results but only with highly selected populations. Studies, such as the present, with a range of patients more typical of psychiatric outpatient settings have consistently achieved lower success rates. The important effect of patient selection on outcome with DST has, to date, received little attention. The present authors discuss selection criteria for DST in the light of the literature and the outcome in their own cases.

The treatment of sexual dysfunction: a review.

In this article we describe and contrast the psychodynamic and directive approaches to the treatment of sexual dysfunction. We have also summarized and critically reviewed published reports with ten or more cases. No firm conclusions can be drawn on the efficacy of the psychodynamic approach with this population because of the absence of controlled studies. Fairly conclusive evidence for the efficacy of the directive approaches is now available, but solely with highly selected populations. Success rates in studies with unselected psychiatric outpatient populations are much less favorable. The effect of characteristics of the patient population on outcome with the directive sex therapies has received dangerously little attention.