Mickey Trockel is the Director of Evidence Based Innovation for the Stanford University School of Medicine WellMD Center. His development of novel measurement tools has led to growing focus on professional fulfillment as a foundational aim of efforts to promote physician well-being. His scholarship also identifies interpersonal interactions at work as a modifiable core determinate of an organizational culture that cultivates wellness.
Dr. Trockel serves as the chair of the Physician Wellness Academic Consortium Scientific Board, which is a group of academic medical centers working together to improve physician wellbeing. The consortium sites have adopted the physician wellness assessment system Dr. Trockel and his colleagues have developed, which offers longitudinal data for benchmarking and natural experiment based program evaluation. His previous research included focus on college student health, and evaluation of the efficacy of a national evidence based psychotherapy dissemination effort. His more recent scholarship has focused on physician wellbeing. He is particularly interested in developing and demonstrating the efficacy of interventions designed to promote wellbeing by improving social culture determinants of wellbeing across student groups, employee work teams, or larger organizations.
Clinical Professor, Psychiatry and Behavioral Sciences
Residency: Stanford University Pain Management Fellowship (2009) CA
Medical Education: University Of Illinois (2005) IL
Board Certification: American Board of Psychiatry and Neurology, Psychiatry (2012)
Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment.
Academic medicine : journal of the Association of American Medical Colleges
2020; Publish Ahead of Print
These are challenging times for physicians. Extensive changes in the practice environment have altered the nature of physician's interactions with patients and their role in the health care delivery system. Many physicians feel as if they are "cogs in the wheel" of austere corporations that care more about productivity and finances than compassion or quality. They often do not see how the strategy and plan of their organization align with the values of the profession. Despite their expertise, they frequently do not feel they have a voice or input in the operational plan of their work unit, department, or organization. At their core, the authors believe all of these factors represent leadership issues. Many models of leadership have been proposed, and there are a number of effective philosophies and approaches. Here, the authors propose a new integrative model of Wellness-Centered Leadership (WCL). WCL includes core skills and qualities from the foremost leadership philosophies along with evidence on the relationship between leadership and physician well-being and distills them into a single framework designed to cultivate leadership behaviors that promote engagement and professional fulfillment. The 3 elements of WCL are: care about people always, cultivate individual and team relationships, and inspire change. A summary of the mindset, behaviors, and outcomes of the elements of the WCL model is presented and the application of the elements for physician leaders is discussed. The authors believe that learning and developing the skills that advance these elements should be the aspiration of all health care leaders and a foundational focus of leadership development programs. If cultivated, the authors believe that WCL will empower individual and team performance to address the current problems faced by health care organizations as well as the iterative innovation needed to address challenges that may arise in the decades to come.
View details for DOI 10.1097/ACM.0000000000003907
View details for PubMedID 33394666
Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors.
JAMA network open
2020; 3 (12): e2028111
Importance: Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error.Objective: To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.Design, Setting, and Participants: This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.Exposures: Sleep-related impairment.Main Outcomes and Measures: Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.Results: Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r=0.51; P<.001), work exhaustion (r=0.58; P<.001), and overall burnout (r=0.59; P<.001) were large. Sleep-related impairment correlation with professional fulfillment (r=-0.40; P<.001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.Conclusions and Relevance: In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.
View details for DOI 10.1001/jamanetworkopen.2020.28111
View details for PubMedID 33284339
Association of Physician Burnout With Suicidal Ideation and Medical Errors.
JAMA network open
2020; 3 (12): e2028780
Importance: Addressing physician suicide requires understanding its association with possible risk factors such as burnout and depression.Objective: To assess the association between burnout and suicidal ideation after adjusting for depression and the association of burnout and depression with self-reported medical errors.Design, Setting, and Participants: This cross-sectional study was conducted from November 12, 2018, to February 15, 2019. Attending and postgraduate trainee physicians randomly sampled from the American Medical Association Physician Masterfile were emailed invitations to complete an online survey in waves until a convenience sample of more than 1200 practicing physicians agreed to participate.Main Outcomes and Measures: The primary outcome was the association of burnout with suicidal ideation after adjustment for depression. The secondary outcome was the association of burnout and depression with self-reported medical errors. Burnout, depression, suicidal ideation, and medical errors were measured using subscales of the Stanford Professional Fulfillment Index, Maslach Burnout Inventory-Human Services Survey for Medical Personnel, and Mini-Z burnout survey and the Patient-Reported Outcomes Measurement Information System depression Short Form. Associations were evaluated using multivariable regression models.Results: Of the 1354 respondents, 893 (66.0%) were White, 1268 (93.6%) were non-Hispanic, 762 (56.3%) were men, 912 (67.4%) were non-primary care physicians, 934 (69.0%) were attending physicians, and 824 (60.9%) were younger than 45 years. Each SD-unit increase in burnout was associated with 85% increased odds of suicidal ideation (odds ratio [OR], 1.85; 95% CI, 1.47-2.31). After adjusting for depression, there was no longer an association (OR, 0.85; 95% CI, 0.63-1.17). In the adjusted model, each SD-unit increase in depression was associated with 202% increased odds of suicidal ideation (OR, 3.02; 95% CI, 2.30-3.95). In the adjusted model for self-reported medical errors, each SD-unit increase in burnout was associated with an increase in self-reported medical errors (OR, 1.48; 95% CI, 1.28-1.71), whereas depression was not associated with self-reported medical errors (OR, 1.01; 95% CI, 0.88-1.16).Conclusions and Relevance: The results of this cross-sectional study suggest that depression but not physician burnout is directly associated with suicidal ideation. Burnout was associated with self-reported medical errors. Future investigation might examine whether burnout represents an upstream intervention target to prevent suicidal ideation by preventing depression.
View details for DOI 10.1001/jamanetworkopen.2020.28780
View details for PubMedID 33295977
- Advancing Physician Well-Being: A Population Health Framework. Mayo Clinic proceedings 2020
Association of Occupational Distress and Sleep-Related Impairment in Physicians With Unsolicited Patient Complaints.
Mayo Clinic proceedings
2020; 95 (4): 719–26
OBJECTIVE: To study the relationship between occupational distress and sleep-related impairment in physicians and unsolicited patient complaints.PARTICIPANTS AND METHODS: We used deidentified data from an academic medical center's physician survey administered in April and May of 2013 to perform a retrospective cohort study. Third-party stewards of the identifiable information regarding unsolicited patient complaints from January 1, 2013, through December 31, 2016, matched these data with corresponding physicians' occupational distress data. Unsolicited patient complaints were used to calculate the Patient Advocacy Reporting System (PARS) score, a validated predictor of malpractice litigation risk and clinical outcomes. Physicians were grouped into 1 of 3 PARS risk categories based on previously defined thresholds: low risk (score of 0), intermediate risk (score of 1-12), or high risk (score ≥13).RESULTS: Each 1-point increase in burnout and sleep-related impairment, on a 5-point scale, was associated with a 69% (odds ratio [OR], 1.69; 95% CI, 1.12-2.54) and 49% (OR, 1.49; 95% CI, 1.08-2.05) increased odds of being in the next higher PARS risk category, respectively, averaged across all 4 years. Professional fulfillment was a protective factor, associated with fewer unsolicited patient complaints. Each 1-point decrease in professional fulfillment was associated with a 68% (OR, 1.68; 95% CI, 1.16-2.44) increased odds of being in the next higher PARS risk category. The effect of depression on PARS risk category was not significant (OR, 1.33; 95% CI, 0.84-2.10).CONCLUSION: Findings from this research suggest that occupational distress and sleep-related impairment in physicians are associated with unsolicited patient complaints.
View details for DOI 10.1016/j.mayocp.2019.09.025
View details for PubMedID 32247345
- Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA 2020
Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness.
JAMA network open
2020; 3 (6): e207961
Although leadership behavior of physician supervisors is associated with the occupational well-being of the physicians they supervise, the factors associated with leadership behaviors are poorly understood.To evaluate the associations between burnout, professional fulfillment, and self-care practices of physician leaders and their independently assessed leadership behavior scores.This survey study of physicians and physician leaders at Stanford University School of Medicine (n = 1924) was conducted from April 1 to May 13, 2019. The survey included assessments of professional fulfillment, self-valuation, sleep-related impairment, and burnout. Physicians also rated the leadership behaviors of their immediate physician supervisors using a standardized assessment. Leaders' personal well-being metrics were paired with their leadership behavior scores as rated by the physicians they supervised. All assessment scores were converted to a standardized scale (range, 0-10). Data were analyzed from October 20, 2019, to March 10, 2020.Association between leaders' own well-being scores and their independently assessed leadership behavior.Of 1924 physicians invited to participate, 1285 (66.8%) returned surveys, including 67 of 117 physician leaders (57.3%). Among these respondents, 651 (50.7%) were women and 729 (56.7%) were 40 years or older. Among the 67 leaders, 57 (85.1%) had their leadership behaviors evaluated by at least 5 physicians (median, 11 [interquartile range, 9-15]) they supervised. Overall, 9.8% of the variation in leaders' aggregate leadership behavior scores was associated with their own degree of burnout. In models adjusted for age and sex, each 1-point increase in burnout score of the leaders was associated with a 0.19-point decrement in leadership behavior score (β = -0.19; 95% CI, -0.35 to -0.03; P = .02), whereas each 1-point increase in their professional fulfillment and self-valuation scores was associated with a 0.13-point (β = 0.13; 95% CI, 0.01-0.26; P = .03) and 0.15-point (β = 0.15; 95% CI, 0.02-0.29; P = .03) increase in leadership behavior score, respectively. Each 1-point increase in leaders' sleep-related impairment was associated with a 0.15-point increment in sleep-related impairment among those they supervised (β = 0.15; 95% CI, 0.02-0.29; P = .03). The associations between leaders' well-being scores in other dimensions and the corresponding well-being measures of those they supervised were not significant.In this survey study, burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness. Training, skill building, and support to improve leader well-being should be considered a dimension of leadership development rather than simply a dimension of self-care.
View details for DOI 10.1001/jamanetworkopen.2020.7961
View details for PubMedID 32543700
Self-valuation: Attending to the Most Important Instrument in the Practice of Medicine.
Mayo Clinic proceedings
OBJECTIVE: To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment.METHODS: We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment.RESULTS: Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with-1.10 point lower burnout score (95% CI,-1.16 to-1.05; standardized beta=-0.53; P<.001) and 0.81 point lower sleep-related impairment score (95% CI,-0.85 to-0.76; standardized beta=-0.47; P<.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout.CONCLUSION: Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being.
View details for DOI 10.1016/j.mayocp.2019.04.040
View details for PubMedID 31543254
Selecting physician well-being measures to assess health system performance and screen for distress: Conceptual and methodological considerations.
Current problems in pediatric and adolescent health care
Following national calls to address burnout among U.S. physicians, healthcare systems across the nation are integrating measures of physician well-being into institutional assessments. In this paper, we review important conceptual and methodological considerations for selecting self-reported physician well-being measures to monitor health system performance and to screen individual physicians for symptoms of distress. First, we discuss the importance of selecting any given measure of physician well-being based on the degree to which evidence supports the validity of the measure within the context of its intended use. Second, we present a conceptual model explaining the relationship between physician well-being and the larger healthcare context, to assist health systems in identifying the intended goals of physician well-being assessment. Well-being assessments are metrics of individual-level physician wellness/distress and may be indicators of system-level performance. We highlight proposed roles of physician well-being as a performance metric (i.e., as a downstream effect of the medical practice environment, as a predictor of health system outcomes, and as a mediator of the practice environment's effect on health system outcomes). Using this framework, we review the evidence supporting the validity of four of the most commonly used measures of well-being in U.S. physicians, identify gaps in the literature, and present practical recommendations for healthcare organizations' selection of appropriate measurement tools. We conclude by offering directions for future research to advance the measurement of physician well-being outcomes.
View details for DOI 10.1016/j.cppeds.2019.100662
View details for PubMedID 31562054
Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study.
BMC health services research
2018; 18 (1): 851
BACKGROUND: Awareness of the economic cost of physician attrition due to burnout in academic medical centers may help motivate organizational level efforts to improve physician wellbeing and reduce turnover. Our objectives are: 1) to use a recent longitudinal data as a case example to examine the associations between physician self-reported burnout, intent to leave (ITL) and actual turnover within two years, and 2) to estimate the cost of physician turnover attributable to burnout.METHODS: We used de-identified data from 472 physicians who completed a quality improvement survey conducted in 2013 at two Stanford University affiliated hospitals to assess physician wellness. To maintain the confidentially of survey responders, potentially identifiable demographic variables were not used in this analysis. A third party custodian of the data compiled turnover data in 2015 using medical staff roster. We used logistic regression to adjust for potentially confounding factors.RESULTS: At baseline, 26% of physicians reported experiencing burnout and 28% reported ITL within the next 2years. Two years later, 13% of surveyed physicians had actually left. Those who reported ITL were more than three times as likely to have left. Physicians who reported experiencing burnout were more than twice as likely to have left the institution within the two-year period (Relative Risk (RR)=2.1; 95% CI=1.3-3.3). After adjusting for surgical specialty, work hour categories, sleep-related impairment, anxiety, and depression in a logistic regression model, physicians who experienced burnout in 2013 had 168% higher odds (Odds Ratio=2.68, 95% CI: 1.34-5.38) of leaving Stanford by 2015 compared to those who did not experience burnout. The estimated two-year recruitment cost incurred due to departure attributable to burnout was between $15,544,000 and $55,506,000. Risk of ITL attributable to burnout was 3.7 times risk of actual turnover attributable to burnout.CONCLUSIONS: Institutions interested in the economic cost of turnover attributable to burnout can readily calculate this parameter using survey data linked to a subsequent indicator of departure from the institution. ITL data in cross-sectional studies can also be used with an adjustment factor to correct for overestimation of risk of intent to leave attributable to burnout.
View details for PubMedID 30477483
Building a Program on Well-Being: Key Design Considerations to Meet the Unique Needs of Each Organization.
Academic medicine : journal of the Association of American Medical Colleges
The current health care practice environment has resulted in a crescendo of burnout among physicians, nurses, and advanced practice providers. Burnout among health care professionals is primarily caused by organizational factors rather than problems with personal resilience. Four major drivers motivate health care leaders to build well-being programs: the moral-ethical case (caring for their people), the business case (cost of turnover and lower quality), the tragic case (a physician suicide), and the regulatory case (accreditation requirements). Ultimately, health care provider burnout harms patients. The authors discuss the purpose; scope; structure and resources; metrics of success; and a framework for action for organizational well-being programs. The purpose such a program is to oversee organizational efforts to reduce the occupational risk for burnout, cultivate professional well-being among health care professionals and, in turn, optimize the function of health care systems. The program should measure, benchmark, and longitudinally assess these domains. The successful program will develop deep expertise regarding the drivers of professional fulfillment among health care professionals; an approach to evaluate system flaws and relevant dimensions of organizational culture; and knowledge and experience with specific tactics to foster improvement. Different professional disciplines have both shared challenges and unique needs. Effective programs acknowledge and address these differences rather than ignore them. Ultimately, a professional workforce with low burnout and high professional fulfillment is vital to providing the best care to patients. Vanguard institutions have embraced this understanding and are pursuing health care provider well-being as a core organizational strategy.
View details for PubMedID 30134268
Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness and Reduce Burnout
ANNALS OF INTERNAL MEDICINE
2017; 166 (10): 743-+
View details for PubMedID 28418518
A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians.
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry
The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being.A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale.Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment.PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.
View details for PubMedID 29196982
Effects of Cognitive Behavioral Therapy for Insomnia on Suicidal Ideation in Veterans
2015; 38 (2): 259-265
To examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on suicidal ideation among Veterans with insomnia.Longitudinal data collected in the course of an uncontrolled evaluation of a large-scale CBT-I training program.Outpatient and residential treatment facilities.Four hundred five Veterans presenting for treatment of insomnia.Cognitive behavioral therapy for insomnia (CBT-I).At baseline, 32% of patients, compared with 21% at final assessment, endorsed some level of suicidal ideation [χ(2)(df = 1) = 125; P < 0.001]. After adjusting for demographic variables and baseline insomnia severity, each 7-point decrease in Insomnia Severity Index (ISI) score achieved during CBT-I treatment was associated with a 65% (OR = 0.35; 95% CI = 0.24 to 0.52) reduction in odds of suicidal ideation. The effect of change in insomnia severity on change in depression severity was also significant. After controlling for change in depression severity and other variables in the model, the effect of change in insomnia severity on change in suicidal ideation remained significant.This evaluation of the largest dissemination of CBT-I in the United States found a clinically meaningful reduction in suicidal ideation among Veterans receiving CBT-I. The mechanisms by which effective treatment of insomnia with CBT-I reduces suicide risk are unknown and warrant investigation. The current results may have significant public health implications for preventing suicide among Veterans.
View details for DOI 10.5665/sleep.4410
View details for Web of Science ID 000348757800014
View details for PubMedID 25515115
View details for PubMedCentralID PMC4288607
Perceived electronic health record usability as a predictor of task load and burnout among US physicians: A mediation analysis.
Journal of medical Internet research
BACKGROUND: EHR usability and physician task load both contribute to physician professional burnout. The association between perceived EHR usability and workload has not previously been studied at a national level. Better understanding these interactions could give further information as to the drivers of extraneous task load.OBJECTIVE: To determine the relationship between physician perceived EHR usability and workload by specialty, and evaluate for associations with professional burnout.METHODS: A secondary analysis of a cross-sectional survey of US physicians from all specialties that was conducted from October 2017 to March 2018. Among the 1,250 physicians invited to respond to the sub-survey analyzed here, 848 (67.8%) completed it. EHR usability was assessed with the System Usability Scale (SUS; range 0-100). Provider task load (PTL) was assessed using the mental demand, physical demand, temporal demand, and effort required subscales of the NASA-Task Load Index (TLX; range 0-400). Burnout was measured using the Maslach Burnout Inventory.RESULTS: The mean scores were SUS 46.1 (SD 46.1) and PTL 262.5 (SD 71.7). On multivariable analysis adjusting for age, gender, relationship status, medical specialty, practice setting, hours worked per week, and number of nights on call per week, physician-rated EHR usability was associated with PTL with each 1 point more favorable SUS score associated with a 0.57 point lower PTL score (p < .001). On mediation analysis, higher SUS was associated with lower PTL, which was associated with lower odds of burnout.CONCLUSIONS: A strong association was observed between EHR usability and workload among US physicians with more favorable usability associated with less workload. Both outcomes were associated with the odds of burnout with task load acting as a mediator between EHR usability and burnout. Improving EHR usability while decreasing task load has the potential to allow practicing physicians more working memory for medical decision-making and patient communication.CLINICALTRIAL: Not applicable.
View details for DOI 10.2196/23382
View details for PubMedID 33289493
Resilience and Burnout Among Physicians and the General US Working Population.
JAMA network open
2020; 3 (7): e209385
Importance: The prevalence of physician burnout is well documented, and resilience training has been proposed as an option to support physician well-being. However, the resilience of physicians compared with that of the US working population is not established, and the association between resilience and physician burnout is not well understood.Objectives: To evaluate resilience among physicians and US workers, and to determine the association between resilience and burnout among US physicians.Design, Setting, and Participants: A cross-sectional national survey study of 5445 US physicians and a probability-based sample of 5198 individuals in the US working population was conducted between October 12, 2017, and March 15, 2018.Main Outcomes and Measures: Resilience was measured using the 2-item Connor-Davidson Resilience Scale (total scores range from 0-8; higher scores indicate greater resilience); burnout was measured using the full Maslach Burnout Inventory with overall burnout indicated by a score of at least 27 on the 0 to 54 emotional exhaustion subscale and/or at least 10 on the depersonalization subscale (higher scores indicate greater burnout).Results: Of 30 456 physicians who received an invitation to participate, 5445 (17.9%) completed surveys (2995 men [62.1%]; median [IQR] age of 53 [42-62] years). In multivariable analysis, mean (SD) resilience scores were higher among physicians than the general employed population (6.49 [1.30] vs 6.25 [1.37]; adjusted mean difference, 0.25 points; 95% CI, 0.19-0.32; P<.001). Among physicians, resilience was associated with burnout. Physicians without overall burnout had higher mean (SD) resilience scores than physicians with burnout (6.82 [1.15] vs 6.13 [1.36]; adjusted mean difference, 0.68 points, 95% CI, 0.61-0.76; P<.001). Each 1-point increase in resilience score was associated with 36% lower odds of overall burnout (odds ratio, 0.64; 95% CI, 0.60-0.67; P<.001). However, 392 of 1350 physicians (29%) with the highest possible resilience score had burnout.Conclusions and Relevance: The findings of this national survey study suggest that physicians exhibited higher levels of resilience than the general working population in the US. Resilience was inversely associated with burnout symptoms, but burnout rates were substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.
View details for DOI 10.1001/jamanetworkopen.2020.9385
View details for PubMedID 32614425
Describing the emotional exhaustion, depersonalization, and low personal accomplishment symptoms associated with Maslach Burnout Inventory subscale scores in US physicians: an item response theory analysis.
Journal of patient-reported outcomes
2020; 4 (1): 42
PURPOSE: Current US health policy discussions regarding physician burnout have largely been informed by studies employing the Maslach Burnout Inventory (MBI); yet, there is little in the literature focused on interpreting MBI scores. We described the burnout symptoms and precision associated with MBI scores in US physicians.METHODS: Using item response theory (IRT) analyses of secondary, cross-sectional survey data, we created response profiles describing the probability of burnout symptoms associated with US physicians' MBI emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) subscale scores. Response profiles were mapped to raw subscale scores and used to predict symptom endorsements at mean scores and commonly used cut-points.RESULTS: The average US physician was likely to endorse feeling he/she is emotionally drained, used up, frustrated, and working too hard and all PA indicators once weekly or more but was unlikely to endorse feeling any DP symptoms once weekly or more. At the commonly used EE and DP cut-points of 27 and 10, respectively, a physician was unlikely to endorse feeling burned out or any DP symptoms once weekly or more. Each subscale assessed the majority of sample score ranges with ≥ 0.70 reliability.CONCLUSIONS: We produced a crosswalk mapping raw MBI subscale scores to scaled scores and response profiles calibrated in a US physician sample. Our results can be used to better understand the meaning and precision of MBI scores in US physicians; compare individual/group MBI scores against a reference population of US physicians; and inform the selection of subscale cut-points for defining categorical physician burnout outcomes.
View details for DOI 10.1186/s41687-020-00204-x
View details for PubMedID 32488344
- Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians. JAMA network open 2020; 3 (6): e207374
CONTENT AND AFFECT ANALYSIS OF TEXT CORRESPONDENCE OF PARTICIPANTS IN A DIGITAL GUIDED SELF-HELP FOR EATING DISORDERS
OXFORD UNIV PRESS INC. 2020: S44
View details for Web of Science ID 000546262400093
Depression and anxiety mediate the relationship between insomnia and eating disorders in college women.
Journal of American college health : J of ACH
Objective: This study examined the associations between insomnia, anxiety, and depression in college women with eating disorders (EDs). Participants: Six hundred and ninety women from 28US colleges who screened positive for an ED were assessed for psychiatric comorbidities. Women were, on average, 22.12years old, mostly White (60.1%) and undergraduates (74.3%). Methods: Two mediation models were tested to determine if depression and/or anxiety mediated the relationship between insomnia and ED symptomatology. Results: One-fifth of the sample (21.7%) reported clinically moderate and severe levels of insomnia. Both depression (B=.13, p<.001) and anxiety (B=.13, p<.001) significantly mediated the relationship between insomnia and ED psychopathology. Conclusions: Insomnia is relatively common in college-age women with EDs. Findings suggest that this association between ED and sleep disturbances can be explained, in part, by changes in depression and anxiety. Clinicians should consider incorporating mental health assessments for insomnia, depression, and anxiety into current ED prevention, intervention, and screening efforts on college campuses.
View details for DOI 10.1080/07448481.2019.1710152
View details for PubMedID 31971482
Disparities in Burnout and Satisfaction With Work-Life Integration in U.S. Physicians By Gender and Practice Setting.
Academic medicine : journal of the Association of American Medical Colleges
To explore the interaction between practice setting (academic practice [AP], private practice [PP]) and gender in relation to physician burnout and satisfaction with work-life integration (WLI).In 2017, the authors administered a cross-sectional survey of U.S. physicians and characterized rates of burnout and satisfaction with WLI using previously validated and/or standardized tools. They conducted multivariable logistic regression to determine the interaction between the included variables.Of the 3,603 participants in the final analysis, female physicians reported a higher prevalence of burnout than male physicians in both AP (50.7% vs 38.2%, P < .0001) and PP (48.1% vs 40.7%, P = .001). However, the multivariable analysis found no statistically significant gender-based differences in burnout (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.76 - 1.17, P = .60). Women and men in AP were less likely to report burnout than men in PP (OR 0.70, 95% CI 0.52 - 0.94, P = .01 and OR 0.69, 95% CI 0.53 - 0.90, P < .01, respectively); women in PP did not report different burnout rates from men in PP (OR 0.89, 95% CI 0.68 - 1.16, P = .38). Women in both AP and PP were less likely to be satisfied with WLI than men in PP (OR 0.62, 95% CI 0.47 - 0.83, P < .01 and OR 0.75, 95% CI 0.58 - 0.97, P = .03, respectively); men in AP did not report different satisfaction with WLI than men in PP (OR 1.05, 95% CI 0.82 - 1.33, P = .71).Gender differences in rates of burnout are related to practice setting and other differences in physicians' personal and professional lives. These results highlight the complex relationships among gender, practice setting, and other personal and professional factors in their influence on burnout and satisfaction with WLI.
View details for DOI 10.1097/ACM.0000000000003521
View details for PubMedID 32459677
Burnout, Depression, Career Satisfaction, and Work-Life Integration by Physician Race/Ethnicity.
JAMA network open
2020; 3 (8): e2012762
Previous research suggests that the prevalence of occupational burnout varies by demographic characteristics, such as sex and age, but the association between physician race/ethnicity and occupational burnout is less well understood.To investigate possible differences in occupational burnout, depressive symptoms, career satisfaction, and work-life integration by race/ethnicity in a sample of US physicians.In this cross-sectional study, data for this secondary analysis of 4424 physicians were originally collected from a cross-sectional survey of US physicians between October 12, 2017, and March 15, 2018. The dates of analysis were March 8, 2019, to May 21, 2020. Multivariable logistic regression, including statistical adjustment for physician demographic and clinical practice characteristics, was performed to examine the association between physician race/ethnicity and occupational burnout, depressive symptoms, career satisfaction, and work-life integration.Physician demographic and clinical practice characteristics included race/ethnicity, sex, age, clinical specialty, hours worked per week, primary practice setting, and relationship status.Physicians with a high score on the emotional exhaustion or depersonalization subscale of the Maslach Burnout Inventory were classified as having burnout. Depressive symptoms were measured using the Primary Care Evaluation of Mental Disorders instrument. Physicians who marked "strongly agree" or "agree" in response to the survey items "I would choose to become a physician again" and "My work schedule leaves me enough time for my personal/family life" were considered to be satisfied with their career and work-life integration, respectively.Data were available for 4424 physicians (mean [SD] age, 52.46 [12.03] years; 61.5% [2722 of 4424] male). Most physicians (78.7% [3480 of 4424]) were non-Hispanic White. Non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic Black physicians comprised 12.3% (542 of 4424), 6.3% (278 of 4424), and 2.8% (124 of 4424) of the sample, respectively. Burnout was observed in 44.7% (1540 of 3447) of non-Hispanic White physicians, 41.7% (225 of 540) of non-Hispanic Asian physicians, 38.5% (47 of 122) of non-Hispanic Black physicians, and 37.4% (104 of 278) of Hispanic/Latinx physicians. The adjusted odds of burnout were lower in non-Hispanic Asian physicians (odds ratio [OR], 0.77; 95% CI, 0.61-0.96), Hispanic/Latinx physicians (OR, 0.63; 95% CI, 0.47-0.86), and non-Hispanic Black physicians (OR, 0.49; 95% CI, 0.30-0.79) compared with non-Hispanic White physicians. Non-Hispanic Black physicians were more likely to report satisfaction with work-life integration compared with non-Hispanic White physicians (OR, 1.69; 95% CI, 1.05-2.73). No differences in depressive symptoms or career satisfaction were observed by race/ethnicity.Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians. Future research is necessary to confirm these results, investigate factors contributing to increased rates of burnout among non-Hispanic White physicians, and assess factors underlying the observed patterns in measures of physician wellness by race/ethnicity.
View details for DOI 10.1001/jamanetworkopen.2020.12762
View details for PubMedID 32766802
Effectiveness of a Digital Cognitive Behavior Therapy-Guided Self-Help Intervention for Eating Disorders in College Women: A Cluster Randomized Clinical Trial.
JAMA network open
2020; 3 (8): e2015633
Eating disorders (EDs) are common, serious psychiatric disorders on college campuses, yet most affected individuals do not receive treatment. Digital interventions have the potential to bridge this gap.To determine whether a coached, digital, cognitive behavior therapy (CBT) intervention improves outcomes for college women with EDs compared with referral to usual care.This cluster randomized trial was conducted from 2014 to 2018 at 27 US universities. Women with binge-purge EDs (with both threshold and subthreshold presentations) were recruited from enrolled universities. The 690 participants were followed up for up to 2 years after the intervention. Data analysis was performed from February to September 2019.Universities were randomized to the intervention, Student Bodies-Eating Disorders, a digital CBT-guided self-help program, or to referral to usual care.The main outcome was change in overall ED psychopathology. Secondary outcomes were abstinence from binge eating and compensatory behaviors, as well as ED behavior frequencies, depression, anxiety, clinical impairment, academic impairment, and realized treatment access.A total of 690 women with EDs (mean [SD] age, 22.12 [4.85] years; 414 [60.0%] White; 120 [17.4%] Hispanic; 512 [74.2%] undergraduates) were included in the analyses. For ED psychopathology, there was a significantly greater reduction in the intervention group compared with the control group at the postintervention assessment (β [SE], -0.44 [0.10]; d = -0.40; t1387 = -4.23; P < .001), as well as over the follow-up period (β [SE], -0.39 [0.12]; d = -0.35; t1387 = -3.30; P < .001). There was not a significant difference in abstinence from any ED behaviors at the postintervention assessment (odds ratio, 1.48; 95% CI, 0.48-4.62; P = .50) or at follow-up (odds ratio, 1.51; 95% CI, 0.63-3.58; P = .36). Compared with the control group, the intervention group had significantly greater reductions in binge eating (rate ratio, 0.82; 95% CI, 0.70-0.96; P = .02), compensatory behaviors (rate ratio, 0.68; 95% CI, 0.54-0.86; P < .001), depression (β [SE], -1.34 [0.53]; d = -0.22; t1387 = -2.52; P = .01), and clinical impairment (β [SE], -2.33 [0.94]; d = -0.21; t1387 = -2.49; P = .01) at the postintervention assessment, with these gains sustained through follow-up for all outcomes except binge eating. Groups did not differ in terms of academic impairment. The majority of intervention participants (318 of 385 participants [83%]) began the intervention, whereas only 28% of control participants (76 of 271 participants with follow-up data available) sought treatment for their ED (odds ratio, 12.36; 95% CI, 8.73-17.51; P < .001).In this cluster randomized clinical trial comparing a coached, digital CBT intervention with referral to usual care, the intervention was effective in reducing ED psychopathology, compensatory behaviors, depression, and clinical impairment through long-term follow-up, as well as realizing treatment access. No difference was found between the intervention and control groups for abstinence for all ED behaviors or academic impairment. Given its scalability, a coached, digital, CBT intervention for college women with EDs has the potential to address the wide treatment gap for these disorders.ClinicalTrials.gov Identifier: NCT02076464.
View details for DOI 10.1001/jamanetworkopen.2020.15633
View details for PubMedID 32865576
A Framework for Applying Natural Language Processing in Digital Health Interventions.
Journal of medical Internet research
2020; 22 (2): e13855
Digital health interventions (DHIs) are poised to reduce target symptoms in a scalable, affordable, and empirically supported way. DHIs that involve coaching or clinical support often collect text data from 2 sources: (1) open correspondence between users and the trained practitioners supporting them through a messaging system and (2) text data recorded during the intervention by users, such as diary entries. Natural language processing (NLP) offers methods for analyzing text, augmenting the understanding of intervention effects, and informing therapeutic decision making.This study aimed to present a technical framework that supports the automated analysis of both types of text data often present in DHIs. This framework generates text features and helps to build statistical models to predict target variables, including user engagement, symptom change, and therapeutic outcomes.We first discussed various NLP techniques and demonstrated how they are implemented in the presented framework. We then applied the framework in a case study of the Healthy Body Image Program, a Web-based intervention trial for eating disorders (EDs). A total of 372 participants who screened positive for an ED received a DHI aimed at reducing ED psychopathology (including binge eating and purging behaviors) and improving body image. These users generated 37,228 intervention text snippets and exchanged 4285 user-coach messages, which were analyzed using the proposed model.We applied the framework to predict binge eating behavior, resulting in an area under the curve between 0.57 (when applied to new users) and 0.72 (when applied to new symptom reports of known users). In addition, initial evidence indicated that specific text features predicted the therapeutic outcome of reducing ED symptoms.The case study demonstrates the usefulness of a structured approach to text data analytics. NLP techniques improve the prediction of symptom changes in DHIs. We present a technical framework that can be easily applied in other clinical trials and clinical presentations and encourage other groups to apply the framework in similar contexts.
View details for DOI 10.2196/13855
View details for PubMedID 32130118
Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians.
Journal of general internal medicine
BACKGROUND: Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians.OBJECTIVE: To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes.DESIGN AND PARTICIPANTS: Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded.MEASURES: Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes.KEY RESULTS: Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001).CONCLUSIONS: Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians.
View details for DOI 10.1007/s11606-019-05376-x
View details for PubMedID 31734790
The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians.
Mayo Clinic proceedings
OBJECTIVE: To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians.PARTICIPANTS AND METHODS: This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory.RESULTS: Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the "not acceptable" range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001).CONCLUSION: The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.
View details for DOI 10.1016/j.mayocp.2019.09.024
View details for PubMedID 31735343
- Developing a Portfolio to Support Physicians' Efforts to Promote Well-being: One Piece of the Puzzle. Mayo Clinic proceedings 2019; 94 (11): 2171–77
- Characteristics of Academic Physicians Associated With Patient Satisfaction AMERICAN JOURNAL OF MEDICAL QUALITY 2019: 1062860619876344
- Associations Between Dietary Patterns and Sleep-Related Impairment in a Cohort of Community Physicians: A Cross-sectional Study AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2019
- Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017 MAYO CLINIC PROCEEDINGS 2019; 94 (9): 1681–94
- Medical student depression and its correlates across three international medical schools WORLD JOURNAL OF PSYCHIATRY 2019; 9 (4): 65–77
Healing the Professional Culture of Medicine.
Mayo Clinic proceedings
The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.
View details for DOI 10.1016/j.mayocp.2019.03.026
View details for PubMedID 31303431
- Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App BEHAVIORAL SLEEP MEDICINE 2019; 17 (4): 481–91
Screening and offering online programs for eating disorders: Reach, pathology, and differences across eating disorder status groups at 28U.S. universities.
The International journal of eating disorders
OBJECTIVE: The Internet-based Healthy Body Image (HBI) Program, which uses online screening to identify individuals at low risk of, high risk of, or with an eating disorder (ED) and then directs users to tailored, evidence-based online or in-person interventions to address individuals' risk or clinical status, was deployed at 28U.S. universities as part of a randomized controlled trial. The purpose of this study is to report on: (a) reach of HBI, (b) screen results, and (c) differences across ED status groups.METHOD: All students on participating campuses ages 18years or older were eligible, although recruitment primarily targeted undergraduate females.RESULTS: The screen was completed 4,894 times, with an average of 1.9% of the undergraduate female student body on each campus taking the screen. ED risk in participating students was high-nearly 60% of students screened were identified as being at high risk for ED onset or having an ED. Key differences emerged across ED status groups on demographics, recruitment method, ED pathology, psychiatric comorbidity, and ED risk factors, highlighting increasing pathology and impairment in the high-risk group.DISCUSSION: Findings suggest efforts are needed to increase reach of programs like HBI. Results also highlight the increasing pathology and impairment in the high-risk group and the importance of programs such as HBI, which provide access to timely screening and intervention to prevent onset of clinical EDs.
View details for DOI 10.1002/eat.23134
View details for PubMedID 31268183
Burnout, Professional Fulfillment and Intent-to-Leave Among Ophthalmologists: A National Study
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
View details for Web of Science ID 000488800705045
Estimating the Attributable Cost of Physician Burnout in the United States.
Annals of internal medicine
Background: Although physician burnout is associated with negative clinical and organizational outcomes, its economic costs are poorly understood. As a result, leaders in health care cannot properly assess the financial benefits of initiatives to remediate physician burnout.Objective: To estimate burnout-associated costs related to physician turnover and physicians reducing their clinical hours at national (U.S.) and organizational levels.Design: Cost-consequence analysis using a mathematical model.Setting: United States.Participants: Simulated population of U.S. physicians.Measurements: Model inputs were estimated by using the results of contemporary published research findings and industry reports.Results: On a national scale, the conservative base-case model estimates that approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States. This estimate ranged from $2.6 billion to $6.3 billion in multivariate probabilistic sensitivity analyses. At an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7600 per employed physician each year.Limitations: Possibility of nonresponse bias and incomplete control of confounders in source data. Some parameters were unavailable from data and had to be extrapolated.Conclusion: Together with previous evidence that burnout can effectively be reduced with moderate levels of investment, these findings suggest substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.
View details for DOI 10.7326/M18-1422
View details for PubMedID 31132791
A protected time policy to improve dental health among resident physicians
JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
2019; 150 (5): 362-+
Resident physicians underuse preventive dental health services. The authors assessed the barriers to and need for oral health care among residents and piloted a program to enhance dental health care among house staff.Participants from 5 residency programs received 2 hours of protected time during business hours for visits to a nearby dental office. The authors surveyed participating residents before and after the visits about barriers to seeking oral health care and their experiences with the program. The authors recorded dental findings for each participant.A total of 35 of 243 eligible residents (14.4%) participated in the study; 71.4% reported delaying or skipping preventive dental examinations during residency. Lack of time and norms and peer perceptions were important barriers; 28.6% of residents had dental findings requiring further management.Residents neglect preventive oral health care because of work obligations. More than one-quarter of residents had clinically significant dental findings. Providing protected time addressed common barriers and was well received.Resident physicians have unmet oral health care needs. Collaborations between residency programs and dental practices to provide protected time for residents to seek oral health care could address common barriers to care.
View details for DOI 10.1016/j.adaj.2018.12.016
View details for Web of Science ID 000465431400024
View details for PubMedID 31029211
Burnout Among Physicians Compared With Individuals With a Professional or Doctoral Degree in a Field Outside of Medicine.
Mayo Clinic proceedings
2019; 94 (3): 549–51
View details for PubMedID 30832797
Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017.
Mayo Clinic proceedings
OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and2014.PARTICIPANTS AND METHODS: Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools.RESULTS: Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults.CONCLUSION: Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.
View details for PubMedID 30803733
Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis.
Annals of internal medicine
Whether health care provider burnout contributes to lower quality of patient care is unclear.To estimate the overall relationship between burnout and quality of care and to evaluate whether published studies provide exaggerated estimates of this relationship.MEDLINE, PsycINFO, Health and Psychosocial Instruments (EBSCO), Mental Measurements Yearbook (EBSCO), EMBASE (Elsevier), and Web of Science (Clarivate Analytics), with no language restrictions, from inception through 28 May 2019.Peer-reviewed publications, in any language, quantifying health care provider burnout in relation to quality of patient care.2 reviewers independently selected studies, extracted measures of association of burnout and quality of care, and assessed potential bias by using the Ioannidis (excess significance) and Egger (small-study effect) tests.A total of 11 703 citations were identified, from which 123 publications with 142 study populations encompassing 241 553 health care providers were selected. Quality-of-care outcomes were grouped into 5 categories: best practices (n = 14), communication (n = 5), medical errors (n = 32), patient outcomes (n = 17), and quality and safety (n = 74). Relations between burnout and quality of care were highly heterogeneous (I2 = 93.4% to 98.8%). Of 114 unique burnout-quality combinations, 58 indicated burnout related to poor-quality care, 6 indicated burnout related to high-quality care, and 50 showed no significant effect. Excess significance was apparent (73% of studies observed vs. 62% predicted to have statistically significant results; P = 0.011). This indicator of potential bias was most prominent for the least-rigorous quality measures of best practices and quality and safety.Studies were primarily observational; neither causality nor directionality could be determined.Burnout in health care professionals frequently is associated with poor-quality care in the published literature. The true effect size may be smaller than reported. Future studies should prespecify outcomes to reduce the risk for exaggerated effect size estimates.Stanford Maternal and Child Health Research Institute.
View details for DOI 10.7326/M19-1152
View details for PubMedID 31590181
- Authors' response. Journal of the American Dental Association (1939) 2019; 150 (7): 568–69
Medical student depression and its correlates across three international medical schools.
World journal of psychiatry
2019; 9 (4): 65–77
Medical students have high rates of depression, anxiety, and burnout that have been found to affect their empathy, professional behaviors, and performance as a physician. While studies have examined predictors for burnout and depression in the United States (US), no study, to our knowledge, has compared depression in medical students cross-culturally, or has attempted to examine the effect of factors influencing rates including burnout, exercise, stress, unmet mental health needs, and region.To examine rates of depression in three international cohorts of medical students, and determine variables that may explain these differences.Convenience samples of medical students from three countries (US, China, and a Middle Eastern country whose name remains anonymous per request from the school) were surveyed in this observational study. Using the Patient Health Questionnaire-2 (PHQ-2) and a modified Maslach Burnout Inventory, depression and burnout were examined among medical students from the three cohorts (n = 473). Chi-square test and analysis of variance were used to examine differences in demographics, behavioral, and psychological variables across these three schools to identify potentially confounding descriptive characteristics. Analysis of covariance compared depression and the emotional exhaustion component of burnout identified through Principal Component Analysis across countries. Multiple linear regression was used to analyze the impact of demographic, behavioral, and psychological variables on screening positive for depression.Medical students from the Middle Eastern country had the highest rates of positive depression screens (41.1%), defined as a PHQ-2 score of ≥ 3, followed by China (14.1 %), and then the US (3.8%). More students in the Middle Eastern school had unmet mental health needs (50.8%) than at the medical school in China (34.8%) or the school in the US (32.8%) (Pearson chi-square significance < 0.05). Thus, PHQ-2 scores were adjusted for unmet mental health needs; however, the Middle Eastern country continued to have the highest depression. Adjusting for PHQ-2 score, medical students from the US scored the highest on emotional exhaustion (a measure of burnout). Demographic variables did not significantly predict medical student depression; however, lack of exercise, unmet mental health needs, stress, and emotional exhaustion predicted nearly half of depression in these cohorts. In comparison to the US, coming from the Middle Eastern country and China predicted higher levels of depression.Depression rates differ in three international cohorts of medical students. Measured factors contributed to some observed differences. Identifying site-specific prevention and intervention strategies in medical student mental health is warranted.
View details for DOI 10.5498/wjp.v9.i4.65
View details for PubMedID 31799152
View details for PubMedCentralID PMC6885455
Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial.
Journal of medical Internet research
2018; 20 (12): e296
BACKGROUND: Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak.OBJECTIVE: The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN.METHODS: Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU).RESULTS: A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the E@T or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls' expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=-15.5 [CI -26.6 to -4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating.CONCLUSIONS: Despite a significant increase in girls' EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention.TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; http://www.isrctn.com/ISRCTN18614564 (Archived by WebCite at http://www.webcitation.org/74FTV1EpF).
View details for PubMedID 30552078
Correlates of suicidal ideation in college women with eating disorders.
The International journal of eating disorders
OBJECTIVE: To identify the correlates of suicidal ideation (SI) in a large sample of college women with eating disorders (EDs).METHOD: A total of 690 female college students from 28 US colleges who screened positive for an ED, with the exception of anorexia nervosa, were assessed for SI. Univariate logistic regression analyses were performed to determine independent correlates of SI. Measures included: ED psychopathology, ED behaviors (i.e., binge eating, vomiting, laxatives, compulsive exercise), current co-morbid psychopathology (i.e., depression, anxiety, insomnia), weight/shape concerns, ED-related clinical impairment, and body mass index (BMI). All significant variables were included in a backward binary multivariate logistic regression model to determine which variables were most strongly associated with SI.RESULTS: A total of 25.6% of the sample reported SI. All variables examined were significantly independently associated with SI, with the exception of compulsive exercise. Depression, anxiety, and vomiting remained as significant correlates of SI in the multivariate logistic regression model.DISCUSSION: ED screening on college campuses should assess for suicidality, and prevention and treatment efforts should target vomiting and co-morbid depression and anxiety symptoms to reduce risk of SI for high-risk individuals.
View details for PubMedID 29626350
A Roadmap for Research on Resident Well-Being
AMERICAN JOURNAL OF MEDICINE
2018; 131 (3): 323–28
View details for PubMedID 29246867
What Do We Mean by Physician Wellness? A Systematic Review of Its Definition and Measurement
2018; 42 (1): 94–108
Physician wellness (well-being) is recognized for its intrinsic importance and impact on patient care, but it is a construct that lacks conceptual clarity. The authors conducted a systematic review to characterize the conceptualization of physician wellness in the literature by synthesizing definitions and measures used to operationalize the construct.A total of 3057 references identified from PubMed, Web of Science, and a manual reference check were reviewed for studies that quantitatively assessed the "wellness" or "well-being" of physicians. Definitions of physician wellness were thematically synthesized. Measures of physician wellness were classified based on their dimensional, contextual, and valence attributes, and changes in the operationalization of physician wellness were assessed over time (1989-2015).Only 14% of included papers (11/78) explicitly defined physician wellness. At least one measure of mental, social, physical, and integrated well-being was present in 89, 50, 49, and 37% of papers, respectively. The number of papers operationalizing physician wellness using integrated, general-life well-being measures (e.g., meaning in life) increased [X 2 = 5.08, p = 0.02] over time. Changes in measurement across mental, physical, and social domains remained stable over time.Conceptualizations of physician wellness varied widely, with greatest emphasis on negative moods/emotions (e.g., burnout). Clarity and consensus regarding the conceptual definition of physician wellness is needed to advance the development of valid and reliable physician wellness measures, improve the consistency by which the construct is operationalized, and increase comparability of findings across studies. To guide future physician wellness assessments and interventions, the authors propose a holistic definition.
View details for PubMedID 28913621
A screening tool for detecting eating disorder risk and diagnostic symptoms among college-age women.
Journal of American college health : J of ACH
As eating disorders (EDs) often emerge during college, managing EDs would ideally integrate prevention and treatment. To achieve this goal, an efficient tool is needed that detects clinical symptoms and level of risk. This study evaluated the performance of a screen designed to identify individuals at risk for or with an ED.Five hundred forty-nine college-age women.Participants completed a screen and diagnostic interview.Using parsimonious thresholds for ED diagnoses, screen sensitivity ranged from 0.90 (anorexia nervosa) to 0.55 (purging disorder). Specificity ranged from 0.99 (anorexia nervosa) to 0.78 (subthreshold binge eating disorder) compared to diagnostic interview. Moderate to high area under the curve values were observed. The screen had high sensitivity for detecting high risk.The screen identifies students at risk and has acceptable sensitivity and specificity for identifying most ED diagnoses. This tool is critical for establishing stepped care models for ED intervention.
View details for PubMedID 29979922
View details for PubMedCentralID PMC6320726
Factors Associated With Provider Burnout in the NICU
2017; 139 (5)
NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.
View details for DOI 10.1542/peds.2016-4134
View details for Web of Science ID 000400371500040
View details for PubMedID 28557756
"Physician Wellness" as Published in Academic Psychiatry
2017; 41 (2): 155–58
View details for PubMedID 28213884
Reciprocal longitudinal relations between weight/shape concern and comorbid pathology among women at very high risk for eating disorder onset.
Eating and weight disorders : EWD
Understanding how known eating disorder (ED) risk factors change in relating to one another over time may inform efficient intervention targets. We examined short-term (i.e., 1 month) reciprocal longitudinal relations between weight/shape concern and comorbid symptoms (i.e., depressed mood, anxiety) and behaviors (i.e., binge drinking) over the course of 24 months using cross-lagged panel models.Participants were 185 women aged 18-25 years at very high risk for ED onset, randomized to an online ED preventive intervention or waitlist control. We also tested whether relations differed based on intervention receipt.Weight/shape concern in 1 month significantly predicted depressed mood the following month; depressed mood in 1 month also predicted weight/shape concern the following month, but the effect size was smaller. Likewise, weight/shape concern in 1 month significantly predicted anxiety the following month, but the reverse was not true. Results showed no temporal relations between weight/shape concern and binge drinking in either direction. Relations between weight/shape concern, and comorbid symptoms and behaviors did not differ based on intervention receipt.Results support focusing intervention on reducing weight/shape concern over reducing comorbid constructs for efficient short-term change.Level I, evidence obtained from a properly designed randomized controlled trial.
View details for PubMedID 29285745
View details for PubMedCentralID PMC6170712
Encouraging Mindfulness in Medical House Staff via Smartphone App: A Pilot Study.
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry
2017; 41 (5): 646–50
Stress and burnout are increasingly recognized as urgent issues among resident physicians, especially given the concerning implications of burnout on physician well-being and patient care outcomes.The authors assessed how a mindfulness and meditation practice among residents, supported via a self-guided, smartphone-based mindfulness app, affects wellness as measured by prevalidated surveys.Residents in the departments of general surgery, anesthesia, and obstetrics and gynecology were recruited for participation in this survey-based, four-week, single-arm study. All participants used the app (Headspace) on a self-guided basis, and took surveys at enrollment, at 2 weeks, and at 4 weeks. The Positive and Negative Affect Schedule (PANAS) assessed mood, and the Freiburg Mindfulness Inventory (FMI) measured mindfulness.Forty-three residents enrolled in this study from April 2015 to August 2016; 30 residents (90% female) completed two or more surveys, and so were included for further analysis. In a comparison of baseline scores to week four scores, there was a significant increase in FMI at week four (36.88 ± 7.00; Cohen's d = 0.77, p = 0.005), a trend toward increase in the positive affect score (PAS) (31.73 ± 6.07; Cohen's d = 0.38, p = 0.08), and no change in negative affect score (NAS) (21.62 ± 7.85; Cohen's d = -0.15, p = NS). In mixed-effect multivariate modeling, both the PAS and the FMI scores showed significant positive change with increasing use of the smartphone app (PAS, 0.31 (95% CI 0.03-0.57); FMI, 0.38 (95% CI 0.11-0.66)), while the NAS did not show significant change.Study limitations include self-guided app usage, a homogenous study subject population, insufficient study subjects to perform stratified analysis of the impact of specialty on the findings, lack of control group, and possible influence from the Hawthorne effect. This study suggests the feasibility and efficacy of a short mindfulness intervention delivered by a smartphone app to improve mindfulness and associated resident physician wellness parameters.
View details for PubMedID 28795335
Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App.
Behavioral sleep medicine
Clinicians' perceptions of CBT-I Coach, a patient-facing mobile app for cognitive-behavioral therapy for insomnia (CBT-I), are critical to its adoption and integration into practice. Diffusion of innovations theory emphasizes the influence of perceptions, including the relative advantage to current practice, the compatibility to clinicians' needs, the complexity, the innovation's trialability, and observability. This study intended to evaluate the use and perceptions of CBT-I Coach among Veterans Affairs (VA)-trained CBT-I clinicians.Clinicians (N = 108) were surveyed about their use, feedback, and perceptions of CBT-I Coach a year after the app became available.Overall perceptions of CBT-I Coach were favorable. Fifty percent of clinicians reported using CBT-I Coach, with 98% intending to continue use. The app was perceived to increase sleep diary completion and homework compliance. Clinicians viewed the app as providing accessibility to helpful tools and improving patient engagement. Of those not using the app, 83% endorsed intention to use it. Reasons for nonuse were lack of patient access to smart phones, not being aware of the app, not having time to learn it, and inability to directly access app data. Those who reported using CBT-I Coach had more favorable perceptions across all constructs (p < .01 - p < .001), except relative advantage, compared to nonusers. Users perceived it as less complex and more compatible with their practice than nonusers.Continued efforts are needed to increase adoption and enhance use of CBT-I Coach, as well as study if reported benefits can be evidenced more directly.
View details for PubMedID 29120247
Web-Based Aftercare for Women With Bulimia Nervosa Following Inpatient Treatment: Randomized Controlled Efficacy Trial.
Journal of medical Internet research
2017; 19 (9): e321
Relapse rates in bulimia nervosa (BN) are high even after successful treatment, but patients often hesitate to take up further treatment. An easily accessible program might help maintain treatment gains. Encouraged by the effects of Web-based eating disorder prevention programs, we developed a manualized, Web-based aftercare program (IN@) for women with BN following inpatient treatment.The objective of this study was to determine the efficacy of the web-based guided, 9-month, cognitive-behavioral aftercare program IN@ for women with BN following inpatient treatment.We conducted a randomized controlled efficacy trial in 253 women with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) BN and compared the results of IN@ with treatment as usual (TAU). Assessments were carried out at hospital admission (T0), hospital discharge/baseline (T1), postintervention (T2; 9 months after baseline), 9-month follow-up (T3; 18 months after baseline). The primary outcome, abstinence from binge eating and compensatory behaviors during the 2 months preceding T2, was analyzed by intention to treat, using logistic regression analyses. Frequencies of binge eating and vomiting episodes, and episodes of all compensatory behaviors were analyzed using mixed effects models.At T2, data from 167 women were available. There were no significant differences in abstinence rates between the TAU group (n=24, 18.9%) and the IN@ group (n=27, 21.4%; odds ratio, OR=1.29; P=.44). The frequency of vomiting episodes in the IN@ group was significantly (46%) lower than in the TAU group (P=.003). Moderator analyses revealed that both at T2 and T3, women of the intervention group who still reported binge eating and compensatory behaviors after inpatient treatment benefited from IN@, whereas women who were already abstinent after the inpatient treatment did not (P=.004; P=.002). Additional treatment utilization was high in both groups between baseline and follow-up.Overall, data from this study suggest moderate effects of IN@. High rates of outpatient treatment utilization after inpatient treatment may have obscured potential intervention effects on abstinence. An aftercare intervention might be more beneficial as part of a stepped-care approach.International Standard Randomized Controlled Trial Number (ISRCTN): 08870215; http://www.isrctn.com/ISRCTN08870215 (Archived by WebCite at http://www.webcitation.org/6soA5bIit).
View details for PubMedID 28939544
View details for PubMedCentralID PMC5630693
Efficacy of Cognitive-Behavioral Therapy for Insomnia Combined With Antidepressant Pharmacotherapy in Patients With Comorbid Depression and Insomnia: A Randomized Controlled Trial.
journal of clinical psychiatry
2016; 77 (10): e1316-e1323
The Treatment of Insomnia and Depression (TRIAD) study evaluated the efficacy of combining depression pharmacotherapy (using MED, an ecologically valid and generalizable antidepressant medication algorithm) with cognitive-behavioral therapy for insomnia (CBT-I) among individuals with comorbid insomnia and major depressive disorder (MDD) to determine if change in insomnia severity mediates antidepressant outcome.This 16-week, 3-site, randomized controlled trial (RCT) randomly assigned 150 participants (recruited between March 2009 and August 2013), who met DSM-IV-TR criteria for insomnia and MDD and were not receiving treatment for either, to receive depression pharmacotherapy plus 7 sessions of either CBT-I or a credible control therapy for insomnia (CTRL). Depression pharmacotherapy followed a standardized 2-step algorithm, which included escitalopram, sertraline, and desvenlafaxine in a prescribed sequence. Primary measures were the Hamilton Depression Rating Scale and the depression module of the Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Nonpatient Edition, administered by raters masked to treatment assignment, and the self-administered Insomnia Severity Index (ISI).CBT-I was superior to CTRL in reducing insomnia severity (P = .028). The overall difference in depression remission between the treatments was not statistically significant (44% in CBT-I and 36% in CTRL; number needed to treat = 15). However, planned secondary analysis revealed that improvements in insomnia at week 6 mediated eventual remission from depression, with early change in ISI predicting depression remission in the CBT-I (P = .0002) but not in the CTRL arm (P = .26).CBT-I is an efficacious treatment for insomnia comorbid with MDD among patients treated with antidepressant medications. Improvement in insomnia may be related to the change in depression. Future studies should identify which patients are most likely to benefit from the addition of an insomnia-focused therapy to standard antidepressant treatments.ClinicalTrials.gov identifier NCT00767624.
View details for DOI 10.4088/JCP.15m10244
View details for PubMedID 27788313
Facebook usage among those who have received treatment for an eating disorder in a group setting.
International journal of eating disorders
2016; 49 (8): 764-777
This study explored Facebook use among individuals with a history of receiving treatment for an eating disorder (ED) in a group setting (e.g., inpatient, residential, outpatient group), focusing primarily on comparisons individuals make about their bodies, eating, or exercise to those of their peers from treatment on Facebook and the relation between these comparisons and ED pathology.Individuals (N = 415; mean age 28.15 years ± 8.41; 98.1% female) who self-reported receipt of ED treatment in a group setting were recruited via e-mail and social media to complete an online survey.Participants reported having an average of 10-19 Facebook friends from treatment and spending up to 30 min per day interacting on Facebook with individuals from treatment or ED-related organizations. More comparison to treatment peers on Facebook was associated with greater ED psychopathology and ED-related impairment. Conversely, positive interaction with treatment peers on Facebook was associated with lower ED psychopathology and ED-related impairment. Individuals who had been in treatment longer, more times, and more recently had more Facebook friends from treatment and ED-related organizations as well as spent more time in ED groups' pages on Facebook. Few participants (19.5%) reported that a therapist asked about the impact of Facebook on pathology.Interactions on Facebook could affect patients' recovery and potential for relapse. It may be helpful for treatment providers to discuss Facebook use and its potential benefits and drawbacks with patients preparing for discharge from group treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:764-777).
View details for DOI 10.1002/eat.22567
View details for PubMedID 27302908
Reducing Eating Disorder Onset in a Very High Risk Sample With Significant Comorbid Depression: A Randomized Controlled Trial
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2016; 84 (5): 402-414
Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated.206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II.ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4).An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research. (PsycINFO Database Record
View details for DOI 10.1037/ccp0000077
View details for Web of Science ID 000374765200003
View details for PubMedID 26795936
View details for PubMedCentralID PMC4836995
Universal prevention efforts should address eating disorder pathology across the weight spectrum: Implications for screening and intervention on college campuses.
Given shared risk and maintaining factors between eating disorders and obesity, it may be important to include both eating disorder intervention and healthy weight management within a universal eating disorder care delivery program. This study evaluated differential eating disorder screening responses by initial weight status among university students, to assess eating disorder risk and pathology among individuals with overweight/obesity versus normal weight or underweight.1529 individuals were screened and analyzed. Screening was conducted via pilot implementation of the Internet-based Healthy Body Image program on two university campuses.Fifteen percent of the sample had overweight/obesity. Over half (58%) of individuals with overweight/obesity screened as high risk for an eating disorder or warranting clinical referral, and 58% of individuals with overweight/obesity endorsed a ≥10-pound weight change over the past year. Compared to individuals with normal weight or underweight, individuals with overweight/obesity were more likely to identify as Black, endorse objective binge eating and fasting, endorse that eating disorder-related concerns impaired their relationships/social life and made them feel badly, and endorse higher weight/shape concerns.Results suggest rates of eating disorder pathology and clinical impairment are highest among students with overweight/obesity, and targeted intervention across weight categories and diverse races/ethnicities is warranted within universal eating disorder intervention efforts. Integrating eating disorder intervention and healthy weight management into universal prevention programs could reduce the incidence and prevalence of eating disorders, unhealthy weight control practices, and obesity among university students.
View details for DOI 10.1016/j.eatbeh.2016.03.019
View details for PubMedID 27090854
Non-suicidal self-injury and suicidal ideation in relation to eating and general psychopathology among college-age women.
2016; 235: 77-82
Non-suicidal self-injury (NSSI) and suicidal ideation are potent risk factors for suicide and are associated with general and eating disorder-specific psychopathology. Limited research has examined the effects of combined NSSI+suicidal ideation thus concurrent examination is needed to understand potential differential effects on psychopathology. College-aged women (N=508) completed self-report measures of NSSI, suicidal ideation, general psychopathology, and Eating Disorder-specific psychopathology. MANOVAs determined whether the NSSI/SI status groups differed on general and eating disorder pathology measures as a set. Significant MANOVAs were followed up with univariate ANOVAs and posthoc tests. Thirteen women endorsed NSSI+Suicidal Ideation, 70 endorsed NSSI-only, 25 endorsed Suicidal Ideation-only, and 400 endorsed no NSSI/Suicidal Ideation. Both general and eating disorder-specific psychopathology differed across groups. NSSI+Suicidal Ideation and Suicidal Ideation-only groups typically endorsed higher general psychopathology than the no NSSI/Suicidal Ideation and NSSI-only groups. Regarding eating disorder pathology, the NSSI+Suicidal Ideation group was more pathological than no NSSI/Suicidal Ideation and NSSI-only, except on the weight concerns scale, where NSSI+Suicidal Ideation only differed from no NSSI/Suicidal Ideation. The NSSI+Suicidal Ideation group was only greater than Suicidal Ideation-only on measures of depression and eating concern. Results highlight the importance of screening for both NSSI and suicidal ideation, especially for individuals with eating disorder symptoms. Likewise, screening for eating disorder pathology may be beneficial for individuals presenting with NSSI and suicidal ideation.
View details for DOI 10.1016/j.psychres.2015.11.046
View details for PubMedID 26654754
View details for PubMedCentralID PMC4724479
An exploration of key issues and potential solutions that impact physician wellbeing and professional fulfillment at an academic center.
Background. Physician wellness is a vital element of a well-functioning health care system. Not only is physician wellness empirically associated with quality and patient outcomes, but its ramifications span individual, interpersonal, organizational, and societal levels. The purpose of this study was to explore academic physicians' perceptions about their work-related wellness, including the following questions: (a) What are the workplace barriers and facilitators to their wellness? (b) What workplace solutions do theythinkwouldimprove their wellness? (c)What motivates their work? and (d) What existing wellness programs are they aware of? Methods. A multi-method design was applied to conduct a total of 19 focus group sessions in 17 clinical departments. All academic faculty ranks and career lines were represented in the 64 participating physicians, who began the sessions with five open-ended survey questions pertaining to physician wellness in their work environment. Participants entered their answers into a web-based survey program that enabled anonymous data collection. The initial survey component was followed by semi-structured focus group discussion. Data analysis of this qualitative study was informed by the general inductive approach as well as a review of extant literature through September 2015 on physician wellness, professional fulfillment, satisfaction, dissatisfaction, burnout and work-life. Results. Factors intrinsic to the work of physicians dominated the expressed reasons for work motivation. These factors all related to the theme of overall contribution, with categories of meaningful work, patient care, teaching, scientific discovery, self-motivation and matching of career interests. Extrinsic factors such as perceptions of suboptimal goal alignment, inadequate support, restricted autonomy, lack of appreciation, and suboptimal compensation and benefits dominated the risk of professional dissatisfaction. Discussion. Our findings indicate that the factors that enhance professional fulfillment and those that precipitate burnout are distinct: motivation and quality of work performed were supported by domains intrinsic to the work itself, whereas external dysfunctional work aspects resulted in frustration. Thus, it can be anticipated that optimization of physician wellness would require tailored approaches in each of these dimensions with sustained funding and support for wellness initiatives. Physicians identified the availability of resources to enable them to thrive and provide excellent patient care as their most important wellness-enhancing factor.
View details for DOI 10.7717/peerj.1783
View details for PubMedID 26989621
View details for PubMedCentralID PMC4793321
Effectiveness of Cognitive Behavioral Therapy for Veterans with Depression and Suicidal Ideation
ARCHIVES OF SUICIDE RESEARCH
2016; 20 (4): 677-682
The current study examined suicidal ideation (SI) and depression outcomes among Veterans receiving Cognitive Behavioral Therapy for depression (CBT-D) throughout the Department of Veterans Affairs health care system. Patient outcomes included Beck Depression Inventory-II total score and SI item. Of 902 patients, 427 (47%) had no SI, 405 (45%) had SI but no suicidal intent, 26 (3%) indicated suicidal desire, 8 (1%) indicated suicide intent if they had the chance, and 36 (4%) did not answer this question at session one. The odds of SI decreased by 64% from 1.03 at session one to 0.37 at final assessment (OR = 0.36; 95% CI: 0.31, 0.43). Findings reveal that CBT-D was associated with significant decreases in SI and depression among Veterans.
View details for DOI 10.1080/13811118.2016.1162238
View details for Web of Science ID 000392982200014
View details for PubMedID 26983897
CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia
JOURNAL OF CLINICAL SLEEP MEDICINE
2016; 12 (4): 597-606
This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176).VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released.Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes.Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.
View details for DOI 10.5664/jcsm.5700
View details for Web of Science ID 000374140000019
View details for PubMedID 26888586
View details for PubMedCentralID PMC4795288
Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders
JOURNAL OF AMERICAN COLLEGE HEALTH
2016; 64 (4): 300-308
To examine the misuse of attention-deficit/hyperactivity disorder (ADHD)-specific stimulants in a college population at high risk for or with clinical or subclinical eating disorders.Four hundred forty-eight college-age women aged 18-25 at high risk for or with a clinical or subclinical eating disorder.Participants completed assessments of stimulant misuse and psychopathology from September 2009 to June 2010.Greater eating disorder pathology, objective binge eating, purging, eating disorder-related clinical impairment, depressive symptoms, perceived stress, and trait anxiety were associated with an increased likelihood of stimulant misuse. Subjective binge eating, excessive exercise, and dietary restraint were not associated with stimulant misuse.ADHD-specific stimulant misuse is associated with eating disorder and comorbid pathology among individuals at high risk for or with clinical or subclinical eating disorders. Screening for stimulant misuse and eating disorder pathology may improve identification of college-age women who may be engaging in maladaptive behaviors and inform prevention efforts.
View details for DOI 10.1080/07448481.2016.1138477
View details for Web of Science ID 000375464400004
View details for PubMedID 26822019
View details for PubMedCentralID PMC4904716
Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans
BEHAVIOUR RESEARCH AND THERAPY
2015; 74: 25-31
This paper examines the effects of Acceptance and Commitment Therapy for depression (ACT-D), and the specific effects of experiential acceptance and mindfulness, in reducing suicidal ideation (SI) and depression among Veterans.Patients included 981 Veterans, 76% male, mean age 50.5 years. Depression severity and SI were assessed using the BDI-II. Experiential acceptance and mindfulness were measured with the Acceptance and Action Questionnaire-II (AAQ-II) and the Five Facet Mindfulness Questionnaire, respectively.Of the 981 patients, 647 (66.0%) completed 10 or more sessions or finished early due to symptom relief. For Veterans with SI at baseline, mean BDI-II score decreased from 33.5 to 22.9. For Veterans with no SI at baseline, mean BDI-II score decreased from 26.3 to 15.9. Mixed models with repeated measurement indicated a significant reduction in depression severity from baseline to final assessment (b = -10.52, p < .001). After adjusting for experiential acceptance and mindfulness, patients with SI at baseline demonstrated significantly greater improvement in depression severity during ACT-D treatment, relative to patients with no SI at baseline (b = -2.81, p = .001). Furthermore, increases in experiential acceptance and mindfulness scores across time were associated with a reduction in depression severity across time (b = -0.44, p < .001 and b = -0.09, p < .001, respectfully), and the attenuating effect of mindfulness on depression severity increased across time (b = -0.05, p = .042). Increases in experiential acceptance scores across time were associated with lower odds of SI across time (odds ratio = 0.97, 95% CI [0.95, 0.99], p = .016) and the attenuating effect of experiential acceptance on SI increased across time (odds ratio = 0.96, 95% CI [0.92, 0.99], p = .023). Overall the number of patients with no SI increased from 44.5% at baseline to 65% at follow-up.Veterans receiving ACT-D demonstrated decreased depression severity and decreased odds of SI during treatment. Increases in experiential acceptance and mindfulness scores were associated with reduction in depression severity across time and increases in experiential acceptance scores were associated with reductions in SI across time.
View details for DOI 10.1016/j.brat.2015.08.012
View details for Web of Science ID 000364269400004
View details for PubMedID 26378720
Group Dialectical-Behavior Therapy Skills Training for Conversion Disorder With Seizures.
journal of neuropsychiatry and clinical neurosciences
2015; 27 (3): 240-243
Neuroimaging evidence suggests deficits in affective regulation in conversion disorder (CD). Dialectical-behavior therapy skills training (DBT-ST) was developed to target emotion dysregulation. This study was aimed to test the feasibility of stand-alone DBT-ST for CD using Linehan's manual for borderline personality disorder. In a prospective naturalistic design, 19 adult outpatients diagnosed with video EEG-confirmed seizure type CD were recruited and received weekly group DBT. Seventeen out of 19 subjects finished an average of 20.5 weeks of treatment. The mean seizure rate decreased by 66%. Cessation of seizures occurred in 35% of the sample. Completion rates reached 90%.
View details for DOI 10.1176/appi.neuropsych.13120359
View details for PubMedID 25959039
Identification as overweight by medical professionals: Relation to eating disorder diagnosis and risk
2015; 17: 62-68
Discussions about weight between medical professionals and young adults may increase risk of eating disorders (EDs). Clarifying the relation between screening for overweight and ED risk is needed.548 college-age women were classified as at-risk (n=441) or with an ED (n=107), and were assessed for disordered eating attitudes, behaviors, and relevant history, including, "Has a doctor, nurse, or other medical professional ever told you that you were overweight?" Regression analyses were used to evaluate the relations between being identified as overweight and current disordered eating behaviors, attitudes, and ED diagnosis, without and with covariates (history of weight-related teasing, history of an ED, family history of being identified as overweight, and current body mass index).146 (26.6%) women reported being previously identified as overweight by a medical professional. There was no relation between being previously identified as overweight and having an ED. Those identified as overweight were more likely to have weight/shape concerns above a high-risk cutoff, but showed no difference in dietary restraint, binge eating, purging behaviors, or excessive exercise compared to those not identified.Being previously identified as overweight by a medical professional was associated with increased weight/shape concerns but not with current disordered eating behaviors or ED status. Minimizing the potential negative effects of overweight screening on weight and shape concerns by providing patients with strategies to increase healthy lifestyle behaviors and long-term support for healthy weight loss goals may have a positive impact on reducing the public health problem of overweight and obesity.
View details for DOI 10.1016/j.eatbeh.2014.12.013
View details for Web of Science ID 000351834000013
View details for PubMedID 25602172
View details for PubMedCentralID PMC4380786
National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans.
International journal of geriatric psychiatry
2015; 30 (3): 308-315
Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.A total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings. Copyright © 2014 John Wiley & Sons, Ltd.
View details for DOI 10.1002/gps.4143
View details for PubMedID 24890708
Comparison of the Effectiveness of Cognitive Behavioral Therapy for Depression among Older Versus Younger Veterans: Results of a National Evaluation.
journals of gerontology. Series B, Psychological sciences and social sciences
2015; 70 (1): 3-12
The effectiveness of cognitive behavioral therapy for depression (CBT-D) among older adults in routine clinical settings has received limited attention. The current article examines and compares outcomes of older versus younger veterans receiving CBT-D nationally.Patient outcomes were assessed using the Beck Depression Inventory-II and World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.A total of 764 veterans aged 18-64 and 100 veterans aged 65+ received CBT-D; 68.0% of older and 68.3% of younger patients completed all sessions or finished early due to symptom relief, and mean depression scores declined from 27.0 (standard deviation [SD] = 10.7) to 16.2 (SD = 12.4) in the older group and from 29.1 (SD = 11.2) to 17.8 (SD = 13.5) in the younger group. Within-group effect sizes were d = 1.01 for both groups. Significant increases in quality of life and therapeutic alliance were observed for both groups.CBT-D resulted in significant improvements in depression and quality of life among older patients. Outcomes and rate of attrition were equivalent to younger patients. Findings indicate that CBT-D is an effective and acceptable treatment for older veterans in real-world settings with often high levels of depression.
View details for DOI 10.1093/geronb/gbt096
View details for PubMedID 24218096
- Psychiatric co-morbidity in women presenting across the continuum of disordered eating EATING BEHAVIORS 2014; 15 (4): 686-693
- Moderators and mediators of outcome in Internet-based indicated prevention for eating disorders BEHAVIOUR RESEARCH AND THERAPY 2014; 63: 114-121
- Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help BEHAVIOUR RESEARCH AND THERAPY 2014; 63: 90-98
A population-wide screening and tailored intervention platform for eating disorders on college campuses: the healthy body image program.
Journal of American college health
2014; 62 (5): 351-356
Abstract Objectives: This article presents a new approach to intervention for eating disorders and body image concerns on college campuses, using a model of integrated eating disorder screening and intervention. Formative data on implementation feasibility are presented. Participants: College students enrolled at 2 universities between 2011 and 2012. Methods: The Healthy Body Image program is an evidence-based screening and intervention platform, enacted via community and online resources. An online screen was used to identify students at varying levels of risk or eating disorder symptom status; responses were used to direct students to universal or targeted online interventions or further evaluation. Universal prevention programs to improve healthy weight regulation and body image culture were offered to all students. Results: Formative data from 1,551 students illustrates the application of this model. Conclusions: The Healthy Body Image program is feasible to deliver and provides a comprehensive system of screening, evidence-based intervention, and community culture change.
View details for DOI 10.1080/07448481.2014.901330
View details for PubMedID 24621000
View details for PubMedCentralID PMC4031301
Cognitive Behavioral Therapy for insomnia with veterans: Evaluation of effectiveness and correlates of treatment outcomes.
Behaviour research and therapy
2014; 53: 41-46
This paper examines the effectiveness of Cognitive Behavioral Therapy for insomnia (CBT-I) in Veterans and the effects of two process measures on CBT-I outcomes: 1) therapist ratings of patient adherence and 2) patient ratings of therapeutic alliance. Data are from 316 therapists in the Department of Veterans Affairs CBT-I Training Program and 696 patients receiving CBT-I from therapists undergoing training. Mixed effects model results indicate Insomnia Severity Index scores decreased from 20.7 at baseline to 10.9 (d = 2.3) during a typical course of CBT-I. Patients with highest tercile compared to those with lowest tercile adherence achieved, on average, 4.1 points greater reduction in ISI scores (d = 0.95). The effect of therapeutic alliance on change in insomnia severity was not significant after adjusting for adherence to CBT-I. These results support the effectiveness and feasibility of large-scale training in and implementation of CBT-I and indicate that greater focus on patient adherence may lead to enhanced outcomes. The current findings suggest that CBT-I therapists and training programs place greater emphasis on attending to and increasing patient adherence.
View details for DOI 10.1016/j.brat.2013.11.006
View details for PubMedID 24412462
- An Internet-based positive psychology program: Strategies to improve effectiveness and engagement JOURNAL OF POSITIVE PSYCHOLOGY 2014; 9 (6): 494-501
Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help.
Behaviour research and therapy
2014; 63C: 90–98
Student Bodies, an internet-based intervention, has successfully reduced weight/shape concerns and prevented eating disorders in a subset of college-age women at highest risk for an eating disorder. Student Bodies includes an online, guided discussion group; however, the clinical utility of this component is unclear. This study investigated whether the guided discussion group improves program efficacy in reducing weight/shape concerns in women at high risk for an eating disorder. Exploratory analyses examined whether baseline variables predicted who benefitted most. Women with high weight/shape concerns (N = 151) were randomized to Student Bodies with a guided discussion group (n = 74) or no discussion group (n = 77). Regression analyses showed weight/shape concerns were reduced significantly more among guided discussion group than no discussion group participants (p = 0.002; d = 0.52); guided discussion group participants had 67% lower odds of having high-risk weight/shape concerns post-intervention (p = 0.02). There were no differences in binge eating at post-intervention between the two groups, and no moderators emerged as significant. Results suggest the guided discussion group improves the efficacy of Student Bodies in reducing weight/shape concerns in college students at high risk for an eating disorder.
View details for PubMedID 25461783
Moderators and mediators of outcome in Internet-based indicated prevention for eating disorders.
Behaviour research and therapy
2014; 63C: 114–21
The objective of this study was to investigate moderators and mediators of the effect of an indicated prevention program for eating disorders (ED) on reduction of dysfunctional attitudes and specific ED symptoms. 126 women (M age = 22.3; range 18-33) reporting subthreshold ED symptoms were randomized to the Student Bodies™+ (SB+) intervention or an assessment-only control condition. Assessments took place at pre-intervention, mid-intervention (mediators), post-intervention, and 6-month follow-up. Mixed effects modeling including all available data from all time points were used for the data analysis. Intervention effects on the reduction of binge rate were weaker for participants with higher baseline BMI and for participants with a lower baseline purge rate. Intervention effects on reduction of eating disorder pathology were weaker for participants with higher baseline purge rate and with initial restrictive eating. No moderators of the intervention effect on restrictive eating were identified. An increase in knowledge mediated the beneficial effect of SB+ on binge rate. The results suggest that different moderators should be considered for the reduction of symptoms and change in attitudes of disturbed eating and that SB+ at least partially operates through psychoeducation.
View details for PubMedID 25461786
Validation of a Six-Item Male Body Image Concerns Scale (MBICS).
2014; 22 (5): 420-434
Elevated body image concerns may be a risk factor for eating disorders among males and contribute to a range of other mental health problems. This study tested a 6-item measure of general male body image concerns in two studies with adolescent males ages 14-18 (total N = 122). The measure showed strong convergent validity, scale score reliability, and test-retest reliability, and was significantly correlated with the number of episodes of binge eating in the past month. A short scale will relieve participant burden and provide a useful research tool for studies with males at risk for or with eating disorders.
View details for DOI 10.1080/10640266.2014.925768
View details for PubMedID 24964387
National Dissemination of Cognitive Behavioral Therapy for Insomnia in Veterans: Therapist- and Patient-Level Outcomes
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2013; 81 (5): 912-917
Objective: To evaluate the effects of national training in and implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I) in the U.S. Department of Veterans Affairs (VA) health care system on clinicians' competency and patients' insomnia severity, symptoms of depression, and quality of life. Method: A prospective cohort of 102 VA clinicians (including mental health staff in various mental health and primary care settings) participated in the VA CBT-I Training Program during 2011 and 2012. Patients included 182 veterans treated by clinicians enrolled in the training. Clinicians were rated on taped therapy sessions, using a standardized competency rating form. Patients' symptoms were assessed using the Insomnia Severity Index (ISI) and standardized measures of depression and quality of life. Results: Of 102 clinicians attending workshop training, 94 (92%) met all training requirements, including minimum competency score criteria. Of 182 patients, 122 (67%) completed treatment. The mixed effects model revealed significant reductions in average patient ISI score (from 19.9 to 10.2, standard error = 3.0). Patients also improved on measures of depression and quality of life. Conclusion: National training in and implementation of CBT-I resulted in a significant increase in therapist competency to deliver CBT-I for almost all clinicians and in a large reduction in insomnia severity and improvement in depression and quality of life among veterans. Observed effect sizes are comparable to results of randomized clinical trials. These results suggest CBT-I can be feasibly and effectively disseminated to routine clinical settings, with very favorable patient outcomes. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
View details for DOI 10.1037/a0032554
View details for Web of Science ID 000324780500017
View details for PubMedID 23586730
- Training in and implementation of Acceptance and Commitment Therapy for depression in the Veterans Health Administration: Therapist and patient outcomes BEHAVIOUR RESEARCH AND THERAPY 2013; 51 (9): 555-563
Effectiveness of acceptance and commitment therapy for depression: Comparison among older and younger veterans
AGING & MENTAL HEALTH
2013; 17 (5): 555-563
Limited data exist on outcomes of older adults receiving psychotherapy for depression in real-world settings. Acceptance and Commitment Therapy for depression (ACT-D) offers potential utility for older individuals who may experience issues of loss, reduced control, and other life changes. The present article examines and compares outcomes of older and younger Veterans receiving ACT-D nationally in the U.S. Department of Veterans Affairs health care system.Patient outcomes were assessed using the Beck Depression Inventory-Second Edition and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory-Short Revised.Six hundred fifty-five Veterans aged 18-64 and 76 Veterans aged 65+ received ACT-D. Seventy-eight percent of older and 67% of younger patients completed all sessions or finished early. Mean depression scores declined from 28.4 (SD = 11.4) to 17.5 (SD = 12.0) in the older group and 30.3 (SD = 10.6) to 19.1 (SD = 14.3) in the younger group. Within-group effect sizes were d = .95 and d = 1.06 for the two age groups, respectively. Quality of life and therapeutic alliance also increased during treatment.The findings suggest that ACT-D is an effective and acceptable treatment for older Veterans treated in routine clinical settings, including those with high levels of depression.
View details for DOI 10.1080/13607863.2013.789002
View details for Web of Science ID 000320913300005
View details for PubMedID 23607328
What constitutes clinically significant binge eating? Association between binge features and clinical validators in college-age women
INTERNATIONAL JOURNAL OF EATING DISORDERS
2013; 46 (3): 226-232
To investigate the association between binge features and clinical validators.The Eating Disorder Examination assessed binge features in a sample of 549 college-age women: loss of control (LOC) presence, binge frequency, binge size, indicators of impaired control, and LOC severity. Clinical validators were self-reported clinical impairment and current psychiatric comorbidity, as determined via a semistructured interview.Compared with women without LOC, those with LOC had significantly greater odds of reporting clinical impairment and comorbidity (ps < 0.001). Among women with LOC (n = 252), the indicators of impaired control and LOC severity, but not binge size or frequency, were associated with greater odds of reporting clinical impairment and/or comorbidity (ps < 0.05). DICUSSION: Findings confirm that the presence of LOC may be the hallmark feature of binge eating. Further, dimensional ratings about the LOC experience--and possibly the indicators of impaired control--may improve reliable identification of clinically significant binge eating.
View details for DOI 10.1002/eat.22115
View details for Web of Science ID 000316216100004
View details for PubMedID 23386591
- Motivation and Changes in Depression COGNITIVE THERAPY AND RESEARCH 2013; 37 (2): 368-379
National Dissemination of Cognitive Behavioral Therapy for Depression in the Department of Veterans Affairs Health Care System: Therapist and Patient-Level Outcomes
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2012; 80 (5): 707-718
The Department of Veterans Affairs (VA) health care system is nationally disseminating and implementing cognitive behavioral therapy for depression (CBT-D). The current article evaluates therapist and patient-level outcomes associated with national training in and implementation of CBT-D in the VA health care system.Therapist competencies were assessed with the Cognitive Therapy Rating Scale (CTRS). Patient outcomes were assessed with the Beck Depression Inventory-II and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed with the Working Alliance Inventory-Short Revised. Two-hundred twenty-one therapists have received training, and 356 veteran patients have received treatment through the VA CBT-D Training Program.Of therapists who have participated in the program, 182 (82%) completed all training requirements and achieved competency, reflected by a score of 40 on the CTRS. Of 356 patients, nearly 70% completed 10 or more sessions or improved sufficiently to stop therapy before the 10th session. Mean depression scores decreased by approximately 40% from initial to later treatment phase. Effect sizes of changes ranged from d = 0.39 to d = 0.74 for quality of life and from d = 0.47 to d = 0.66 for therapeutic alliance measures.National training in and implementation of CBT-D within the VA health care system is associated with significant, positive therapist training outcomes, as evidenced by increases in CBT core competencies. The implementation of the protocol by newly trained CBT-D therapists is associated with significantly improved patient outcomes, as evidenced by large decreases in depression and improvements in quality of life.
View details for DOI 10.1037/a0029328
View details for Web of Science ID 000309312400001
View details for PubMedID 22823859
Effects of an Internet-based intervention for subthreshold eating disorders: A randomized controlled trial
15th Annual Meeting of the Eating-Disorders-Research-Society
PERGAMON-ELSEVIER SCIENCE LTD. 2012: 93–99
Women reporting initial eating disorder (ED) symptoms are at highest risk for the development of an eating disorder. Preventive interventions should, therefore, be specifically tailored for this subgroup.To adapt and evaluate the effects of the Internet-based prevention program "Student Bodies™" for women with symptoms of disordered eating and/or subthreshold eating disorder (ED) syndromes.126 women, reporting subthreshold ED symptoms (high weight and shape concerns and below threshold bingeing, purging, chronic dieting or several of these symptoms) were randomly assigned to a Student Bodies™+ (SB+) intervention or a wait-list control group and assessed at pre-intervention, post-intervention, and 6-month follow-up. "Student Bodies™" was adapted to be suitable for subthreshold EDs. Main outcome measures were attitudes and symptoms of disordered eating. Pre-follow-up data were analyzed by ANCOVAS with mixed effects.At 6-month follow-up, compared to participants in the control group, participants in the intervention group showed significantly greater improvements on ED-related attitudes. Intervention participants also showed 67% (95% CI = 20-87%) greater reductions in combined rates of subjective and objective binges, and 86% (95% CI = 63-95%) greater reduction in purging episodes. Also, the rates of participants abstinent from all symptoms of disordered eating (restrictive eating, binge eating and any compensatory behavior) were significantly higher in the intervention group (45.1% vs. 26.9%). Post-hoc subgroup analyses revealed that for participants with binge eating the effect on EDE-Q scores was larger than in the pure restricting subgroup.The adapted "SB+" program represents an effective intervention for women with subthreshold EDs of the binge eating subtype.
View details for DOI 10.1016/j.brat.2011.09.013
View details for Web of Science ID 000301019200002
Depressive symptom dimensions and cardiac prognosis following myocardial infarction: results from the ENRICHD clinical trial
2012; 42 (1): 51-60
Depression following myocardial infarction (MI) independently increases risk for early cardiac morbidity and mortality. Studies suggest that somatic, but not cognitive, depressive symptoms are responsible for the increased risk. However, the effects of somatic depressive symptoms at follow-up, after sufficient time has elapsed to allow for physical recovery from the initial infarction, are not known. Our aim was to examine the relationship between cognitive and somatic depressive symptom dimensions at baseline and 12 months post-MI and subsequent mortality and cardiovascular morbidity.Patients were 2442 depressed and/or socially isolated men and women with acute MI included in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial. We used principal components analysis (PCA) of the Beck Depression Inventory (BDI) items to derive subscales measuring cognitive and somatic depressive symptom dimensions, and Cox regression with Bonferroni correction for multiple testing to examine the contribution of these dimensions to all-cause mortality, cardiovascular mortality, and first recurrent non-fatal MI.After adjusting for medical co-morbidity and Bonferroni correction, the somatic depressive symptom dimension assessed proximately following MI did not significantly predict any endpoints. At 12 months post-MI, however, this dimension independently predicted subsequent all-cause [hazard ratio (HR) 1.43, 95% confidence interval (CI) 1.13-1.81] and cardiovascular mortality (HR 1.60, 95% CI 1.17-2.18). No significant associations were found between the cognitive depressive symptom dimension and any endpoints after Bonferroni correction.Somatic symptoms of depression at 12 months post-MI in patients at increased psychosocial risk predicted subsequent mortality. Psychosocial interventions aimed at improving cardiac prognosis may be enhanced by targeting somatic depressive symptoms, with particular attention to somatic symptom severity at 12 months post-MI.
View details for DOI 10.1017/S0033291711001000
View details for Web of Science ID 000298961600005
View details for PubMedID 21682949
Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues
JOURNAL OF CLINICAL SLEEP MEDICINE
2012; 8 (2): 209-218
Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.
View details for DOI 10.5664/jcsm.1786
View details for Web of Science ID 000302862200017
View details for PubMedID 22505869
View details for PubMedCentralID PMC3311421
An e-mail delivered CBT for sleep-health program for college students: effects on sleep quality and depression symptoms.
Journal of clinical sleep medicine
2011; 7 (3): 276-281
We examined the effects of a cognitive behavioral self-help program (Refresh) to improve sleep, on sleep quality and symptoms of depression among first-year college students.Students in one residence hall (n = 48) participated in Refresh and students in another residence hall (n = 53) participated in a program of equal length (Breathe) designed to improve mood and increase resilience to stress. Both programs were delivered by e-mail in 8 weekly PDF files. Of these, 19 Refresh program participants and 15 Breathe program participants reported poor sleep quality at baseline (scores ≥ 5 on the Pittsburgh Sleep Quality Index [PSQI]). Participants completed the PSQI and the Center for Epidemiological Studies-Depression Scale (CES-D) at baseline and post-intervention.Among students with poor sleep (PSQI > 5) at baseline, participation in Refresh was associated with greater improvements in sleep quality and greater reduction in depressive symptoms than participation in Breathe. Among students with high sleep quality at baseline there was no difference in baseline to post-intervention changes in sleep (PSQI) or depressive symptom severity (CES-D).A cognitive behavioral sleep improvement program delivered by e-mail may be a cost effective way for students with poor sleep quality to improve their sleep and reduce depressive symptoms. An important remaining question is whether improving sleep will also reduce risk for future depression.
View details for DOI 10.5664/JCSM.1072
View details for PubMedID 21677898
View details for PubMedCentralID PMC3113967
- An E-mail Delivered CBT for Sleep-Health Program for College Students: Effects on Sleep Quality and Depression Symptoms JOURNAL OF CLINICAL SLEEP MEDICINE 2011; 7 (3): 273-278
Binge Drinking in Women at Risk for Developing Eating Disorders
INTERNATIONAL JOURNAL OF EATING DISORDERS
2009; 42 (5): 409-414
To determine binge drinking rates in college-age women at risk for eating disorders and to examine factors related to binge drinking over time.Participants were 480 college-age women who were at high risk for developing an eating disorder (ED) and who had a body mass index (BMI) between 18 and 32. Participants were assessed annually for 4 years.Participants reported high rates of binge drinking and frequent binge drinking throughout college. Binge drinking was positively correlated with dietary restraint, coping using substances, coping using denial, and life events.The study's findings suggest that binge drinking is highly prevalent in women at high risk for developing eating disorders. Results also indicated that binge drinking was related to dieting and maladaptive coping patterns. Intervention for women with strong weight and shape concerns should also address problematic alcohol use.
View details for Web of Science ID 000267299100005
View details for PubMedID 19115362
Smoking Behavior Postmvocardial Infarction Among ENRICHD Trial Participants: Cognitive Behavior Therapy Intervention for Depression and Low Perceived Social Support Compared With Care as Usual
2008; 70 (8): 875-882
Patients with cardiovascular disease who stop smoking lower their risk of subsequent morbidity and mortality. However, patients who have suffered a myocardial infarction (MI) are more likely to be depressed than the general population, which may make smoking cessation more difficult. Poor social support may also make smoking cessation more difficult for some patients. This study examines the effect of cognitive behavior therapy (CBT) for depression, low perceived social support or both on smoking behavior in post-MI patients.Participants were 1233 patients with a history of smoking enrolled in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial who provided 7-day point-prevalence smoking behavior information at baseline and at two or more follow-up assessments. The ENRICHD trial enrolled post-MI patients with depression, low perceived social support or both. Participants were randomly assigned to either CBT intervention or usual care. We used mixed effects models to accommodate data from multiple smoking point-prevalence measures for each individual participant.CBT did not significantly reduce post-MI smoking across all intervention patients with a history of smoking. However, CBT did reduce post-MI smoking among the subgroup of depressed patients with adequate perceived social support (OR, 0.68; 95% CI, 0.47-0.98).CBT for depression without more specific attention to smoking cessation may have little overall value as a strategy for helping post-MI patients refrain from smoking. However, use of CBT to treat depression may have the gratuitous benefit of reducing smoking among some post-MI patients.
View details for DOI 10.1097/PSY.0b013e3181842897
View details for Web of Science ID 000260401100006
View details for PubMedID 18842753
When the party for some becomes a problem for others: The effect of perceived secondhand consequences of drinking behavior on drinking norms
JOURNAL OF PSYCHOLOGY
2008; 142 (1): 57-69
The authors examined the influence of fraternity men's expectancies regarding secondhand consequences of excessive drinking behavior on normative standards regarding alcohol use and consumption levels. Participants were 381 men from 26 chapters of 2 national fraternities. One organization participated in a brief intervention involving discussion of secondhand consequences of excessive drinking. Immediate influence of the intervention on perceived secondhand consequences of alcohol use was assessed using a posttest-only, randomized groups design. Results supported a hypothesized measurement model with 1 overall secondhand consequence expectancy construct and 4 subfactors: (a) Noise Disruptive of Sleep and Study, (b) Violence, (c) Sexual Assault, and (d) Property Damage. Cross-sectional analysis at the chapter and individual levels demonstrated that secondhand expectancies had an indirect effect on alcohol consumption, mediated by personal consumption standards for limiting alcohol consumption. The intervention had an effect on secondhand expectancies. Findings suggest that interventions with intact groups can increase secondhand expectancies regarding excessive drinking and may lead to a reduction in excessive alcohol consumption.
View details for Web of Science ID 000253432400004
View details for PubMedID 18350844