Chronic Mental Health Conditions Research Articles

Chronic Care, Dementia Care Management, and Financial Considerations

The needs of persons living with Alzheimer's disease and Alzheimer's disease–related dementia (AD/ADRD) are challenged by tremendous complexity impacting both care delivery and financing. Most persons living with dementia (PLWD) also suffer from other chronic medical or mental health conditions, which further burden quality of life and function. In addition to difficult treatment choices, optimal dementia care models likely involve people and services that are not typical pieces of the health care delivery system but are all critical partners—care partners, social workers, and community services, to name a few. More than 200 models of dementia care have demonstrated some efficacy. However, these successful interventions that might address much of the care needed by PLWD are uninsured in the United States, where insurance coverage has focused on acute care needs. This poses great difficulties for both care provision and care financing. In this article, we review these 3 key challenges: dementia care for those with chronic comorbid disease; care models that require people who are not typical providers in traditional care delivery systems; and the mandate to provide high-quality care that is currently not funded by usual health care insurance. We propose promising next steps that could substantially improve the lives of PLWD and the lives of their care partners, and highlight some of the many research questions that remain.

Social Inferences as Mediators of Wellbeing in Depression.

BackgroundDepression is an increasingly prevalent chronic mental health condition that involves a range of potentially negative implications, in the long term. Theory of Mind (ToM) serves to form and maintain social relationships, by accurately identifying thoughts and emotions in others. Defective ToM abilities have been noted in people with a history of clinical depression.PurposeTo identify whether impairments of emotion recognition are correlated with a lower subjective feeling of wellbeing in people diagnosed with a chronic depressive illness.Patients and MethodsIn a cross-sectional analysis of a recurrent depressive disorder (RDD, as per WHO ICD-10 nosology) cohort (n=57), the BECK depression scale and the “Reading the mind in the eyes” test were employed for the diagnosis of clinical symptoms, and for the evaluation of individual ToM skills, respectively. Wellbeing was quantified using the FANLCT scale.ResultsThe wellbeing of service-users decreased significantly, in correlation with their defective emotion recognition abilities. Additionally, a low capacity for the correct perception of emotions in other people appears to significantly influence the social relationships status, with scores of 14.00 (10.00–18.50) at low capacity vs 23.00 (17.58–24.75) at normal capacity (Mann–Whitney U-test, p < 0.001). Our study findings indicate that a normal ability for a correct recognition of emotions in others is significantly and strongly correlated with adequate social relationships (Spearman r = 0.757, p < 0.05).ConclusionWellbeing is significantly correlated with the individual ability for a correct recognition of emotions in others.

Attachment-Based Treatment of Chronic Medical Disorders: Learning from Stress-Based Mental Health Conditions

Adaptation to stressful conditions has been considered as a cause of chronic medical disorders for many years. However, the failure of adaptation involved in the genesis of these disorders has never been connected to mental health conditions that have the same adaptation failures to stress. A failure in the type of attachment in which parents help their children adapt to fearful conditions, which involves the hippocampus and amygdala regions in the brain, might be an underlying cause for both chronic medical disorders and mental health conditions. This paper will provide evidence for the underlying continuity of these conditions, as they relate to a similar type of attachment failure, as it impedes successful adaptation to stress. To demonstrate this continuity, case material is provided on patients with both conditions who are given model treatments that resolve each sequentially, indicating that they have a common attachment-based root. The importance of treating patients’ attachment-based deficits for both their medical and mental health issues concurrently supports using alternative, holistic medical strategies and attachment-based psychotherapy, in which the therapist can experience the fear of the patient and then advocate for them to help them resolve their problems for both types of conditions. The importance of using these therapies in treating chronic medical and mental health conditions is strongly supported by this evidence. These interventions are not adjunctive to the medical treatments but are as primary as the medical interventions in developing more pervasive resolution of the conditions.

Biopsychosocial factors and health outcomes associated with cannabis, opioids and benzodiazepines use among older veterans

ABSTRACT Background: Older Veterans may experience injuries that result in chronic pain and mental health conditions. Given the increasing availability of medical cannabis, it is important to examine if it serves as a viable or undesirable form of care relative to existing approaches. Objectives: We compared cannabis, prescription opioids, and benzodiazepines use between older Veteran and non-Veterans, and identified outcomes of cannabis use among Veterans. Because of the physical and mental conditions experienced by older Veterans we expected Veterans to report higher use of opioids and benzodiazepines compared to non-Veterans. Methods: We collected surveys from individuals aged 60 and older enrolled in the Illinois Medical Cannabis Patient Program and conducted logistic regression to identify factors associated with cannabis, opioids and benzodiazepines use between Veterans (N = 514, 90.2% male) and Non-Veterans (N = 2758, 41.1% male) across biopsychosocial factors. Results: Both groups reported similar levels of pain, quality of life, social satisfaction, and sleep quality. Veterans were more likely to use cannabis for mental health conditions (p = <.001) while they reported lower use for pain-related conditions (p = <.001) than non-Veterans. Veterans were less likely to use opioids (p = .013) and benzodiazepines (p < .01) compared to non-Veterans. Veterans also reported desirable health outcomes of cannabis use for pain, sleep quality, health conditions, and quality of life. Conclusions: Our work provides insights for clinicians and policy makers to consider whether cannabis can be a viable option to reduce or replace opioid and benzodiazepine use by older Veterans with chronic physical and mental health conditions.

Enhancing Diabetes Self-Management Education and Psychological Services for Veterans With Comorbid Chronic Health and Mental Health Conditions.

Veterans experience a higher prevalence of type 2 diabetes mellitus (T2DM) compared with the rate of their civilian counterparts. Veterans may experience vulnerability to chronic stress, in particular comorbid mental health conditions, and may not benefit from traditional diabetes education. This study evaluated clinical and psychological measures among veterans engaged in health psychology services. Individualized motivational interviewing and cognitive behavioral interventions were provided to address T2DM distress and promote veterans' diabetes self-management. Pre-/postobjective and self-report measures were evaluated for clinical relevancy and statistically significant changes. The sample consisted of 13 older adults: mean age 62.8 years; 12 were male and 9 were prescribed insulin. More than half had comorbid hypertension, hyperlipidemia, and/or a diagnosis of chronic pain. Eleven participants were diagnosed with a mental health disorder. Baseline measures indicated mild depressive symptoms, mild anxiety symptoms, and moderate levels of T2DM distress. Postintervention reductions were shown for T2DM distress; emotional burden, and regimen-related distress, depressive symptoms, and enhanced diabetes empowerment. Veterans with comorbid conditions may benefit from individualized psychology services that offer cognitive behavioral strategies for self-management of T2DM-related distress, integrated with traditional primary care and diabetes education.

Health and adverse childhood experiences among homeless youth

BackgroundHomelessness is associated with health problems and with adverse childhood experiences (ACEs). The risk of chronic health conditions for homeless compared to housed youth, and how this risk interacts with ACEs remains unclear. This study investigated the relationship between ACEs, housing, and child health, and whether: 1) ACEs and health vary by housing context; 2) ACEs and homelessness confer independent health risks; and 3) ACEs interact with housing with regard to adolescent health.MethodsUsing data from 119,254 8th–11th graders, we tested independent and joint effects of ACEs and past-year housing status (housed, family homelessness, unaccompanied homelessness) on overall health and chronic health conditions, controlling for sociodemographic covariates.ResultsThe prevalence of ACEs varied by housing status, with 34.1% of housed youth experiencing ≥1 ACE vs. 56.3% of family-homeless and 85.5% of unaccompanied-homeless youth. Health status varied similarly. Homelessness and ACEs were independently associated with low overall health and chronic health conditions, after adjusting for covariates. Compared to housed youth, both family-homeless youth and unaccompanied-homeless youth had increased odds of low overall health and chronic physical and/or mental health conditions. All ACE x housing-status interactions were significant (all p < 0.001), such that ACE-related health risks were moderated by housing status.ConclusionsACEs and housing status independently predict health status during adolescence beyond other sociodemographic risks. Experiencing homelessness, whether unaccomapnied or with family, is associated with increased health risk, and every additional ACE increases this risk. Clinicians and health systems should advocate for policies that include stable housing as a protective factor.

Exploring factors associated with personal recovery in bipolar disorder.

BackgroundPersonal recovery is increasingly recognized as important outcome for people with bipolar disorder (BD), but research addressing associated factors of personal recovery in this group remains scarce. This study aimed to explore the association of sociodemographic variables, social participation, psychopathology, and positive emotion regulation with personal recovery in BD.MethodsBaseline data from a randomized controlled trial and survey data were combined (N = 209) and split into a training (n = 149) and test sample (n = 60). Block‐wise regression analyses and model training were used to determine the most relevant predictors. The final parsimonious model was cross‐validated in the test sample.ResultsIn the final parsimonious model, satisfaction with social roles (β = .442, p < .001), anxiety symptoms (β = −.328, p < .001), manic symptoms (β = .276, p < .001), and emotion‐focused positive rumination (β = .258, p < .001) were independently associated with personal recovery. The model explained 57.3% variance in personal recovery (adjusted R 2 = .561) and performed well in predicting personal recovery in the independent test sample (adjusted R 2 = .491).ConclusionsOur findings suggest that especially social participation, anxiety and positive rumination might be relevant treatment targets when aiming to improve personal recovery.Practitioner points Personal recovery is considered an increasingly important outcome for people with chronic mental health conditions, including bipolar disorder.We found that anxiety and manic symptoms as well as positive rumination and social participation were independently associated with personal recovery in bipolar disorder.Therefore, these outcomes might be relevant treatment targets when aiming to improve personal recovery in bipolar disorder.Possible interventions to improve these outcomes are discussed, including supported employment and vocational rehabilitation for social participation and exercising with savoring strategies to increase positive rumination.

Changing practice: assessing attitudes toward a NICE-informed collaborative treatment pathway for bipolar disorder.

Bipolar disorder is a chronic mental health condition, which can result in functional impairment despite medication. A large evidence base supports use of psychological therapies and structured care in the treatment of mood disorders, but these are rarely implemented. e-Pathways are digital structures that inform and record patient progress through a healthcare system, although these have not yet been used for bipolar disorder. To assess the perceived benefits and costs associated with implementing a collaborative NICE-informed e-pathway for bipolar disorder. Healthcare professionals and people with bipolar disorder attended a workshop to share feedback on e-pathways. Data were collected through questionnaires (n = 26) and transcription of a focus group, analysed qualitatively by a framework analysis. Patients and healthcare professionals welcomed the development of an e-pathway for bipolar disorder. There were five elements to the framework: quality and delivery of care, patient-clinician collaboration, flexibility and adaptability, impact on staff and impact on healthcare services. Identification of benefits and costs ensures that future development of e-pathways addresses concerns of healthcare professionals and people with bipolar disorder, which would be essential for successful implementation. Recommendations for this development include making e-pathways less complicated for patients, ensuring sufficient training and ensuring clinicians do not feel their skills become invalidated. Limitations of the study, and directions for future research, are discussed.

Confidence of psychiatry trainees in meeting the needs of borderline personality disorder in comparison with schizophrenia.

Borderline personality disorder (BPD) and schizophrenia are both serious and chronic mental health conditions of similar prevalence. This study was designed to assess trainees' confidence in the assessment, management and treatment of BPD in comparison with schizophrenia. A survey was used to assess psychiatry trainees' confidence and experience of training with regard to managing BPD and schizophrenia. Eighty-two psychiatry trainees completed the survey. Overall, confidence scores of respondents with respect to BPD were significantly lower in comparison with schizophrenia. Trainees reported a preference for working with patients with schizophrenia compared with BPD. Respondents reported receiving less adequate supervision and training in the assessment, management and treatment of BPD than for schizophrenia. The results suggest an urgent need to enhance training and supervision in skills related to the diagnosis, management and treatment of BPD, with a greater focus on psychotherapy to improve trainee psychiatrists' confidence in working with people diagnosed with BPD.

Interprofessional primary care during COVID-19: a survey of the provider perspective

BackgroundInterprofessional primary care (IPC) teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during the COVID-19 pandemic, including older adults, and patients with chronic physical and mental health conditions. There has been little focus on the experiences of healthcare teams and no studies have examined IPC practice during the early phase of the COVID-19 pandemic. The objective of the study was to describe the state of interprofessional health provider practice within IPC teams during the COVID-19 pandemic.MethodsObservational cross-sectional design. A web-based survey was deployed to IPC providers working in team-based primary care clinics in the province of Ontario, Canada. The survey included 26 close-ended and six open-ended questions. Close-ended questions were analyzed using descriptive statistics. Content analysis was used to analyze the open-ended questions.Results445 surveys were included in the final analysis. Service delivery shifted from in-person care (77% pre-COVID-19) to telephone (76.5% during the COVID-19 pandemic). Less than half of the respondents (40%) reported receiving any training for virtual delivery. Wait times to access team members were reported to have decreased. There has also been a shift in what IPC providers report as the most commonly seen conditions, with increases in visits related to mental health concerns, acute infections (including COVID-19), social isolation, and resource navigation. Respondents also reported a reduction in healthcare provision for multiple chronic conditions including diabetes, cardiovascular disease, and chronic pain.ConclusionsIPC teams are rapidly shifting their practice to supporting their patients during the pandemic. A surge in mental health issues has been seen and is expected to continue to increase in response to COVID-19. Understanding early experiences can help plan for future pandemic waves.

Do as I Do: Physician- and Learner-Led Mind-Body Medicine Group Visits.

Care of patients with chronic medical and mental health conditions can be a source of frustration for primary care clinicians and may present a challenge in modeling effective interventions for medical learners. Mind-body medicine (MBM) interventions have shown success for a variety of conditions, and training in MBM has been associated with decreased burnout and improved professional satisfaction.8 We piloted MBM collaborative visits led by faculty physicians and facilitated by medical learners. We then assessed their efficacy treating patients with complex needs. We conducted a series of eight weekly 2.5-hour MBM interventions for groups of five to eight participants (52 in total) with chronic health conditions. Matched-pair hypothesis t tests analyzed nine health indicators measured pre- and postintervention: the Patient Health Questionnaire-9 (PHQ-9) as well as participants' perceived mental and physical health, stress and stress coping, agency, and capacity to connect with others. We made conservative calculations of effect size using Hedges' g. Participants showed significant, large improvements in their PHQ-9 scores ( P<.005, g=0.807), and moderate improvements in ability to cope with stress (P<.005, g=0.502), sense of control over their diagnoses (P<.05, g=0.413), and perceived overall mental health (P<.05, g=0.424). Other outcomes were nonsignificant, including a small improvement in participants' perceived overall health ( P=.071, g=0.286). Patients completing the intervention enjoyed largely improved outcomes despite unchanged stress at work and home. Physician-led MBM collaborative visits comprise a feasible, reproducible, and reimbursable treatment option for improving patient care. They also immerse medical learners in an evidence-based practice model supportive of professional satisfaction.

Does it matter what your reasons are when deciding to disclose (or not disclose) a disability at work? The association of workers\u2019 approach and avoidance goals with perceived positive and negative workplace outcomes

Deciding whether to disclose a disability to others at work is complex. Many chronic mental and physical health conditions are associated with episodic disability and include times of relative wellness punctuated by intermittent periods of activity limitations. This research draws on the disclosure processes model to examine approach and avoidance disclosure and non-disclosure goals and their association with perceived positive and negative workplace outcomes. Participants were 896 employed individuals (57.7% women) living with a chronic physical or mental health/cognitive condition. They were recruited from an existing national panel and completed an online, cross-sectional survey. Participants were asked about disclosure decisions, reasons for disclosure/non-disclosure, demographic, work context and perceived positive and negative disclosure decision outcomes (e.g., support, stress, lost opportunities). About half the sample (51.2%) had disclosed a disability to their supervisor. Decisions included both approach and avoidance goals. Approach goals (e.g., desire support, want to build trust, maintain the status quo at work) were significantly associated with perceived positive work outcomes regardless of whether a participant disclosed or did not disclose a disability at work, while avoidance goals (e.g., concerns about losing one’s job, feeling forced to disclose because others notice a problem) were associated with perceived negative work outcomes. The findings highlight benefits and challenges that workers perceive arise when they choose to disclose or not disclose personal health information. By better understanding disclosure decisions, we can inform organizational health privacy and support gaps to help sustain the employment of people living with disabilities.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

"Then COVID happened…": Veterans' Health, Wellbeing, and Engagement in Whole Health Care During the COVID-19 Pandemic.

BackgroundLittle is known about the COVID-19 pandemic’s impact on US military veterans’ health, wellbeing, and care engagement. Healthcare systems like VA need additional information about the pandemic’s biopsychosocial impacts and how a Whole Health approach may help to address them.ObjectiveTo examine how the pandemic has affected veterans’ health, wellbeing, and engagement in the VA Whole Health System of Care.MethodWe conducted qualitative interviews with 40 veterans at a large multicampus VA healthcare system during the pandemic. Informed by a Whole Health approach, interviews used open-ended questions to holistically explore pandemic impacts on mental and physical health, healthcare access and engagement, social support, coping strategies, and use of VA healthcare and wellness services. Interviews were conducted by telephone, audio-recorded, and analyzed using a matrix-based technique. Interviews were supplemented by an original survey assessing pandemic impacts; descriptive frequencies were calculated to describe and characterize the interviewed sample.Interview ResultsNearly, all participating veterans described significant pandemic impacts on their wellbeing, especially loneliness and sorrow stemming from isolation and disruptions to ordinary routines. These emotional impacts—sometimes combined with new constraints on care access and personal mobility—disrupted veterans’ health plans and sometimes deterred engagement in both routine and wellness care. Veterans already struggling with chronic mental and physical health conditions and those who experienced transitions or losses during the pandemic described the most severe impacts on their wellbeing. Virtual VA wellness services, especially health coaching and mind-body wellness groups, were a key source of support and connection for those who engaged in them.ConclusionWe discuss the implications of our findings for care systems attempting to implement a Whole Health System of Care, including how they can address postpandemic barriers to engagement in healthcare and wellness programs, and how wellness programs can be leveraged to support those most at risk after the COVID-19 pandemic and in future crises.

Placing Youth at the Forefront of Tackling Non-Communicable Diseases: An Op-Ed Piece

Non-communicable diseases (NCDs) is an umbrella term used to describe a cluster of diseases constituting of Cardiovascular and Chronic Respiratory complications, Cancer, Diabetes and Mental Health conditions. The World Health Organisation (WHO) estimates that nearly 71% of all deaths worldwide (41 million people) can be attributed to inadequate and untimely intervention for Non-communicable diseases. Out of the 41 million people affected, the most vulnerable groups placed at the epicentre to face the repercussions of the growing impacts of NCDs are children, young people, people of lower socio-economic status (SES) and those belonging to lower and lower-middle income countries (LMICs). We call for policies to be more youth-inclusive and suggest further recommendations to incorporate youth voices and interventions to combat the global burden of NCDs as young people constitute of a major demographic widely affected by NCDs yet remain underrepresented in their say on tackling NCDs across local, regional, national and global levels.

The Future of Personal Health Records and Patient Portals

Over the last two decades, the early development of standalone Personal Health Records (PHRs), and later tethered patient portals, have had a transformative effect on engaging patients by providing them with tools to manage their health and unprecedented access to their heath data. However, despite anticipated benefits and continued high consumer demand for online access to personal health information, adoption and sustained use has been less than expected. Moreover, powerful forces are transforming healthcare, necessitating change and adaptation. This aim of this paper is to examine several significant trends that are influencing the intersection of health care and technology and provide an assessment of the impact of these trends on the future of PHRs and patient portals. An aging population with an increased prevalence of chronic disease and mental health conditions, coupled with rising consumerism and more diverse care settings, has significant implications for patient-facing tools such as patient portals. Similarly, the proliferation of data generating consumer health technology and technical advances such as artificial intelligence and emerging data standards calls for the next iteration of tools to support care delivery. Moreover, the acceleration of virtual care driven by national policy changes and the COVID 19 pandemic requires better tools to realize the promising potential of the technology in an increasingly complex and interconnected world. Taken together, these factors may provide the perfect storm that will enable a critical shift to envision a more holistic patient-centric information and resource hub that is characterized by improved architecture, optimized design and content, a robust set of well-designed tools and functions, and enhanced integration with clinical care processes and structures. This personal health portal could provide a long desired single comprehensive longitudinal personal health record with best of breed design and features to empower patients as they navigate their health journey.

Are all homebound older adults frail?

Seven million adults in the United States are homebound and suffer the negative, powerful synergies of multiple chronic conditions, functional impairment, social stressors, and limited social capital. The prevalence of frailty in this vulnerable homebound population is unknown. Using representative data from the National Health and Aging Trends study (NHATS) study linked to Medicare claims (n=4756) we sought to assess the prevalence of frailty in the homebound population (n=361). Among the homebound, 68.5% met the frailty criteria compared to 12.3% of the non-homebound population. The frail homebound had lower educational attainment, were more likely to live alone, self-reported poorer health and more chronic physical and mental health conditions than the non-frail homebound (p<0.05 for all). Frail homebound older adults utilized more health services utilization than non-frail homebound and were twice as likely to be hospitalized (49.8% versus 28.0%, p=0.004).

The Joint Effect of Physical Multimorbidity and Mental Health Conditions Among Adults in Australia.

IntroductionThe prevalence of chronic physical and mental health conditions is rising globally. Little evidence exists on the joint effect of physical and mental health conditions on health care use, work productivity, and health-related quality of life in Australia.MethodsWe analyzed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, waves 9 (2009), 13 (2013), and 17 (2017). Economic effects associated with multimorbidity were measured through health service use, work productivity loss, and health-related quality of life. We used generalized estimating equations to assess the effect of the association between physical multimorbidity and mental health conditions and economic outcomes.ResultsFrom 2009 through 2017 the prevalence of physical multimorbidity increased from 15.1% to 16.2%, and the prevalence of mental health conditions increased from 11.2% to 17.3%. The number of physical health conditions was associated with the number of health services used (general practitioner visits, incidence rate ratio = 1.41), work productivity loss (labor force participation, adjusted odds ratio = 0.71), and reduced health-related quality of life (SF-6D score: Coefficient = −0.03). These effects were exacerbated by the presence of mental health conditions and low socioeconomic status.ConclusionHaving multiple physical health conditions (physical multimorbidity) creates substantial health and financial burdens on individuals, the health system, and society, including increased use of health services, loss of work productivity, and decreased health-related quality of life. The adverse effects of multimorbidity on health, quality of life, and economic well-being are exacerbated by the co-occurrence of mental health conditions and low socioeconomic status.

Disentangling comorbidity in chronic pain: A study in primary health care settings from India.

ObjectivesThe study examined the prevalence, sociodemographic, and clinical correlates of chronic pain among primary care patients in the state of Kerala, India. It also examined the patterns and relationships of chronic physical and mental health conditions with chronic pain.MethodsThis study is a cross-sectional survey conducted among 7165 adult patients selected randomly by a multi-stage stratified design from 71 primary health centers. The questionnaires administered included Chronic pain screening questionnaire, self-reported Chronic physical health condition checklist, Patient Health Questionnaire-SADS, The Alcohol Use Disorders Identification Test, Fagerström Test for Nicotine Dependence, WHO Disability Assessment Schedule and WHOQOL- BREF for Quality/Satisfaction with Life. The prevalence and comorbid patterns of chronic pain were determined. Logistic regression analysis and generalized linear mixed-effects model was employed to examine the relationship of chronic pain to socio-demographic variables and examined physical and mental health conditions.ResultsA total of 1831 (27%) patients reported chronic pain. Among those with chronic pain, 28.3% reported no co-occurring chronic mental or physical illness, 35.3% reported one, and 36.3% reported multi-morbidity. In the multivariate analysis, patients with chronic pain when compared to those without had higher odds of being older, female, having lower education, not living with their family, greater disability, and poor satisfaction with life. Chronic pain was independently associated with both medical (hypertension, diabetes mellitus, tuberculosis, arthritis, and other medical illnesses) and mental health conditions (depressive disorders, anxiety disorders, and tobacco dependence). It showed a varying strength of association and additive effect with increasing number of co-occurring physical and mental illnesses.ConclusionsChronic pain is a common condition among primary care attendees associated with significant burden of medical and mental health comorbidity. The findings highlight the need to incorporate treatment models that will ensure appropriate management to improve outcomes within the resource constraints.

Recommendations From the Twitter Hashtag #DoctorsAreDickheads: Qualitative Analysis.

BackgroundThe social media site Twitter has 145 million daily active users worldwide and has become a popular forum for users to communicate their health care concerns and experiences as patients. In the fall of 2018, a hashtag titled #DoctorsAreDickheads emerged, with almost 40,000 posts calling attention to health care experiences.ObjectiveThis study aims to identify common health care conditions and conceptual themes represented within the phenomenon of this viral Twitter hashtag.MethodsWe analyzed a random sample of 5.67% (500/8818) available tweets for qualitative analysis between October 15 and December 31, 2018, when the hashtag was the most active. Team coders reviewed the same 20.0% (100/500) tweets and the remainder individually. We abstracted the user’s health care role and clinical conditions from the tweet and user profile, and used phenomenological content analysis to identify prevalent conceptual themes through sequential open coding, memoing, and discussion of concepts until an agreement was reached.ResultsOur final sample comprised 491 tweets and unique Twitter users. Of this sample, 50.5% (248/491) were from patients or patient advocates, 9.6% (47/491) from health care professionals, 4.3% (21/491) from caregivers, 3.7% (18/491) from academics or researchers, 1.0% (5/491) from journalists or media, and 31.6% (155/491) from non–health care individuals or other. The most commonly mentioned clinical conditions were chronic pain, mental health, and musculoskeletal conditions (mainly Ehlers-Danlos syndrome). We identified 3 major themes: disbelief in patients’ experience and knowledge that contributes to medical errors and harm, the power inequity between patients and providers, and metacommentary on the meaning and impact of the #DoctorsAreDickheads hashtag.ConclusionsPeople publicly disclose personal and often troubling health care experiences on Twitter. This adds new accountability for the patient-provider interaction, highlights how harmful communication affects diagnostic safety, and shapes the public’s viewpoint of how clinicians behave. Hashtags such as this offer valuable opportunities to learn from patient experiences. Recommendations include developing best practices for providers to improve communication, supporting patients through challenging diagnoses, and promoting patient engagement.