Primary Care Medical Settings Research Articles

The factor structure the PHQ-9 in Russian patients recovered from COVID-19

IntroductionThe nine-item Patient Health Questionnaire-9 (PHQ-9) is the first choice for screening for depression in primary care and other medical settings. The PHQ-9 has been shown to be a reliable and valid measure of depression symptoms, but there is disagreement among researchers about the factor structure of this questionnaire. Recent systematic reviews have found four different factor models of the PHQ-9, with one- and two-factor models being the most common. This discrepancy may be due to linguistic, cultural and clinical differences between the populations studied. The factor structure of the Russian version of the PHQ-9 during the COVID-19 pandemic has not been examined in any study to date.ObjectivesThe aim of our study was to determine the factorial structure and internal consistency of the Russian version of the PHQ-9 in COVID-19 survivors.MethodsFourteen thousand 725 (female - 11479 (78.0%), age - 18-79 years (M - 47.09, SD - 12.70) participants completed an online survey including the PHQ-9 and an ad hoc questionnaire focusing on sociodemographic and COVID-related characteristics. McDonald’s omega coefficient was estimated to determine the internal consistency of the questionnaire. Exploratory structural equation modelling (ESEM) with weighted least squares mean and variance adjusted estimator and geomin rotation was performed in Mplus 7.ResultsESEM provided evidence for a three-factor structure of the PHQ-9, representing affective (items 2, 6, 9), anergic (items 1, 3) and somatic (items 3, 5, 7, 8) dimensions of depression. These factors fit the data well (CFI - 0.998; TLI - 0.994; RMSEA (95% CI) - 0.028 (0.024 - 0.032)), better than a single factor (CFI - 0. 955; TLI - 0. 940; RMSEA (95% CI) - 0.089 (0.087 - 0.092)) and two-factor (CFI - 0.985; TLI - 0.971; RMSEA (95% CI) - 0.062 (0.059 - 0.065)). The McDonald’s omega was 0.82.ConclusionsOur study revealed a three-factor structure of the Russian version of the PHQ-9 in COVID-19 survivors. COVID-19. A high internal consistency of the Russian version of the instrument was confirmed.Disclosure of InterestNone Declared

Physician Communication Behaviors on Patient Satisfaction in Primary Care Medical Settings in Bangladesh.

This study aims at exploring the effects of physicians' communication behaviors on patients' satisfaction in primary care medical consultations in Chattogram, Bangladesh. The study used a quantitative research approach designed with a cross-sectional survey. Data were collected using post-consultation and facilitator administered questionnaire from the patients who visited the physician for medical consultation in different hospitals and clinics in Chattogram city. Seven hundred patients were included as the study participants. A hierarchical linear regression analysis was performed to examine the factors contributing to the outcome variables. A statistically significant difference (P < .001) appeared regarding patients' perception of adequate consultation, physicians' nonverbal behavior, inhibiting behavior and patients' participating behavior in private and public settings. However, R2 value shows that physicians' patient-centered behaviors appeared as the stronger predictors of patient satisfaction toward medical interviews, followed by socioeconomic variables of patients and physicians and patients' participation during the consultation. Presence of a third person with patients during consultation (β = -.05, P = .040), physicians' private setting of consultation (β = .16, P < .001), physicians' seniority (β = .05, P = .042), patients' participating behavior during consultation (β = .20, P < .001), physicians' nonverbal behavior (β = .10, P < .001), physicians' inhibiting behavior (β = -.39, P < .001), and physicians' facilitating behavior with patients (β = .32, P < .001) were reported as the influencing factors of patients' satisfaction with medical consultation. This study suggests the profound impact of physicians' patient-centered communication behaviors on patient satisfaction in primary care settings, overshadowing even socioeconomic factors and patient participation.

Rapid screening for suicide risk: An algorithmic approach.

In the United States, primary medical care settings are the first accessed resource for both medical and behavioral health care. Thus, there is a clear need for accurate and efficient behavioral health screening in this setting, including routine surveillance screening for suicide risk. The Multidimensional Behavioral Health Screen (MBHS), a broadband but very brief screening tool developed specifically for primary care, has been updated to include an algorithm that classifies suicide risk based on the interpersonal-psychological theory of suicide, and associated interview and decision framework. This study aims to evaluate the predictive accuracy of the new MBHS 2.0 suicide risk algorithm, with actual risk determined by clinical suicide risk interview. Data were collected as part of a larger study that, overall, included 551 college student participants. Of these, 309 completed the MBHS 2.0 and the clinical suicide risk interview, the two measures reported here. The final participant count was 299 following the removal of incomplete or invalid cases. Predicted suicide risk as determined by the MBHS 2.0 (Low, Mild, At least Moderate) was compared to actual risk as determined by clinical interview (Low, Moderate, Severe, Extreme). Utilizing chi-square analyses, data show a significant association between the predicted suicide risk category based on the MBHS 2.0 algorithm and the actual risk category based on the semi-structured clinical interview. Furthermore, classification analyses suggest that primary care providers will be able to confidently assess the suicide risk level for the majority of their patients when using the MBHS. Findings suggest that the MBHS 2.0 can be an accurate and efficient tool for use by primary care providers in classifying suicide risk. Future research will be useful to evaluate the utility of the suicide risk algorithm among primary care populations.

Using digital assessment technology to detect neuropsychological problems in primary care settings.

Screening for neurocognitive impairment and psychological distress in ambulatory primary and specialty care medical settings is an increasing necessity. The Core Cognitive Evaluation™ (CCE) is administered/scored using an iPad, requires approximately 8 min, assesses 3- word free recall and clock drawing to command and copy, asks questions about lifestyle and health, and queries for psychological distress. This information is linked with patients' self- reported concerns about memory and their cardiovascular risks. A total of 199 ambulatory patients were screened with the CCE as part of their routine medical care. The CCE provides several summary indices, and scores on 44 individual digital clock variables across command and copy tests conditions. Subjective memory concerns were endorsed by 41% of participants. Approximately 31% of participants reported psychological distress involving loneliness, anxiety, or depression. Patients with self-reported memory concerns scored lower on a combined delay 3- word/ clock drawing index (p < 0.016), the total summary clock drawing command/ copy score (p < 0.050), and clock drawing to command Drawing Efficiency (p < 0.036) and Simple and Complex Motor (p < 0.029) indices. Patients treated for diabetes and atherosclerotic cardiovascular disease (ASCVD) scored lower on selected CCE outcome measures (p < 0.035). Factor analyses suggest that approximately 10 underlying variables can explain digital clock drawing performance. The CCE is a powerful neurocognitive assessment tool that is sensitive to patient's subjective concerns about possible decline in memory, mood symptoms, possible cognitive impairment, and cardiovascular risk. iPad administration ensures total reliability for test administration and scoring. The CCE is easily deployable in outpatient ambulatory primary care settings.

The Integration and Application of Extended Reality (XR) Technologies within the General Practice Primary Medical Care Setting: A Systematic Review

The COVID-19 pandemic instigated a paradigm shift in healthcare delivery with a rapid adoption of technology-enabled models of care, particularly within the general practice primary care setting. The emergence of the Metaverse and its associated technology mediums, specifically extended reality (XR) technology, presents a promising opportunity for further industry transformation. Therefore, the objective of this study was to explore the current application and utilisation of XR technologies within the general practice primary care setting to establish a baseline for tracking its evolution and integration. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted and registered with the international database of prospectively registered systematic reviews as PROSPERO-CRD42022339905. Eleven articles met the inclusion criteria and were quality appraised and included for review. All databases searched, inclusive of search terms, are supplied to enhance the transparency and reproducibility of the findings. All study interventions used virtual reality technology exclusively. The application of virtual reality within the primary care setting was grouped under three domains: (1) childhood vaccinations, (2) mental health, and (3) health promotion. There is immense potential for the future application of XR technologies within the general practice primary care setting. As technology evolves, healthcare practitioners, XR technology specialists, and researchers should collaborate to harness the full potential of implementing XR mediums.

Technology-enabled Suicide Prevention in Primary Care and Other Medical Settings: A Scalable Solution

Technology-enabled Suicide Prevention in Primary Care and Other Medical Settings: A Scalable Solution

Evaluating the Science to Inform the Physical Activity Guidelines for Americans Midcourse Report

Evaluating the Science to Inform the Physical Activity Guidelines for Americans Midcourse Report

Improving interaction of primary health care facilities and narcological service to provide care to patients with riskу, harmful use or dependency from alcohol or other psychoactive substances

This article provides description of the existing regulatory framework for interaction between medical organizations that provide health to people with risky, hazardous (harmful) use of alcohol or other psychoactive substances in the Russian Federation.Aim. Exploring existing opportunities to improve interaction of primary health care institutions and narcological service to provide care to patients with risky use, harmful use or dependence on psychoactive substances.Materials and methods. The article presents results of implementing the action plan to organize medical prevention in 71 regions of the Russian Federation, based on data provided by chief narcologists of these regions during 2017–2018. The analysis of the existing practice of the interaction of medical institutions for the prevention of the harmful use of psychoactive substances was carried out; were studied the principles of organizing screening and preventive counseling in primary health care; the features of training and education of specialists of medical organizations in the methodology of screening, preventive and motivational counseling were studied in different regions of the Russian Federation.Discussion. During 2017–2018 more than 14.5 million patients were screened in primary health care. Problems alcohol and other psychoactive substances use were identified in more than 300,000 patients (2.4 %). The highest rates of identified substance use disorders’ risks were observed in primary specialized medical care settings (5.1 %); lower rates were observed among those who were undergoing screening in primary health care settings (1.8 %), during preventive health assessment (2.3 %) and during preventive medical check-ups (2.4 %). More than 19,000 health workers have been trained in motivational counseling techniques.Conclusion. The problem of substance abuse and related medical and social consequences remains highly relevant, and therefore requires further implementation of preventive technologies with proven effectiveness.

Screening for PTSD and TBI in Veterans using Routine Clinical Laboratory Blood Tests

Post-traumatic stress disorder (PTSD) is a mental disorder diagnosed by clinical interviews, self-report measures and neuropsychological testing. Traumatic brain injury (TBI) can have neuropsychiatric symptoms similar to PTSD. Diagnosing PTSD and TBI is challenging and more so for providers lacking specialized training facing time pressures in primary care and other general medical settings. Diagnosis relies heavily on patient self-report and patients frequently under-report or over-report their symptoms due to stigma or seeking compensation. We aimed to create objective diagnostic screening tests utilizing Clinical Laboratory Improvement Amendments (CLIA) blood tests available in most clinical settings. CLIA blood test results were ascertained in 475 male veterans with and without PTSD and TBI following warzone exposure in Iraq or Afghanistan. Using random forest (RF) methods, four classification models were derived to predict PTSD and TBI status. CLIA features were selected utilizing a stepwise forward variable selection RF procedure. The AUC, accuracy, sensitivity, and specificity were 0.730, 0.706, 0.659, and 0.715, respectively for differentiating PTSD and healthy controls (HC), 0.704, 0.677, 0.671, and 0.681 for TBI vs. HC, 0.739, 0.742, 0.635, and 0.766 for PTSD comorbid with TBI vs HC, and 0.726, 0.723, 0.636, and 0.747 for PTSD vs. TBI. Comorbid alcohol abuse, major depressive disorder, and BMI are not confounders in these RF models. Markers of glucose metabolism and inflammation are among the most significant CLIA features in our models. Routine CLIA blood tests have the potential for discriminating PTSD and TBI cases from healthy controls and from each other. These findings hold promise for the development of accessible and low-cost biomarker tests as screening measures for PTSD and TBI in primary care and specialty settings.

MANAGEMENT OF DEPRESSION IN OLDER ADULTS RECEIVING CARE IN MEDICAL SETTINGS

Abstract Although rates of major depressive disorder are lower among older adults, depressive symptoms are a common presentation for aging individuals in medical settings. Unique challenges arise when treating depressive symptoms co-occurring with brain health concerns in older adults with a complex medical history. This presentation reviews how cognitive behavioral interventions for later-life depression are relevant for mental health practitioners who work in primary care and general medical settings. Specific clinical and multicultural considerations will be highlighted to support clinicians and interdisciplinary teams to work effectively with older adults who have co-existing depressive symptoms and cognitive concerns.

MULTIDISCIPLINARY PERSPECTIVES ON LATER-LIFE DEPRESSION: THE ROLE OF BRAIN HEALTH

Abstract Bi-directional associations between depression and cognitive functioning are magnified among aging individuals, challenging behavioral health providers who treat older adults experiencing clinical and subsyndromal depression. This symposium contributes to the science and practice of assessing and treating later-life depression while also attending to issues in professional training. The first paper presents pre-treatment data from the multi-site Optimum Study of older adults experiencing treatment-resistant depression (n = 529). The relevance of positive psychological constructs is supported with analyses showing important relationships among cognitive functioning, social participation, and psychological well-being. The second paper describes the development of an updated measure to assess behavioral health providers’ knowledge of later life depression, including brain health concerns. Psychometric data for the measure were generated from a random pool of licensed social workers (N=900) who were mailed the survey packet. The third presentation features an experimental study demonstrating that foundational information about aging, including debunking misconceptions about cognitive aging, influenced continuing education preferences of generalist Licensed Professional Counselors (LPCs). Among the randomly generated pool of LPCs (N = 120), participants who received aging-specific information were more likely to later choose an aging-specific continuing education option. The fourth paper highlights recommendations for mental health practitioners working in primary care and general medical settings with older adults who have co-existing depressive symptoms and cognitive concerns. The fifth and final presentation describes cognitive behavioral clinical tools to address brain health concerns in the context of later-life depression, using the new Brain Health module of a published client workbook.

Remote Collaborative Care With Off-Site Behavioral Health Care Managers: A Systematic Review of Clinical Trials.

In the United States, most patients who require behavioral health care do not receive it owing to an overall shortage of behavioral health specialists. The Collaborative Care Model (CoCM) is a team-based, highly-coordinated approach to treating common mental health conditions in primary care that has a robust evidence base. Several recent randomized controlled trials have demonstrated the effectiveness of remote CoCM teams. As telehealth technology advances and uptake expands, understanding the evidence for remote CoCM becomes increasingly crucial to inform CoCM practice and implementation. The objective of this study was to systematically review randomized controlled trials regarding the effectiveness of remote CoCM teams in treating common psychiatric conditions in primary care and medical settings. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure our review. Our search strategy and development of search terms was informed by knowledge and review of the CoCM literature. Articles were reviewed by 3 authors, and once selected, they were sent to 2 authors for further data extraction to describe various study characteristics and process measures relating to remote CoCM. The literature search identified 13,211 articles, 9 of which met inclusion criteria. The 9 studies collectively demonstrate effectiveness of remote CoCM in treating a range of behavioral health conditions (depression [n= 7], anxiety [n= 2], and PTSD [n= 1]), across various populations and settings. Sample sizes ranged from 191 patients to 704 patients, publication dates from 2004 to 2018, and studies were conducted from 2000 to 2014. Various process measures were also reported. As the 9 studies included in our systematic review demonstrate, remote CoCM can be effective in treating a range of behavioral health conditions in various primary care and specialty medical settings. These findings suggest organizations may have more flexibility in building their CoCM team and drawing upon wider workforces than previously recognized. As recent shifts in telehealth policy and practice continue to motivate telehealth approaches, further research that can inform best practices for remote CoCM will be useful and valuable to those making organizational decisions when implementing integrated care models.

The Psychometrics of Cybersickness in Augmented Reality

Augmented reality (AR) is rapidly being adopted by industry leaders and militaries around the globe. With the Defense Health Agency pushing AR as a solution to the distributed learning problem, along with AR applications being explored within primary care and operational medical settings, it is crucial for these immersive platforms to have a standardized, scientifically based paradigm on which they are designed and used. One area of particular concern is the potential for physiological maladaptation following prolonged AR exposure, which is expected to vary from that associated with virtual reality exposure. Such maladaptation is potentially driven by limitations that exist with regard to the types and extent of perceptual issues characteristic of AR head-worn displays (e.g., mismatches between visually displayed information and other senses, restricted field of view, mismatched interpupillary distance). Associated perceptual limitations can reduce training effectiveness or impose patient and/or trainee safety concerns. Thus, while AR technology has the potential to advance simulation training, there is a need to approach AR-based research—particularly that which relates to long-exposure-duration scenarios—from a bottom-up perspective, where its physiological impact is more fully understood. In the hopes of assisting this process, this study presents a comparison of cybersickness between two common forms of AR displays. Specifically, by comparing the Microsoft HoloLens, a head-worn display that has seen rapid adoption by the scientific community, with an AR Tablet–based platform within the context of long-duration AR training exposure, it will be possible to determine what differences, if any, exist between the two display platforms in terms of their physiological impact as measured via cybersickness severity and symptom profile. Results from this psychometric assessment will be used to evaluate the physiological impact of AR exposure and develop usage protocols to ensure AR is safe and effective to use for military medical training.

Screening for Gambling Disorder in VA Primary Care Behavioral Health: A Pilot Study

The current pilot study assessed the prevalence of at-risk/problem gambling using the Brief Biosocial Gambling Screen (BBGS) among a sample of U.S. military veterans seeking mental health treatment services in a primary care medical setting at a Veterans Affairs (VA) hospital in the Northeast. Out of the 260 veterans screened, 85 veterans (32.7%) reported gambling behaviors within the past 12 months. No significant differences were found between gambling and non-gambling veterans on demographics, medical, or mental health conditions collected in the study. Among veteran past-year gamblers, five veterans (5.9%) screened positive for at-risk/problem gambling. The estimated prevalence of problem gambling was 1.9% among veterans screened in a primary care behavioral health clinic. Results suggest that self-disclosure of problem gambling among veterans, as well as outreach efforts by VA health care providers, could serve to increase veterans’ participation in treatment services for problem gambling. Larger, well-powered studies that examine the utility of the BBGS for detecting problem gambling among military populations are needed.

Comparing the PHQ-9 to the Multidimensional Behavioral Health Screen in Predicting Depression-Related Symptomatology in a Primary Medical Care Sample

Depression is the most common form of psychopathology affecting people in the US. It is commonly diagnosed and treated in primary medical care settings, creating a need for a reliable, quick self-report tool used for the assessment of depression in this context. There is an emerging shift in the way psychopathology is conceptualized, as the field begins to transition from a categorical, syndrome-based model to a dimensional model. This change should be reflected in the assessment tool used within the primary care setting. The PHQ-9 is currently the most frequently used assessment tool for evaluating depression within primary care clinics, despite being based on the heterogenous, categorical method of conceptualizing psychopathology. The Multidimensional Behavioral Health Screen is a brief and efficient screening-level assessment tool for core psychopathology components (rather than syndromes), with a specific focus on depressive symptomatology. This study presents empirical evidence supporting the implementation of the MBHS in primary care clinics as a useful alternative to the PHQ-9.

The Multidimensional Behavioral Health Screen 1.0: A Translational Tool for Primary Medical Care

The Multidimensional Behavioral Health Screen (MBHS) is a brief, 27-item questionnaire designed for screening every patient in primary medical care settings. It measures nine psychopathology constructs that represent the major distinctive core dimensions of the types of behavioral health symptoms most commonly encountered in primary care (anxiety-related, depressive, and attention/cognitive symptoms). The underlying design of the MBHS is based on the major paradigm shift that has occurred in the field of theoretical psychopathology, replacing categorical syndromes, or “disorders,” with hierarchical-dimensional constructs. Existing screening tests such as the PHQ-9 and GAD-7 are based explicitly on the categorical paradigm and thus suffer from the same (numerous) shortcomings as the categorical model itself. The dimensional paradigm supports enhanced measurement precision with very short scales. The goals of the MBHS are threefold: (1) to provide accurate, treatment-relevant behavioral health information to the medical provider; (2) to provide clear referral cut-points; (3) to contribute nine psychometrically sound behavioral health variables to the “healthcare big data cloud” to support future scholarship of discovery. Presented here are the basic psychometric properties of the MBHS, including reliability, convergent and discriminant validity, and classification accuracy, as well as implementation considerations.

Measuring Anxiety in Older Adults: Development, Diagnostic Accuracy, and Preliminary Validation of a Short-Form of the German Geriatric Anxiety Scale (GAS-G-SF)

Anxiety symptoms and anxiety disorders are highly prevalent among older adults, and are associated with considerable distress, functional impairment, and burden. Also, there is growing need for brief instruments to measure anxiety symptoms in primary care and geriatric medical settings. Therefore, the current study focuses on the development and psychometric evaluation of a short-form of the Geriatric Anxiety Scale (GAS-G), a well-established anxiety instrument for use with older adults. Study 1 draws on the original data from the GAS-G validation study (N = 242) to develop the short-form (GAS-G-SF) and determines whether the results replicate with the short-form. Study 2 extends the validation of the GAS-G-SF to a clinical sample (N = 156; 62 patients with heart disease, 94 patients with Parkinson’s disease). Overall, the GAS-G-SF showed promising psychometric properties in terms of internal consistency and validity. Also, the GAS-G-SF showed good discriminatory power based on receiver operating characteristic curve analysis in both studies. These results support the utility of the GAS-G-SF as a brief assessment measure for anxiety.

Electronic self-administered screening for substance use in adult primary care patients: feasibility and acceptability of the tobacco, alcohol, prescription medication, and other substance use (myTAPS) screening tool

BackgroundThe TAPS Tool is a substance use screening and brief assessment instrument that was developed for use in primary care medical settings. It is one of the first screening instruments to provide rapid assessment of all commonly used substance classes, including illicit and prescription opioids, and is one of the only available screeners designed and validated in an electronic self-administered format (myTAPS). This secondary analysis of data from the TAPS Tool validation study describes the feasibility and acceptability of the myTAPS among primary care patients.MethodsAdult patients (N = 2000) from five primary care clinics completed the TAPS Tool on a tablet computer (myTAPS), and in an interviewer-administered format. Requests for assistance and time required were tracked, and participants completed a survey on ease of use, utilization of audio guidance, and format preference. Logistic regression was used to examine outcomes in defined subpopulations, including groups that may have greater difficulty completing an electronic screener, and those that may prefer an electronic self-administered approach.ResultsAlmost all participants (98.3%) reported that the myTAPS was easy to use. The median time to complete myTAPS screening was 4.0 min (mean 4.48, standard deviation 2.57). More time was required by participants who were older, Hispanic, Black, or reported non-medical prescription drug use, while less time was required by women. Assistance was requested by 25% of participants, and was more frequently requested by those who with lower education (OR = 2.08, 95% CI 1.62–2.67) or age > 65 years (OR = 2.79, 95% CI 1.98–3.93). Audio guidance was utilized by 18.3%, and was more frequently utilized by participants with lower education (OR = 2.01, 95% CI 1.54–2.63), age > 65 years (OR = 1.79, 95% CI 1.22–2.61), or Black race (OR = 1.30, 95% 1.01–1.68). The myTAPS format was preferred by women (OR = 1.29, 95% CI 1.00–1.66) and individuals with drug use (OR = 1.43, 95% CI 1.09–1.88), while participants with lower education preferred the interviewer-administered format (OR = 2.75, 95% CI 2.00–3.78).ConclusionsOverall, myTAPS screening was feasible and well accepted by adult primary care patients. Clinics adopting electronic screening should be prepared to offer assistance to some patients, particularly those who are older or less educated, and should have the capacity to use an interviewer-administered approach when required.

Construct Validity of the PHQ-9 Depression Screen: Correlations with Substantive Scales of the MMPI-2-RF.

The PHQ-9 is a brief, 9-item, self-administered screening tool widely used in primary care medical settings to assess the potential presence of Major Depressive Disorder (MDD). Most published research on the PHQ-9 has focused on sensitivity and specificity with regard to the DSM-IV (American Psychiatric Association, in Diagnostic and statistical manual of mental disorders, 4th edn, American Psychiatric Publishing, Arlington, VA, 2000) categorical diagnosis of MDD, and, indeed, the PHQ-9 exhibits very good psychometric properties in this regard. The current research is an effort to more precisely assess what is being measured by the PHQ-9, given the notably heterogeneous nature of MDD as broad diagnostic category. Here, we provide correlations between the PHQ-9 and substantive scales of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, in Minnesota Multiphasic Personality Inventory-Restructured Form: Manual for administration, scoring, and interpretation, University of Minnesota Press, Minneapolis, 2008/2011), a comprehensive measure of personality and psychopathology. Participants were 231 college student volunteers who completed the PHQ-9 and MMPI-2-RF as components of a broader research program. Results show that the PHQ-9 was strongly correlated with the broad Higher-Order EID-Emotional/Internalizing Dysfunction scale of the MMPI-2-RF, as well as with RCd-Demoralization, RC7-Dysfunctional Negative Emotions, NEGE-r-Negative Emotionality, and several specific facet scales. Surprisingly, the correlation with RC2-Low Positive Emotions, was not among the strongest, despite the fact that the PHQ-9 ostensibly targets this specific feature of depression (anhedonia). Substantial correlations with the somatic/cognitive scales of the MMPI-2-RF were also found. Implications for modified interpretation of the PHQ-9, and the need for more precise dimensional (rather than categorical) screening tools, are discussed.

The Implications of the Current Visa System for Foreign Medical Graduates During and After Graduate Medical Education Training.

The current and projected deficit in the physician workforce in the US is a challenge for primary care and specialty medical settings. Foreign medical graduates (FMGs) represent an important component of the US graduate medical education (GME) training pathway and can help to address the US physician workforce deficit. Availability of FMGs is particularly important to the internal medicine community, as recent data demonstrate that internal medicine is the specialty with the highest number of FMGs. System-based and logistical inefficiencies in the current US visa system represent significant obstacles to FMG trainees and have important psychological, emotional, and logistical consequences to FMG engagement and participation in US GME training and in the post-training workforce. In this article, we review the contemporary structure, process, and challenges of obtaining a visa for GME training. The H1B and J1 visa programs are compared and contrasted, with an emphasis on logistical specifics for FMG GME trainees and training programs. The process of and options for J1 visa waivers are reviewed. These considerations are specifically reviewed in the context of recent policy decisions by the Trump administration, with emphasis on the effects of these decisions on FMGs in medical training and practice.