Standard Psychosocial Assessment Research Articles

Association of psychosocial risk factors and liver transplant evaluation outcomes in metabolic dysfunction-associated steatotic liver disease.

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a standardized psychosocial assessment tool used in liver transplantation (LT) evaluation and has been primarily studied in patients with alcohol-associated liver disease. We aimed to evaluate the relationship between SIPAT score and metabolic syndrome severity and LT waitlist outcomes in a large cohort of patients with metabolic dysfunction-associated steatotic liver disease (MASLD). We performed a single-center retrospective cohort study of patients with MASLD evaluated for LT from 2014-2021. The utility of the previously defined total SIPAT cut-off (<21 [excellent/good candidates] vs ≥21 [minimally acceptable/high risk candidates]) was studied. Multivariable logistic regression analyses examined associations between continuous SIPAT score and LT waitlisting outcomes. Youden's J statistic was used to identify the optimal SIPAT cut-off for MASLD patients. A total of 480 patients evaluated for transplant with MASLD were included. Only 9.4% of patients had SIPAT score ≥21. Patients with SIPAT score ≥21 had higher hemoglobin A1c compared to patients with lower psychosocial risk (median (IQR): 7.8 (6.0-9.7) vs 6.6 (5.8, 7.9); p=0.04). There were no other differences in metabolic comorbidities between SIPAT groups. Increasing SIPAT score was associated with decreased odds of listing (OR: 0.82 per five-point increase; p=0.003) in multivariable models. A SIPAT of ≥12 was identified as the optimal cut-off in this population, resulting in an adjusted OR for listing of 0.53 vs SIPAT <12 (p=0.001). In this large cohort of MASLD patients evaluated for LT, few patients met the previously defined high SIPAT cut-off for transplant suitability. Nevertheless, increasing SIPAT score was associated with waitlist outcome. Our suggested SIPAT cut-off of ≥12 for MASLD patients warrants further external validation using data from other centers.

Measuring the psychosocial wellbeing of Rohingya mothers in Cox’s Bazar, Bangladesh: Psychometric properties of an MHPSS assessment battery

Background Psychosocial research in humanitarian settings has been historically dominated by a focus on distress and disorder. As such, there is a need to establish the validity of instruments for a broad range of psychosocial outcomes, particularly among highly affected and under-represented populations. The current study describes the adaptation and testing of multiple psychosocial instruments among displaced Rohingya mothers in Bangladesh. Methods We used baseline data from 600 mothers of malnourished children aged 2 and under enrolled in an intervention study in Cox’s Bazar, Bangladesh. Instruments assessed distress (items from the International Depression Symptom Scale [IDSS] and Kessler-6 [K-6]); functional impairment (World Health Organization Disability Assessment Schedule [WHODAS]); subjective wellbeing (global Satisfaction With Life [SWL] and Personal Wellbeing Index [PWI]; and, coping (items from the Brief COPE and locally developed coping items). Instruments were piloted and refined, then used for data collection by Bangladeshi-Rohingya interviewer pairs. We conducted exploratory factor analysis, evaluated internal consistency, examined construct validity through correlation with other scales, and used regression models to explore demographic factors associated with psychosocial health. Results Both the WHODAS and coping items fit 2-factor models; other scales were unidimensional. Cronbach’s alphas ranged from .76 to .90 for the refined scales. With the exception of coping, scale correlations supported construct validity; separate measures of the same construct were highly correlated, distress and impairment were moderately correlated, and both were inversely correlated with wellbeing. Correlates of poorer psychosocial health included relative socioeconomic disadvantage, current pregnancy, and being unmarried. Conclusions Most of the standard psychosocial assessment tools performed adequately, but they did not appear to fully capture local experiences and included items of little local relevance. Findings highlight the need for further mixed methods research to develop a rich battery of instruments with cross-cultural validity, particularly for positive outcomes such as coping which was particularly challenging to assess.

Measuring the psychosocial wellbeing of Rohingya mothers in Cox’s Bazar, Bangladesh: Psychometric properties of an MHPSS assessment battery

Background: Psychosocial research in humanitarian settings has been historically dominated by a focus on distress and disorder. As such, there is a need to establish the validity of instruments for a broad range of psychosocial outcomes, particularly among highly affected and under-represented populations. The current study describes the adaptation and testing of multiple psychosocial instruments among displaced Rohingya mothers in Bangladesh. Methods: We used baseline data from 600 mothers of malnourished children aged 2 and under enrolled in an intervention study in Cox’s Bazar, Bangladesh. Instruments assessed distress (International Depression Symptom Scale [IDSS] and Kessler-6 [K-6]); functional impairment (World Health Organization Disability Assessment Schedule [WHODAS]); subjective wellbeing (global Satisfaction With Life [SWL] and Personal Wellbeing Index [PWI]; and, coping (Brief COPE and locally developed coping items). Instruments were piloted and refined, then used for data collection by Bangladeshi-Rohingya interviewer pairs. We conducted exploratory factor analysis, evaluated internal consistency, examined construct validity through correlation with other scales, and used regression models to explore demographic factors associated with psychosocial health. Results: Both the WHODAS and coping items fit 2-factor models; other scales were unidimensional. Cronbach’s alphas ranged from .76 to .90 for the refined scales. With the exception of coping, scale correlations supported construct validity; separate measures of the same construct were highly correlated, distress and impairment were moderately correlated, and both were inversely correlated with wellbeing. Correlates of poorer psychosocial health included relative socioeconomic disadvantage, current pregnancy, and being unmarried. Conclusions: Most of the standard psychosocial assessment tools performed adequately, but they did not appear to fully capture local experiences and included items of little local relevance. Findings highlight the need for further mixed methods research to develop a rich battery of instruments with cross-cultural validity, particularly for positive outcomes such as coping which was particularly challenging to assess.

Screening for inattention, hyperactivity and impulsivity in children with haemophilia: A quality improvement intervention.

Children with haemophilia have been reported with increased rates of inattention (IN) and hyperactivity/impulsivity (HI) and, therefore, are particularly vulnerable to poor social and academic outcomes. To examine the benefit of utilizing a formal screening process for IN/HI in children with haemophilia during comprehensive clinic visits using a quality improvement approach. At a single haemophilia treatment centre, screening for psychosocial issues was expanded and formalised to include (1) the Conners 3rd Edition (Conners3) screening tool for IN/HI symptoms administered during the standard psychosocial assessment (SPA) by the social worker and school advocacy coordinator, (2) formal pathways to diagnosis and intervention as indicated including psychology consultation, psychological testing, or referral to community-based mental health professionals, and in-person advocacy assistance in the patient's community school. Forty-four patients, age 9.9±4.8 years (range 3-16) were targeted. The initial screening approach was modified to improve the communication with caretakers during assessments and streamline diagnostic pathways if no, moderate or significant behavioural concerns were identified. Eleven patients had pre-existing mental health diagnoses. Thirteen of the remaining 33 patients (39.4%) received a new mental health diagnosis, ADHD in 8/33 (24.2%). Of the total cohort, 54.5% were found to have a mental health diagnosis. The rate of ADHD (29.5%) was significantly higher than reported in the general population. The described process, developed through a QI approach, allowed formal and objective screening for IN/HI, streamlined a pathway to diagnosis and intervention, and identified undiagnosed disabilities in children with haemophilia improving their access to services.

Screening for Depression in Younger Breast Cancer Survivors: Outcomes From Use of the 9-item Patient Health Questionnaire.

BackgroundMajor cancer organizations recommend depression screening in patients and survivors. The 9-item Patient Health Questionnaire (PHQ-9) is often suggested, with limited information about its use. MethodsEnrollment data collected from younger breast cancer survivors participating in a behavioral intervention trial were used to examine the relationship between PHQ-9 scores (range = 0-27), patient characteristics, and responses to standardized psychosocial assessment tools. Major depressive disorder criterion was met if responses to the first 2 PHQ-9 items (range = 0-6) were 3 or greater. The sample was categorized by total PHQ-9 scores: less than 5 (minimal depressive symptoms), 5-9 (mild to moderate depressive symptoms), and 10 or greater (moderate to severe depression). PHQ-9 category associations with medical, demographic, psychosocial, and behavioral characteristics were examined using analysis of variance for continuous variables and χ2 tests for categorical variables.ResultsA total of 231 women met the study prescreening eligibility criterion of mild depressive symptoms and enrolled in the study. On average, they were 45.2 years old and 2.6 years since diagnosis. At enrollment, 22.1% met the screening criterion for possible major depressive disorder; among those with PHQ-9 scores of 10 or greater, 58.3% met this criterion. Anxiety, fatigue, insomnia, and intrusive thoughts about cancer were frequent and were associated with depressive symptom severity (all P < .001). In contrast, neither demographic nor cancer treatment characteristics were associated with depressive symptoms.ConclusionsDepressive symptoms in this selected sample of younger breast cancer survivors were independent of demographic characteristics or cancer treatment history, suggesting that depression screening is necessary to detect uncontrolled depressive symptoms.

Early Identification of Barriers and Facilitators to Self-Management Behaviors in Pediatric Patients With Sickle Cell Disease to Minimize Hematopoietic Cell Transplantation Complications.

Hematopoietic cell transplantation (HCT) is an elective, curative treatment option for patients with sickle cell disease (SCD). Transplant requires extensive self-management behaviors to be successful. The purpose of this study was to describe potential barriers and facilitators to self-management in a group of pediatric patients with SCD prior to HCT and their medical outcomes post-HCT. A multiple case study approach was used to describe 4 pairs of transplant recipients grouped by age, donor type, and donor source. Each pair included a case with minimal and increased post-HCT complications. Complications included readmissions, graft-versus-host disease, systemic infections, and survival in the first year post-HCT. Variables were retrospectively collected and content analyzed to identify barriers and facilitators within and across pairs using existing self-management frameworks. While higher risk transplants experienced more complications, 3 of the 4 cases with increased complications had a larger number of modifiable barriers identified compared with those experiencing minimal complications. At least one modifiable barrier and multiple facilitators were identified in all cases. A standardized psychosocial assessment process with an established plan to mitigate barriers and promote facilitators to self-management is essential to optimize outcomes in patients with SCD undergoing elective HCT.

Apport de la médecine légale à la protection de l’enfance : présentation d’un mode d’évaluation pluridisciplinaire

Maltreatment is a complex issue and therefore, requires a multidisciplinary approach, which has been commonly used in North America since the 1980s but remains unsystematic in France. Since 1999, the Centre d'Accueil en Urgence des Victimes d'Agression (emergency unit for victims of assault) of the Bordeaux University Hospital has brought together various medical, paramedical, and social actors on this issue. A standardized psychosocial assessment procedure has been introduced and is detailed in this paper, and was consistently conducted in all cases of suspicion of abuse on a minor. The authors studied 74cases of minors having undergone a psychosocial assessment following suspicions of maltreatment between 1July 2014and 30June 2015that were not referred to the courts. Forty-five girls and 29boys, mean age 7years, claiming mainly (75%) to have been subjected to sexual violence, were addressed to us by internal partners (n=15) and external partners (n=37) and 22who came to our unit by self-referral. Following our assessment, 35returned to their home and 36went to court following a police complaint (n=17) and a report filed to the public prosecutor of the Republic (n=19). Three of these cases were subjected to a report on matters of concern sent to the departmental council. Given the absence of a national consensus on the methodology used for assessing suspicions of maltreatment on minors, our psychosocial assessment can facilitate the task with its peer review as well as the detection and judicialization of the maltreatment. The authors also highlight the recent modification of article 226-14of the Penal Code, which aims at protecting professionals reporting matters to legal authorities from any legal proceeding, except if it is established that the individual did not act in good faith.

Validation of Hearts-Map, A Psychosocial Assessment Tool Applied to Children and Youth with Mental Health-Related Paediatric Emergency Visits

Abstract BACKGROUND: Mental health-related pediatric emergency department (PED) visits are increasing annually, and there is a need for a validated comprehensive standardized assessment tool to better manage these patients. OBJECTIVES: The primary objective of this study was to evaluate HEARTSS-MAP, a psychosocial assessment tool, in terms of inter-rater agreement among clinicians as well as the tool’s performance in predicting needs for acute psychiatric consultation for hospitalization. DESIGN/METHODS: The HEARTSS-MAP evaluation was done in two phases. We retrospectively reviewed 101 cases randomly sampled from a cohort of patients who sought care at the BC Children’s Hospital (BCCH) PED for mental health complaints. Narratives pertaining to each patient’s psychosocial assessment were recorded. Clinicians, including two emergency physicians, a bedside nurse, a nurse practitioner, and two psychiatrists, were blinded to the patients' outcomes, and individually applied the HEARTSS-MAP tool to the clinical narratives. The inter-rater agreement was calculated using Cohen’s kappa statistics. We then evaluated the tool’s sensitivity and specificity in predicting admission for the retrospective cohort, as well as a prospective cohort of 62 patients assessed and managed by a PED clinician using the HEARTSS-MAP. RESULTS: There was substantial agreement between the two pediatric emergency reviewers (κ=0.7), and moderate agreement between the pedi-atric emergency physicians and the nurse practitioner (κ=0.6), and the bedside nurse (κ=0.5). Pediatric psychiatrists had fair agreement between themselves (κ=0.3), and between psychiatrists and emergency physicians (κ=0.4). Based on retrospective data, HEARTSS-MAP had a sensitivity of 91% (95%CI: 71 to 99%), and a specificity of 41% (95%CI: 30 to 53%). When applied to prospectively collected data, the sensitivity was 100% (95%CI: 75 to 100%), and specificity was 33% (95%CI: 20 to 48%). CONCLUSION: HEARTSS-MAP, the first standardized psychosocial assessment tool to be implemented at BCCH PED, demonstrates strong inter-rater reliability between emergency clinicians, with a high sensitivity in identifying patients with mental health complaints requiring hospital admission.

The Kaiser Permanente Breast Cancer Survivorship National Clinical Algorithm: Regional variation in implementation processes/strategies within an integrated health care system.

104 Background: Kaiser Permanente (KP) is an integrated healthcare system providing comprehensive services to over 10 million members. The KP Interregional Breast Care Leaders, a multidisciplinary clinician group, developed a comprehensive evidence/consensus-based algorithm for breast cancer survivors, the KP Breast Cancer Survivorship National Clinical Algorithm (BCSNCA). The BCSNCA is intended to reduce variation in medical and psychosocial surveillance and improve outcomes by providing guidance to locally implemented survivorship programs, ie, recommendations for surveillance, late effects management, and risk reduction. As a quality improvement project, we evaluated regional/ facility level implementation. Methods: Qualitative data on BCSNCA implementation was collected from key informant interviews with oncology providers for 20 sites in 6 regions: Georgia, Colorado, Hawaii, Southern (KPSC) and Northern California (KPNC), and Mid-Atlantic, and by attending BCSNCA meetings. Implementation activities were recorded, categorized, and compared to BCSNCA. Results: Facilities in 3 regions implemented discrete BCSNCA components: Northwest and Georgia facilities implemented dedicated survivorship clinics; a KPSC facility piloted a nurse navigator standardized psychosocial assessment; KPNC implemented local guidelines, similar to the BCSNCA. One region has not implemented; Georgia implemented all BCSNCA components. There is variation within each region. Implementation drivers include available resources, competing QI priorities/leadership preferences, and adaptability of extant programs. Conclusions: We found variation between and within regions. The BCSNCA content accommodates variation in implementation, guided by a complex set of factors, including resource availability, leadership preferences, and local organizational goals. Even in integrated systems, the need for locally driven guideline adaptation is critical. Next step: assessment of BCSNCA components on patient-level outcomes.

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression

Background contextInsomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population. PurposesThis study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population. Study design/settingThis was a retrospective study of prospectively captured data. Patient sampleA consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol. Outcome measuresInsomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0–7); subthreshold insomnia (score, 8–14); moderate clinical insomnia (score, 15–21); and severe clinical insomnia (score, 22–28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire. MethodsPatients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses. ResultsThe presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia. ConclusionThis research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.

A simulation-based course for pain management: Improving skills in the utilisation of bio-psychosocial formulation in non-psychiatrists

tional registry on reconstructive transplantation. Results: 50 hand transplants have been performed and over 10 face transplants. Complications have included rejection, poor functional outcomes, hip replacement, cancer and two deaths in face transplant patients. The majority of patients have had varying degrees of functional improvement and sensory return with quality of life and life satisfaction improvements did not necessarily correlated with functional outcome. Noncompliance, depression including a suicide attempt in one case and malingering (feigned blindness) are some of the psychiatric sequelae reported. Social workers, psychologists and psychiatrists have all participated in the evaluation of candidates but no standard psychosocial assessment has been mandated. Body image and the capacity to comply with lengthy rehabilitation are unique features of the assessment. Conclusion: Reconstructive transplantation is increasing and hand transplantation is no longer considered solely a research activity. Psychosomatic medicine specialists assist in the selection of optimal candidates. Standardization and education of the unique aspects of reconstructive transplantation are needed and training of C/L psychiatrists interested in supporting this population of patients is needed.

The Clinical Utility of the Multidimensional Pain Inventory (MPI) in Characterizing Chronic Disabling Occupational Musculoskeletal Disorders

The Multidimensional Pain Inventory (MPI) was designed to help capture unique characteristics of chronic pain patients. The present study examined the proportion of subgroups classified by the MPI in a chronic disabling occupational musculoskeletal disorder (CDOMD) patient cohort, and described characteristics of MPI profile groups in terms of other psychosocial variables. A cohort of 1,270 CDOMD patients undergoing an interdisciplinary functional restoration program was studied. Before the start of the program, all patients received a standard psychosocial assessment battery. A MPI computer program scored and identified pre-defined MPI subgroups: Adaptive Coper (AC); Interpersonally Distressed (ID); and Dysfunctional (DYS). The distribution of MPI profiles for CDOMD patients was similar with those of highly disabled patients, with the largest proportion of patients having the DYS profile (44 %), followed by AC (33 %) and ID (23 %). The DYS profile group showed the highest level of pain severity, and psychosocial distress; the ID group had a moderate level; and the AC profile group had the lowest level. Higher rates of psychiatric disorders were also found in the DYS and ID groups. The DYS profile group was less likely to complete the treatment program. The present study further demonstrated the clinical utility of the MPI classification in a large cohort of CDOMD patients, indicating that the MPI profiles successfully distinguish among patients who may require extra psychosocial attention to achieve successful treatment gains and program completion.

Trial of Therapeutic Assessment in London: randomised controlled trial of Therapeutic Assessment versus standard psychosocial assessment in adolescents presenting with self-harm

ObjectiveTo determine whether Therapeutic Assessment (TA) versus assessment as usual (AAU) improves engagement with follow-up in adolescents presenting with self-harm.DesignRandomised controlled trial with 3 months naturalistic follow-up.SettingChild and adolescent mental...

Discriminating levels of alcohol use associated with self-harm in individuals presenting to a district general hospital

Aims and methodAlthough alcohol is reported as commonly associated with self-harm, there is nothing in the literature that bases the association on validated screening tools. We sought to discern the different types of alcohol use as discriminated by the Alcohol Use Disorders Identification Test (AUDIT). Completed AUDITs from a 2-year period were analysed, all relating to people who had presented to a district general hospital in Northumberland following self-harm.ResultsThe proportion of dependent, harmful and hazardous drinkers identified using AUDIT was many times higher than previously estimated in similar studies that had not used a validated alcohol screening tool.Clinical implicationsThe routine use of an alcohol screening tool should be part of any standard psychosocial assessment of self-harm, to guide appropriate interventions for problematic alcohol use that might otherwise be overlooked.

A Comparative Follow-up Study of Aftercare and Compliance of Suicide Attempters Following Standardized Psychosocial Assessment

This comparative longitudinal study investigated aftercare and compliance of attempted suicide patients after standardized psychosocial assessment. Structured interviews were conducted 1 month (FU1) and 6 months (FU2) after an index suicide attempt. Assessment was associated with more frequent discussion of treatment options with the patient at the hospital and a shorter interval between discharge and contacting the general practitioner (GP). A near significant effect was found for discussing the suicide attempt with the GP more frequently and with start or change of the medication scheme after the index attempt. The current findings support the use of a standardized tool for the assessment of suicide attempters and are in line with the chain of care model for suicide attempters.

The assessment of need in patients presenting to psychiatrists in the general hospital.

The evaluation of psychosocial need is an important part of the assessment of any patient who presents to a psychiatrist. The Camberwell Assessment of Need (CAN) instrument was developed for the systematic assessment of need in people with severe and enduring mental illness. Variations of the CAN have been developed for forensic, elderly and learning disability populations. Patients presenting to psychiatrists in the general hospital may also have different needs to those presenting to psychiatrists in other settings. We set out to examine whether the CAN would be useful in identifying needs in patients referred to psychiatrists in the general hospital with self-harm or alcohol problems. Over a four-month period from September 2004 we prospectively assessed all patients with self-harm or alcohol problems referred to a liaison psychiatry service. We used the short version of the Camberwell Assessment of Need instrument (CANSAS) to assess psychosocial needs. Urgent referrals to a local psychiatric service of patients with severe enduring mental illness (SEMI) were assessed using identical methodology over the same time period and used as a comparison group. Over the study period 53 patients with self-harm, 42 with alcohol problems and 45 with SEMI were assessed. Patients presenting with self-harm and alcohol problems had significantly fewer needs than those with SEMI (4.40 vs 3.98 vs 7.96, p < 0.001). Looking after the home, self-care, daytime activity, psychotic symptoms, safety to others and sexual expression needs were significantly greater in the SEMI group than in either the DSH or alcohol groups. Only safety to self-needs in the DSH group and alcohol needs in the alcohol group were significantly higher than in the SEMI group. The proportion of needs that were unmet was similar in each group. The CANSAS instrument identified some needs in deliberate self-harm and alcohol problem patients that might not have been identified during the course of a standard psychosocial assessment. It was easy to administer and as such was a useful addition to the assessment process. However the development of a more specific instrument for the assessment of need in these populations would be useful.

Smoking status and psychosocioeconomic outcomes of functional restoration in patients with chronic spinal disability

Background context Studies have revealed smoking to have a negative impact on spinal surgery. It is assumed that this is the result of the negative impact of nicotine on revascularization of damaged tissue. However, there is a paucity of research on the role of smoking with regard to nonsurgical rehabilitation, but there exists a clear bias for believing that smoking is strongly associated with poor socioeconomic and psychosocial outcome. Purpose This study was designed to examine the relationship between smoking and outcomes in a chronically disabled work-related spinal disorder (CDWRSD) cohort undergoing functional restoration. Study design A prospective comparison cohort study investigating the effects of smoking status on functional restoration treatment outcomes. Patient sample A cohort of 1,141 consecutive CDWRSD patients were divided into four groups: Group A, patients who did not smoke (n = 710); Group B, patients who smoked less than one cigarette pack/day (n = 157); Group C, patients who smoked 1.0 to 1.9 packs/day (n = 218); Group D, patients who smoked 2.0 or more packs/day (n = 56). Outcome measures Before the start of functional restoration, and upon its completion, patients received a standard psychosocial assessment battery and were assessed on a variety of physical factors. A structured clinical interview examining socioeconomic outcomes was conducted 1 year after the program. Methods Patients underwent an intensive functional restoration chronic pain management rehabilitation program consisting of quantitatively directed exercise progression and a multimodal disability management program for CDWRSD. The program consisted of four phases, the most significant of which involved a 3-week full-day intensive phase after preparatory preprogram phases and before a work transition phase. Results Analysis revealed that the percent of males increased as the smoking level increased (Group A = 51.8% vs Group D = 73.2%; p<.001). Also, as smoking increased, the level of education significantly decreased. In addition, as smoking level increased, the percent of patients completing the rehabilitation program decreased (from 86.3% to 75%; p = .03). No significant differences in 1-year posttreatment socioeconomic outcomes of work status, health utilization, recurrent injury or case closure were related to smoking except work retention, which decreased with more smoking (85 to 71%, p<.05). Surprisingly, the physical cumulative score at posttreatment increased as smoking frequency increased (p<.01). This finding indicates that those who smoked more performed at a higher level on physical measures. Those who smoked more frequently before treatment also appeared more depressed (p<.001), but after treatment, these differences disappeared. Self-reported pain intensity differed only after treatment, and posttreatment disability ratings showed a significant linear trend. Conclusions Contrary to popular belief, CDWRSD patients who smoke do not differ significantly in socioeconomic or psychosocial outcomes relative to those who do not. Although this study does indicate that those who smoke more evidence lower rehabilitation completion rates, those who completed the program had identical 1-year posttreatment outcomes of socioeconomic importance except in retraining work at year end as those who did not smoke. Smokers had slightly higher posttreatment self-reported pain and disability ratings mixed and limited. Overall, there is evidence for the widely held belief that smoking negatively affects tertiary rehabilitation.

Review of Transitions in Dying and Bereavement: A Psychosocial Guide for Hospice and Palliative Care.

THE VICTORIA HOSPICE SOCIETY MOIRA CAIRNS, MARNEY THOMPSON, and WENDY WAINWRIGHT Transitions in Dying and Bereavement: A Psychosocial Guide for Hospice and Palliative Care Baltimore, MD: Health Professions Press, 2003, 408 pages (ISBN 1-87881-292-0, US$44.95 Paperback) This psychosocial guide book for hospice and palliative care represents joint effort between staff and volunteers of Victoria Hospice Society, Victoria, BC, in operation since 1980, and three talented clinicians with background in counseling, palliative care, and The staff at Victoria Hospice has been actively involved, provincially and nationally, in development of number of initiatives for palliative care training, advocacy and research, latter being weakest of their initiatives. The main objective of this book was to describe what palliative and bereavement counselors do and how they do it. The specific goal was to examine psychosocial needs and care of individuals who are dying or bereaved, with ultimate goal being improvement of quality of palliative psychosocial care services. Each chapter addresses significant transitions, identifies psychosocial issues that patients and fami lies may face, addresses team issues, and suggests tips and interventions. case studies provide human context behind these issues. My own voice presents personal stories and insights of individuals other than authors regarding care for dying patients. Perspective sections address important and overarching topics relevant to most transitions. The book starts with principles of palliative hospice care, description of Victoria Hospice's program and team, key concepts, and framework and model used to organize book (Chapter 1). Bates's (1993) definition of psychosocial domain is used to set scope of area, encompassing emotional, intellectual, spiritual, interpersonal, social, cultural and economic dimensions of dying and bereavement. In Chapter 2, they discuss psychosocial assessment and provide questions for conducting such assessment. They state that psychosocial assessments provide a core standardized reference information regarding patients... Unfortunately, no information is provided regarding current attempts in field by authors or others to develop standardized psychosocial assessment instruments to be used during palliative care and The framework for palliative care is provided by Palliative Performance Scale (PPSv2), and model of grief is based on Rando's (1984) phases of grief and Worden's (1992) grief's tasks. A metaphor of last journey through life is used along with PPSv2 to discuss transitions in palliative care and metaphor of walking through labyrinth is used to represent bereavement journey toward healing after loss. The PPSv2 is recommended as tool to assess patients who are dying. PPSv2 is an unpublished version of Palliative Performance Scale (Anderson, Downing, Hill, et al., 1996). Although The PPSv2 is recommended to assess patients who are dying, no information is provided in book (or in its web site reference) about whether this or original version is reliable and valid. The original PPS (Anderson et al., 1996) and PPSv2 only assess general physical functioning, mobility, intake, and conscious level. Based on their extensive clinical experience, in Chapter 2 authors describe psychosocial issues arising during dying journey, discuss importance of psychosocial assessment, and suggest assessment questions to ask. For psychosocial guide on palliative care, it is unfortunate that issues related to standardized psychosocial assessments are not discussed, as it would be useful to reflect on stage of scientific validity of palliative care field in general. The chronicity of disease and its recurrence, which is appropriately called the path not chosen, along with worst fears facing families are described in Chapter 3. …

Gender-related differences in treatment outcomes for patients with musculoskeletal disorders

Background context: Clinicians have long hypothesized that gender may be a risk factor in treatment outcomes of patients with chronic disability associated with musculoskeletal disorders. Although the scientific literature shows a higher prevalence of occupational low back injury in men, and a higher rate of repetitive motion and neck injuries in women, few studies have comprehensively investigated the role of gender regarding cost-related outcome variables of significance after work-related injuries. Purpose: This study was designed to examine the relationship between gender and biopsychosocial treatment outcomes in a predominately chronically disabled spinal disorder (CDSD) workers' compensation cohort undergoing a tertiary functional restoration program. Study design: A prospective comparison cohort study investigating the effect of gender on biopsychosocial treatment outcomes as risk factors for rehabilitation failure. Patient sample: A cohort of 1,827 consecutively treated patients with CDSD were placed into two gender-based groups: men (n=1,158, average age 40.7±10 years) and women (n=669, average age 42.5±10 years). Outcome measures: Before the start of the program, and again upon completion of the program, all patients received a standard psychosocial assessment and were assessed on a variety of physical factors (leading to a cumulative score, calculated on the basis of the aggregates and averages of these physical measures). A structured clinical interview examining socioeconomic outcomes was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study. Methods: All patients underwent a medically directed functional restoration program combining quantitatively guided exercise progression with a multimodal disability management approach using psychological and case management techniques. Results: Men had a significantly higher rate of lumbar injury than women, whereas women had a significantly higher rate of cervical injury. Men returned to work and retained work at a 40 hours/week job at a higher rate at 1-year follow-up. Women evidenced a higher rate of health care–seeking behaviors from new providers. On physical testing immediately after treatment, men had a significantly higher cumulative physical score (gender normalized), both before and after treatment. On depression and disability questionnaires, men showed fewer pre- and posttreatment depressive symptoms with lower pretreatment disability scores. Conclusions: The present study represents the first large-scale examination of the relationship between gender and treatment outcomes for a population with CDSD after work injuries. There was a pattern of moderately better 1-year posttreatment socioeconomic outcome for men. On psychosocial measures, men showed lower disability and depression scores than women, with higher levels of physical functioning both before and after treatment. Overall, male patients with CDSD appeared to show somewhat better biopsychosocial outcomes. This leaves the question of identifying gender-specific risk factors to explain these differences.

Does gender significantly affect treatment outcomes in work-related chronic spinal disorders?

Robert J. Gatchel, PhD, Tom Mayer, MD, Christopher Anagnostes, PhD Candidate, Timothy Proctor, PhD Candidate, Dallas, TX, USAIntroduction: Clinicians have long hypothesized that gender may be a risk factor in treatment outcomes of chronically disabled spinal disorder (CDSD) patients. Although the scientific literature shows a higher prevalence of occupational low back injury in males, and a higher rate of repetitive motion and neck injuries in females, few studies have comprehensively investigated the role of gender regarding cost-related outcome variables of significance after work-related injuries. This study was designed to examine the relationship between gender and biopsychosocial treatment outcomes in a CDSD workers compensation cohort undergoing a tertiary-level functional restoration program.Methods: A large cohort of 1,827 consecutively treated CDSD patients were placed into two gender-based groups: males (M), n = 1,158, average age, 40.7 ± 10 years) and females (F), n = 669, average age, 42.5 ± 10 years). All patients underwent a 3-week medically directed functional restoration program combining quantitatively guided exercise progression with a multimodal disability management approach using psychological and case management techniques. Preprogram preparation included drug detoxification, psychotropic medication management and preparatory aerobic and mobilization training. Before the start of the program, and again upon completion of the program, all patients received a standard psychosocial assessment battery that included the Dallas Pain and Disability Questionnaire, a visual analog scale that measures subjective disability; and the Beck Depression Inventory, which quantifies depressive symptomology. Additionally, patients were assessed on a variety of physical factors, and a cumulative score was calculated that aggregates and averages these physical measures. A structural clinical interview examining socioeconomic outcomes was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study.Results: As expected, men had a significantly higher rate of lumbar injury than women (64% to 53%), whereas women had a higher rate of cervical injury (15% to 10%) than men (p<.001). Men returned to work at a higher rate at 1 year follow-up than women (87% to 81%; p<.01). Men also had a higher rate of work retention to a 40 hour/week job at 1 year follow-up (68% to 61%, p<.01). Women evidenced a higher rate of health-care-seeking behaviors from new providers (31% to 25%, p<.01). Men had a significantly higher cumulative physical score (gender normalized) at both pretreatment (M=41) and postreatment (M=75) than women (F=34 and 67, respectively; p<.001). Men exhibited fewer depressive symptoms, as evidenced by lower pretreatment (M=16; F=18) and posttreatment (M=8; F=10) Beck Depression Inventory scores than women (p<.001). Men also evidenced lower pretreatment disability scores (M=90 versus F=94; p<.01).Conclusion: The present study represents the first large-scale examination of the relationship between gender and treatment outcomes for a CDSD population after work injuries. There is a pattern of moderately improved socioeconomic outcome for men. On psychosocial measures, men showed lower subjective disability scores than women. Men also showed lower levels of depression, with higher levels of physical functioning both before and after treatment. Overall, chronically disabled male spinal patients appeared to show somewhat better biopsychosocial outcomes. This leaves the question of identifying gender-specific risk factors to explain these differences.