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To meet the specific education needs of ethics committee members (primarily full-time healthcare professionals), the Regional Ethics Department of Kaiser Permanente Northern California (KPNCAL) and Washington State University’s Elson Floyd School of Medicine have partnered to create a one-academic year Medical Ethics Certificate Program. The mission-driven nature of the KPNCAL-WSU’s Certificate Program was designed to be a low-cost, high-quality option for busy full-time practitioners who may not otherwise opt to pursue additional education.
This article discusses the specific competency-focused methodologies and pedagogies adopted, as well as how the Certificate Program made permanent changes in response to the global pandemic. This article also discusses in detail one of the Program’s signature features, its Practicum—an extensive simulated clinical ethics consultation placing students in the role of ethics consultant, facilitating a conflict between family members played by paid professional actors. This article concludes with survey data responses from Program alumni gathered as part of a quality study.
Perceived cognitive dysfunction is a common feature of late-life depression (LLD) that is associated with diminished quality of life and greater disability. Similar associations have been demonstrated in individuals with Hoarding Disorder. The degree to which hoarding behaviors (HB) are associated with greater perceived cognitive dysfunction and disability in individuals with concurrent LLD is not known.
Participants and Methods:
Participants with LLD (N=83) completed measures of hoarding symptom severity (Savings Inventory-Revised; SI-R) and were classified into two groups based on HB severity: LLD+HB who exhibited significant HB (SI-R . 41, n = 25) and LLD with low HB (SI-R < 41, n = 58). Additional measures assessed depression severity (Hamilton Depression Rating Scale; HDRS), perceived cognitive difficulties (Everyday Cognition Scale; ECOG), and disability (World Health Organization Disability Assessment Scale [WHODAS]-II-Short). Given a non-normal distribution of ECOG and WHODAS-II scores, non-parametric Wilcoxon-Mann-Whitney tests were used to assess group differences in perceived cognitive dysfunction and disability. A regression model assessed the extent to which perceived cognitive dysfunction was associated with hoarding symptom severity measured continuously, covarying for age, education, gender, and depression severity. A separate regression model assessed the extent to which disability scores were associated with perceived cognitive dysfunction and HB severity covarying for demographics and depression severity.
Results:
LLD+HB endorsed significantly greater perceived cognitive dysfunction (W = 1023, p = 0.003) and greater disability (W = 1006, p = < 0.001) compared to LLD. Regression models accounting for demographic characteristics and depression severity revealed that greater HB severity was associated with greater perceived cognitive dysfunction (β = 0.009, t = 2.765, p = 0.007). Increased disability was associated with greater perceived cognitive dysfunction (β = 4.792, t(71) = 3.551, p = 0.0007) and HB severity (β = 0.080, t(71) = 1.944, p = 0.056) approached significance after accounting for variance explained by depression severity and demographic covariates.
Conclusions:
Our results suggest that hoarding behaviors are associated with increased perceived cognitive dysfunction and greater disability in individuals with LLD. Screening for HB in individuals with LLD may help identify those at greater risk for poor cognitive and functional outcomes. Interventions that target HB and perceived cognitive difficulties may decrease risk for disability in LLD. However, longitudinal studies would be required to further evaluate these relationships.
Late Life Major Depressive Disorder (LLD) and Hoarding Disorder (HD) are common in older adults with prevalence estimates up to 29% and 7%, respectively. Both LLD and HD are characterized by executive dysfunction and disability. There is evidence of overlapping neurobiological dysfunction in LLD and HD suggesting potential for compounded executive dysfunction and disability in the context of comorbid HD and LLD. Yet, prevalence of HD in primary presenting LLD has not been examined and potential compounded impact on executive functioning, disability, and treatment response remains unknown. Thus, the present study aimed to determine the prevalence of co-occurring HD in primary presenting LLD and examine hoarding symptom severity as a contributor to executive dysfunction, disability, and response to treatment for LLD.
Participants and Methods:
Eighty-three adults ages 65-90 participating in a psychotherapy study for LLD completed measures of hoarding symptom severity (Savings Inventory-Revised: SI-R), executive functioning (WAIS-IV Digit Span, Letter-Number Sequencing, Coding; Stroop Interference; Trail Making Test-Part B; Letter Fluency), functional ability (World Health Organization Disability Assessment Schedule-II-Short), and depression severity (Hamilton Depression Rating Scale) at post-treatment. Pearson's Chi-squared tests evaluated group differences in cognitive and functional impairment rates and depression treatment response between participants with (HD+LLD) and without (LLD-only) clinically significant hoarding symptoms. Linear regressions were used to examine the association between hoarding symptom severity and executive function performance and functional ability and included as covariates participant age, years of education, gender, and concurrent depression severity.
Results:
At post-treatment, 24.1% (20/83) of participants with LLD met criteria for clinically significant hoarding symptoms (SI-R.41). Relative to LLD-only, the LLD+HD group demonstrated greater impairment rates in Letter-Number Sequencing (χ2(1)=4.0, p=.045) and Stroop Interference (χ2(1)=4.8, p=.028). Greater hoarding symptom severity was associated with poorer executive functioning performance on Digit Span (t(71)=-2.4, β=-0.07, p=.019), Letter-Number Sequencing (t(70)=-2.1, β=-0.05, p=.044), and Letter Fluency (t(71)=-2.8, β=-0.24, p=.006). Rates of functional impairment were significantly higher in the LLD+HD (88.0%) group compared to the LLD-only (62.3%) group, (χ2(1)=5.41, p=.020). Additionally, higher hoarding symptom severity was related to greater disability (t(72)=2.97, β=0.13, p=.004). Furthermore, depression treatment response rates were significantly lower in the LLD+HD group at 24.0% (6/25) compared to 48.3% (28/58) in the LLD-only group, χ2(1)=4.26, p=.039.
Conclusions:
The present study is among the first to report prevalence of clinically significant hoarding symptoms in primary presenting LLD. The findings of 24.1% co-occurrence of HD in primary presenting LLD and increased burden on executive functioning, disability, and depression treatment outcomes have important implications for intervention and prevention efforts. Hoarding symptoms are likely under-evaluated, and thus may be overlooked, in clinical settings where LLD is identified as the primary diagnosis. Taken together with results indicating poorer depression treatment response in LLD+HD, these findings underscore the need for increased screening of hoarding behaviors in LLD and tailored interventions for this LLD+HD group. Future work examining the course of hoarding symptomatology in LLD (e.g., onset age of hoarding behaviors) may provide insights into the mechanisms associated with greater executive dysfunction and disability.
Anxiety disorders are the most frequently diagnosed psychiatric conditions in children and adolescents. Cognitive behavioural therapy (CBT) is a well-established and effective treatment for anxiety and related disorders across the lifespan. Expectations of psychotherapy have been demonstrated to affect outcomes, yet there is sparse existing literature on adolescent patient and parent perspectives of CBT prior to engagement with treatment.
Aims:
This study aimed to qualitatively explore the expectations and perceptions of CBT for anxiety and related disorders among adolescent patients and parents.
Method:
Fourteen adolescent patients and 16 parents participated in semi-structured individual interviews or focus groups consisting of 2–3 participants. Interview transcripts were analysed using inductive analysis.
Results:
Three themes were identified: worries about CBT, expectations and knowledge of the CBT process, and the role of parents and families. Overall, we found that adolescents and parents had generally positive views of CBT. The outset of CBT saw adolescents and parents express concern about stigma as well as the ambiguity of CBT. Parents continued to express a lack of understanding of what CBT entailed during their child’s treatment course.
Conclusion:
These results suggest that both adolescents and parents would benefit from early discussion and reinforcement of expectations for CBT treatment. Further research efforts are warranted and should be directed towards determining appropriate expectations for parental involvement in a child’s CBT course and effective communication of treatment expectations to both adolescents and parents.
Clinical, epidemiological, and genetic findings support an overlap between eating disorders, obsessive-compulsive disorder (OCD), and anxiety symptoms. However, little research has examined the role of genetics in the expression of underlying phenotypes. We investigated whether the anorexia nervosa (AN), OCD, or AN/OCD transdiagnostic polygenic scores (PGS) predict eating disorder, OCD, and anxiety symptoms in a large developmental cohort in a sex-specific manner.
Methods
Using summary statistics from Psychiatric Genomics Consortium AN and OCD genome-wide association studies, we conducted an AN/OCD transdiagnostic genome-wide association meta-analysis. We then calculated AN, OCD, and AN/OCD PGS in participants from the Avon Longitudinal Study of Parents and Children to predict eating disorder, OCD, and anxiety symptoms, stratified by sex (combined N = 3212–5369 per phenotype).
Results
The PGS prediction of eating disorder, OCD, and anxiety phenotypes differed between sexes, although effect sizes were small. AN and AN/OCD PGS played a more prominent role in predicting eating disorder and anxiety risk than OCD PGS, especially in girls. AN/OCD PGS provided a small boost over AN PGS in the prediction of some anxiety symptoms. All three PGS predicted higher compulsive exercise across different developmental timepoints [β = 0.03 (s.e. = 0.01) for AN and AN/OCD PGS at age 14; β = 0.05 (s.e. = 0.02) for OCD PGS at age 16] in girls.
Conclusions
Compulsive exercise may have a transdiagnostic genetic etiology, and AN genetic risk may play a role in the presence of anxiety symptoms. Converging with prior twin literature, our results also suggest that some of the contribution of genetic risk may be sex-specific.
Although exposure therapy (ET) is an effective treatment for anxiety disorders and obsessive-compulsive disorder, many clinicians report not utilizing it. The present study targeted common utilization barriers by evaluating an intensive ET training experience in a relatively inexperienced sample of pre-professionals. Thirty-two individuals at the undergraduate or college graduate level without formal clinical experience participated as camp counsellors in a 5day exposure-based therapeutic summer camp for youth with anxiety disorders and/or obsessive-compulsive disorder. Participants were trained in ET through a progressive cascading model and answered questionnaires before and after camp. Repeated measure MANOVA revealed significantly increased feelings of self-efficacy conducting exposures, and significantly decreased feelings of disgust sensitivity and contamination-related disgust from pre-camp to post-camp. A subset of individuals providing data 1 month after the camp maintained a significant gain in ET self-efficacy. Regression analyses revealed that contamination-related disgust, but not disgust sensitivity, significantly predicted post-camp ET self-efficacy. These findings suggest that individuals early into their post-secondary education can learn ET, and the progressive cascading model holds promise in its utility across experience levels and warrants further investigation. Disgust may also play a role in feelings of competency conducting ET. Implications on dissemination and implementation efforts are also discussed.
Key learning aims
(1) How can training of CBT techniques such as exposure occur prior to graduate education?
(2) Can self-efficacy in conducting exposures meaningfully increase in an experiential training of pre-professionals?
(3) How does an individual’s tolerance of disgust impact feelings of competence conducting exposures?
OBJECTIVES/GOALS: Obsessive compulsive disorder (OCD) is a serious and impairing disorder. The peripartum is associated with changes in pre-existing OCD, including exacerbation and improvement of the disorder. This meta-analysis seeks to understand the proportion of women reporting a change in OCD during this time. METHODS/STUDY POPULATION: Nine studies with independent samples examining change in obsessive-compulsive symptomology (OCS) in the peripartum were included in the meta-analysis. Studies were included if the sample examined with women with a clinical diagnosis of OCD that pre-existed pregnancy onset. The meta-analysis was conducted using R Studio with Meta, Metafor and Weightr packages. A moderation analysis was conducted to examine the impact of gestational period on OCD symptoms. Gestational periods were defined as pregnancy, postpartum, or the peripartum. Peripartum refers to a collapsed postpartum/pregnant period such that the period was not identified or specified during data collection. RESULTS/ANTICIPATED RESULTS: The summary proportion of women who experienced no change in symptoms was 46.7% (CI: 42.0-51.4%). No change by period was: pregnancy 49.6% (CI: 36.3-62.9%); postpartum 45.6% (CI: 41.4-49.9%); peripartum 52.4% (CI: 42.4-50.3%). The summary proportion of women who experienced exacerbation was 39.2% (CI: 33.5-45.5%). Exacerbation by period: pregnancy 35.5% (CI: 24.8-47.9%); postpartum 42.9% (CI: 34.8-51.4%); peripartum 34.6% (CI: 23.7-47.4%). The summary proportion of women who experienced improvement was 11.5% (CI: 9.3-14.4%). Improvement by period: pregnancy 42.9% (CI: 14.7-77.0%); postpartum 7.8% (CI: 5.7-10.4%); peripartum 19.6% (CI: 13.7-27.3%). Gestational period had a moderating effect. DISCUSSION/SIGNIFICANCE OF IMPACT: During the peripartum 46% report no change, 40% a worsening and 12% an improvement. Improvement typically occurs during pregnancy and may be followed by a postpartum worsening. This may reflect a hormonally-sensitive subsection of women impacted by the acute changes that occur during this time.
OBJECTIVES/SPECIFIC AIMS: By combining clinical knowledge of hoarding disorder (HD) with qualitative methods from cultural anthropology, we hope to build a patient-centered approach that will allow us to better understand the clinician perspectives on patient motivations and explanatory models of individuals with HD, and improve treatment outcomes. We describe the ways that these methodologies are productively merged in this project as a result of TL1 collaboration, and present a preliminary picture of methodological and theoretical issues uncovered as part of this processes. We further describe the analytical methods used for this project, and explore issues raised through the combination of psychological and anthropological data and insights. METHODS/STUDY POPULATION: This study represents an attempt to combine the qualitative methodologies of cultural anthropology with the clinical knowledge of psychology and psychiatry in order to better understand gaps between provider and patient beliefs and knowledge about hoarding disorder. This study will present preliminary methodological issues arising from interviews with hoarding experts. RESULTS/ANTICIPATED RESULTS: This study will discuss preliminary issues including shared language, strengths and limitations of both disciplines, and factors for consideration when combining these disparate methodologies. It will close with recommendations for consideration when moving forward with similar collaborations. DISCUSSION/SIGNIFICANCE OF IMPACT: This project seeks to unite psychological and social factors that may contribute to the lived experience of individuals with HD in order to better understand the way that HD is manifested. It also unites disparate methodologies to provide us with a more holistic and complete picture of the experience of HD. While HD has been studied within psychiatry, it has never been assessed using the qualitative methods of anthropology. These methods provide the possibility of expanding knowledge about the ways that this disorder is experienced by individuals and their families, and potentially impacted by shared beliefs and cultures. Furthermore, qualitative data of this nature provides a patient perspective on the experience of HD as a psychiatric illness. This patient perspective can be used to better inform treatment, improve patient outcomes, and to allow providers and researchers to gain a fuller understanding of this complex population.
Treatment for hoarding disorder is typically performed by mental health professionals, potentially limiting access to care in underserved areas.
Aims
We aimed to conduct a non-inferiority trial of group peer-facilitated therapy (G-PFT) and group psychologist-led cognitive–behavioural therapy (G-CBT).
Method
We randomised 323 adults with hording disorder 15 weeks of G-PFT or 16 weeks of G-CBT and assessed at baseline, post-treatment and longitudinally (≥3 months post-treatment: mean 14.4 months, range 3–25). Predictors of treatment response were examined.
Results
G-PFT (effect size 1.20) was as effective as G-CBT (effect size 1.21; between-group difference 1.82 points, t = −1.71, d.f. = 245, P = 0.04). More homework completion and ongoing help from family and friends resulted in lower severity scores at longitudinal follow-up (t = 2.79, d.f. = 175, P = 0.006; t = 2.89, d.f. = 175, P = 0.004).
Conclusions
Peer-led groups were as effective as psychologist-led groups, providing a novel treatment avenue for individuals without access to mental health professionals.
Declaration of interest
C.A.M. has received grant funding from the National Institutes of Health (NIH) and travel reimbursement and speakers’ honoraria from the Tourette Association of America (TAA), as well as honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. K.D. receives research support from the NIH and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. R.S.M. receives research support from the National Institute of Mental Health, National Institute of Aging, the Hillblom Foundation, Janssen Pharmaceuticals (research grant) and the Alzheimer's Association. R.S.M. has also received travel support from the National Institute of Mental Health for Workshop participation. J.Y.T. receives research support from the NIH, Patient-Centered Outcomes Research Institute and the California Tobacco Related Research Program, and honoraria and travel reimbursement from the NIH for serving as an NIH Study Section reviewer. All other authors report no conflicts of interest.
Bipolar disorder is an etiologically complex syndrome that is dearly heritable. Multiple, genes, working singly or in concert, are likely to cause susceptibility to bipolar disorder. Bipolar disorder genetics has progressed rapidly in the last few decades. However, specific causal genetic mutations for bipolar disorder have not been identified. Both candidate gene studies and complete genome screens have been conducted. They have provided compelling evidence for several potential bipolar disorder susceptibility loci in several regions of the genome. The strongest evidence suggests that bipolar disorder susceptibility loci may lie in one or more genomic regions on chromosomes 18, 4, and 21. Other regions of interest, including those on chromosomes 5 and 8, are also under investigation. New approaches, such as the use of genetically isolated populations and the use of endophenotypes for bipolar disorder, hold promise for continued advancement in the search to identify specific bipolar disorder genes.
Tourette syndrome and chronic tic disorder are heritable but aetiologically complex. Although environment plays a role in their development, existing studies of non-genetic risk factors are inconsistent.
Aims
To examine the association between pre- and perinatal exposures and Tourette syndrome/chronic tic disorder in the Avon Longitudinal Study of Parents and Children (ALSPAC) prospective longitudinal pre-birth cohort.
Method
Relationships between exposures and Tourette syndrome/chronic tic disorder were examined in 6090 children using logistic regression.
Results
Maternal alcohol and cannabis use, inadequate maternal weight gain and parity were associated with Tourette syndrome or Tourette syndrome/chronic tic disorder. Other previously reported exposures, including birth weight and prenatal maternal smoking, were not associated with Tourette syndrome/chronic tic disorder.
Conclusions
This study supports previously reported relationships between Tourette syndrome/chronic tic disorder and prenatal alcohol exposure, and identifies additional previously unexplored potential prenatal risk factors.
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Design
Longitudinal study.
Setting
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Subjects
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Results
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Conclusions
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.