Measuring Emotional Intelligence Enhances the Psychological Evaluation of Chronic Pain

The assessment of emotional factors, in addition to other psychosocial factors, has been recommended as a means of identifying individuals with chronic pain who may not respond to certain pain treatments. Systematic reviews of the evidence regarding the prediction of responsiveness to a treatment called the spinal cord stimulator (SCS) have yielded inconclusive results. Emotional intelligence is a term which refers to the ability to identify and manage emotions in oneself and others and has been shown to be inversely associated with emotional distress and acute pain. This study aims to investigate the relationship between emotional intelligence, chronic pain, and the more established psychosocial factors usually used for SCS evaluations by clinical psychologists in medical settings. A sample of 112 patients with chronic pain on an acute hospital waiting list for SCS procedures in a pain medicine service were recruited. Psychological measures were completed including: a novel measure of emotional intelligence; usual measures of emotional distress and catastrophizing; and a numerical rating scale designed to assess pain intensity, pain-related distress, and interference. As predicted, findings revealed significant associations between most of the measures analyzed and current pain intensity. When entered into a simultaneous regression analysis, emotional intelligence scores remained the only significant predictor of current pain intensity. There are potential clinical, ethical, and organizational implications of emotional intelligence processes partially predicting pain in patients on a waiting list for a medical procedure. These results may offer new insight, understanding, and evaluation targets for clinical psychologists in the field of pain management.

Treatment of refractory ascites with an automated low-flow ascites pump in patients with cirrhosis

BACKGROUND

Refractory ascites (RA) is a frequent complication of cirrhosis, requiring large volume paracentesis or placement of a transjugular intrahepatic portosystemic shunt (TIPSS). The automated low-flow ascites pump (alfapump, Sequana Medical AG, Zurich, Switzerland) is an innovative treatment option for patients with RA.

AIM

To assess safety and efficacy of this treatment in patients with a contraindication to TIPSS.

METHODS

Fifty-six patients (43 males; mean age 62 years) from centres in Germany, Switzerland, UK and Spain were included and followed for up to 24 months. Complications, device deficiencies, paracentesis frequency and patient survival were recorded.

RESULTS

At the time of this analysis, 3 patients completed the 24-month observation period, monitoring of 3 was ongoing, 9 underwent liver transplantation, 17 patients were withdrawn due to serious adverse events and 23 patients died. Most frequently observed technical complication was blocking of the peritoneal catheter. Twenty-three pump-related reinterventions (17 patients) and 12 pump exchanges (11 patients) were required during follow-up. The pump system was explanted in 48% of patients (in 17 patients due to serious adverse events, in 9 at the time of liver transplantation and in 1 due to recovery from RA). Median frequency of paracentesis dropped from 2.17 to 0.17 per month.

CONCLUSIONS

The alfapump can expand therapeutic options for cirrhotic patients with RA. Continuous drainage of ascites in a closed loop automated system led to significant reduction in paracentesis frequency. Technical and procedural improvements are required to reduce the rate of adverse events and reinterventions. https://clinicaltrials.gov/ct2/show/NCT01532427.

Implementation of a 'care bundle' improves the management of patients admitted to hospital with decompensated cirrhosis

BACKGROUND

Since 1970, there has been a 400% increase in liver-related deaths due to the increasing prevalence of chronic liver disease in the United Kingdom (UK). The 2013 UK National Confidential Enquiry into Patient Outcome and Death report found that only 47% of patients who died from alcohol-related liver disease received 'good care' during their hospital stay.

AIM

To develop a 'care bundle' for patients with decompensated cirrhosis, aiming to ensure that evidence-based treatments are delivered within the first 24 h of hospital admission.

METHODS

This work gives practical advice about how to implement the bundle and examines its effects on patient care at three National Health Service Hospital Trusts in the UK by collecting data on patient care before and after introduction of the bundle.

RESULTS

Data were collected on 228 patients across three centres (59% male, median age 53 years). Alcohol-related liver disease was the aetiology of chronic liver disease in 85% of patients. The overall mortality rate during hospital admission was 15%. The audits demonstrated improvements in patient care for patients with a completed care bundle who were significantly more likely to have a diagnostic ascitic performed within the first 24 h (P = 0.020), have an accurate alcohol history documented (P < 0.0001) and be given antibiotics as prophylaxis against infection following a variceal haemorrhage (P = 0.0096). In Newcastle, the bundle completion rate increased from 25% to 90% during the review periods.

CONCLUSIONS

The introduction of a care bundle was associated with increased rates of diagnostic paracentesis and antibiotic prophylaxis with variceal haemorrhage in patients with decompensated cirrhosis.

Health informatics and the cultural divide: a UK perspective

This paper discusses the concerns about the growing ‘digital divide’ within society which has implications for maintaining both health and social inequalities in the UK. The main focus of the paper is about inequalities in health relating to culture and ethnicity. Different theoretical approaches to cultural differences in health are set out as well as different ways of classifying cultural and ethnic differences in health service research. The argument then goes on to suggest that the emphasis on cultural and ethnic categorization only further divides people and fails to reduce inequalities. Transculturalism is defined and set out as a more useful way of approaching cultural difference as it is less restrictive and prescriptive. The paper sets out how this approach can be used to develop better quality health content in health informatics that is useful and relevant to a wider range of users, thus tackling both the digital divide and health inequalities.a

Republished: Non-alcoholic fatty liver disease: a practical approach to treatment

Non-alcoholic fatty liver disease (NAFLD) affects up to a third of the population in many developed countries. Between 10% and 30% of patients with NAFLD have non-alcoholic steatohepatitis (NASH) that can progress to cirrhosis. There are metabolic risk factors common to both NAFLD and cardiovascular disease, so patients with NASH have an increased risk of liver-related and cardiovascular death. Management of patients with NAFLD depends largely on the stage of disease, emphasising the importance of careful risk stratification. There are four main areas to focus on when thinking about management strategies in NAFLD: lifestyle modification, targeting the components of the metabolic syndrome, liver-directed pharmacotherapy for high risk patients and managing the complications of cirrhosis.

Experiences of adults providing care to a partner or relative with depression: A meta-ethnographic synthesis

BACKGROUND

International interest in the informal carer role has grown in part because of the relationship between caring and caregiver burden. It has been suggested that living with someone with depression is comparable to that of other serious mental health problems, such as schizophrenia or dementia.

METHODS

This meta-ethnography included 15 studies exploring experiences of living with a relative or partner with depression. Studies were heterogeneous regarding types of relationship with the depressed individual.

RESULTS

The synthesis revealed a cyclical, psychosocial process that family caregivers undergo whilst providing care to a person with depression. The process consists of four phases: making sense of depression; changes in family dynamics; overcoming challenges; and moving forward. The findings illustrate that care giving is not a static process and that the needs of the depressed person are constantly changing.

LIMITATIONS

Some of the studies presented in the review represent caregivers recruited via support groups and so the person cared for may not have had professional diagnoses of depression.

CONCLUSIONS

This synthesis indicated the need for professional support to be available to caregivers for their own mental health needs. The model put forward suggests that different types of support may be useful for caregivers at different stages of the process including couples or systemic therapy at the initial stages of management, addressing stigma to help those overcoming challenges of caring for their partner or relative and self-compassionate approaches for caregivers who may need support to look after themselves, avoid feelings of guilt and move forward towards acceptance.

'Am I damaging my own family?': Relational changes between foster carers and their birth children

Foster placements are more likely to break down where the foster carers already have birth children. Studies that explore the impact of fostering on foster carers and their birth children have suggested that relational changes occur, but these changes have not been examined in depth. This study aimed to explore the impact of fostering on parent-child relationships within foster families. Nine foster carers (including three couples) were interviewed separately, and the data were analysed using constructivist grounded theory methods. Analysis indicated that birth children may attribute particular importance to their position in the family (e.g. oldest child, youngest child) and that this is a key element of the way in which they relate to their parents. Emotional security and parent-child relationships can therefore be strained by a foster placement not taking this into account. Foster children also introduce significant competition for parental resources, putting a strain on relationships. Foster carers seem to prioritise, consciously or not, the preservation of relationships within the biological family. Reflecting on relationships and making changes to maximise potential improvements in relationships can lead to positive outcomes, and this can have an impact on whether families continue fostering or not.

Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS)

This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.

Republished: Non-alcoholic fatty liver disease: non-invasive investigation and risk stratification

Non-alcoholic fatty liver disease (NAFLD) encompasses a histological spectrum of liver disease, from simple steatosis through to cirrhosis. As the worldwide rates of obesity have increased, NAFLD has become the commonest cause of liver disease in many developed countries, affecting up to a third of the population. The majority of patients have simple steatosis that carries a relatively benign prognosis. However, a significant minority have non-alcoholic steatohepatitis, and have increased liver related and cardiovascular mortality. Identifying those at risk of progressive disease is crucial. Liver biopsy remains the gold standard investigation for assessing stage of disease but its invasive nature makes it impractical for widespread use as a prognostic tool. Non-invasive tools for diagnosis and disease staging are required, reserving liver biopsy for those patients where it offers clinically relevant additional information. This review discusses the non-invasive modalities available for assessing steatosis, steatohepatitis and fibrosis. We propose a pragmatic approach for the assessment of patients with NAFLD to identify those at high risk of progressive disease who require referral to specialist services.

Fighting the Whole System: Dissociative Identity Disorder, Labeling Theory, and Iatrogenic Doubting

This research examines how individuals diagnosed with dissociative identity disorder construe their experiences of being labeled with a contested diagnosis. Semistructured interviews were conducted in the United Kingdom with 5 women and 2 men diagnosed with dissociative identity disorder. A framework analysis was conducted. The analysis identified 2 overarching themes: diagnosis cross-examined and navigating care systems. The diagnosis appeared to be continually assessed by participants for its fit with symptoms, and the doubt among professionals seemed to be unhelpfully reflected in participants' attempts to understand and come to terms with their experiences. The findings are considered in light of labeling theory, the iatrogenic effects of professional doubt, and current debates concerning the reliability and validity of psychiatric diagnostic systems that have been reinvigorated by the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Non-alcoholic fatty liver disease: a practical approach to treatment

Non-alcoholic fatty liver disease (NAFLD) affects up to a third of the population in many developed countries. Between 10% and 30% of patients with NAFLD have non-alcoholic steatohepatitis (NASH) that can progress to cirrhosis. There are metabolic risk factors common to both NAFLD and cardiovascular disease, so patients with NASH have an increased risk of liver-related and cardiovascular death. Management of patients with NAFLD depends largely on the stage of disease, emphasising the importance of careful risk stratification. There are four main areas to focus on when thinking about management strategies in NAFLD: lifestyle modification, targeting the components of the metabolic syndrome, liver-directed pharmacotherapy for high risk patients and managing the complications of cirrhosis.

That's just life: older adult constructs of trauma

OBJECTIVES

Researcher, clinical professional and lay understandings of the meaning of trauma may differ. An awareness of older people's perspectives on trauma may be important, given the potential for historical and cultural features to shape how the term is conceptualised among this group, thereby influencing related help-seeking behaviour.

METHOD

Older people living in Essex, Cambridgeshire and Suffolk were interviewed about their perceptions of the term, as was a group of mental health professionals who work with the elderly.

RESULTS

Many older people regarded significant adversity as just part of life, with collectively understood methods of avoidance or limited support-seeking pointing to emotional management through non-disclosure. This position seemed further informed by views that disclosure may be self-indulgent, which is in stark contrast to the historical and cultural background in which many older people were raised. The professionals also suggested that some older people may be unused to expressing their emotions. The concept of trauma seems to be relative, with stigma and shame appearing to influence the way that responses to adversity are managed by this age group.

CONCLUSION

[corrected] We conclude that focused history taking by clinicians may be needed to help elicit symptoms of trauma among elderly patients, while at the same time services might engage in a compassionate dialogue to encourage those suffering in silence to seek help.

Targeted case finding for hepatitis B using dry blood spot testing in the British-Chinese and South Asian populations of the North-East of England

Chronic infection with the hepatitis B virus (HBV) is a frequent cause of cirrhosis and liver cancer. Targeted HBV screening is recommended by the Centre for Disease Control (CDC) and Prevention for subjects born in countries with >2% HBV prevalence. However, there are no UK guidelines. Here, we applied the (CDC) recommendations to the British-Chinese and British-South Asian community of North-East (NE) England. British-Chinese and South Asian subjects were invited to attend for HBV education and screening sessions held in community centres. Hepatitis B surface antigen (HBsAg) and hepatitis B core total antibody (HBcAb) were tested with dry blood spot tests. South Asians were also tested for hepatitis C antibody (HCVAb). A total of 1126 subjects (606 Chinese and 520 South Asian) were screened. Sixty-two (5.5%) were HBsAg positive. Ten of these reported a previous diagnosis of HBV. The prevalence of HBsAg positivity was 4.6% when previously diagnosed individuals were excluded. The HBsAg prevalence was significantly higher in the Chinese subjects compared with South Asians (8.7% VS. 1.7% P < 0.001). In Chinese subjects, HBsAg positivity was highest in subjects born in Vietnam (17.4%), followed by China (11%), Hong Kong (7.8%) and the UK (6.7%). Subjects from Pakistan had the highest HBsAg and HCV Ab prevalence in the South Asians (3.1% and 1.8%, respectively). Ten percentage of HBsAg positive patients who had follow-up assessment had active disease requiring antiviral treatment. Undiagnosed HBV infection was above the 2% threshold for screening suggested by the CDC in the British-Chinese and Pakistani community of NE England, which provides evidence for a UK HBV-targeted screening programme.

Treatment resistant depression in primary care: co-constructing difficult encounters

Many patients with depression do not recover despite medication or therapy. Individuals with treatment resistant depression often have co-morbid anxiety, personality difficulties and drug or alcohol misuse and have been characterised as difficult, heartsink or problem personalities by general practitioners. Yet critical studies of interaction in medical settings suggest that the context may have a role in constructing the patient. A total of 12 audio-recorded routine consultations were analysed following guidelines for qualitative analysis of medical discourse. The interpretation focused on ways in which the context and structure of primary care consultations in a UK setting construct difficult encounters, which may lead to patients with treatment resistant depression being seen as difficult to manage in various ways. Three overarching observations were that presentation of multiple problems in multiple domains clash with the consultation format; that patients' atypically high level of activity in a time-limited setting prevents patient-centred work; that the question and answer format restricts multifaceted discussions of social and emotional problems, preventing shared understandings emerging. However, although interactions appear uneasy, they are repaired and may be moderately palliative. Suggestions are made for re-orienting general practitioner work with treatment resistant depression towards long-term goal setting outside of the traditional consultation structure in order to develop shared understandings.

Non-alcoholic fatty liver disease: non-invasive investigation and risk stratification

Non-alcoholic fatty liver disease (NAFLD) encompasses a histological spectrum of liver disease, from simple steatosis through to cirrhosis. As the worldwide rates of obesity have increased, NAFLD has become the commonest cause of liver disease in many developed countries, affecting up to a third of the population. The majority of patients have simple steatosis that carries a relatively benign prognosis. However, a significant minority have non-alcoholic steatohepatitis, and have increased liver related and cardiovascular mortality. Identifying those at risk of progressive disease is crucial. Liver biopsy remains the gold standard investigation for assessing stage of disease but its invasive nature makes it impractical for widespread use as a prognostic tool. Non-invasive tools for diagnosis and disease staging are required, reserving liver biopsy for those patients where it offers clinically relevant additional information. This review discusses the non-invasive modalities available for assessing steatosis, steatohepatitis and fibrosis. We propose a pragmatic approach for the assessment of patients with NAFLD to identify those at high risk of progressive disease who require referral to specialist services.

Normative data for healthy older adults and an abbreviated version of the Stroop test

Normative data for the Kaplan version of the Stroop Test are presented for 153 healthy, cognitively intact older adults aged 50-89 years. Increasing age was associated with decreased performance on all three subtests (Stroop A, Stroop B, and Stroop C), while years of education was only associated with Stroop B performance. Hence the normative data were stratified by age into three groups (50-64, 65-74, 75-89). Completion times for the first half of each trial (half-time scores) were found to have good split-half reliability and correlated highly with the original full administration scores. Means and standard deviations for the half-time administration are also presented for this sample. The current study provides more comprehensive normative data for older adults than previously available, as well as normative information for half-time scores that may have future clinical utility as an alternative, abbreviated version of the Kaplan Stroop Test.

General practitioner management of depression: a systematic review

Understanding how primary care clinicians manage depression is a key backdrop to current and future initiatives to improve detection and treatment of depression. We systematically reviewed, identified, and extracted findings from 13 qualitative studies that examined general practitioner (GP) management of depression. We assessed articles for quality using Critical Appraisal Skills Program guidelines for assessing qualitative research but did not exclude any articles based on quality. We carried out a thematic analysis for systematic review of qualitative research in which we identified four main themes with various subthemes: "negotiating the nature of depression," "detect and diagnose," "interventions," and "burden." The results of the analysis illuminate the complex dilemma faced by GPs in managing depression, which appears to be characterized by a sense of dissonance between the medicalization of depression and a sense of its social determinants.

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

BACKGROUND

Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression.

METHODS/DESIGN INDEX GROUP

Patients with treatment resistant/treatment refractory depression.

DEFINITION & INCLUSION CRITERIA

Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, ≥14 on the HRSD or ≥21 on the BDI-II, plus complex personality and/or psycho-social difficulties.

EXCLUSION CRITERIA

Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years.

DESIGN

Pragmatic, randomised controlled trial with qualitative and clinical components.

TEST INTERVENTION

18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort.

CONTROL CONDITION

Treatment as usual, managed by the referring practitioner.

RECRUITMENT

GP referrals from primary care.

RCT MAIN OUTCOME

HRSD (with ≤14 as remission).

SECONDARY OUTCOMES

depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records).

FOLLOW-UP

2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change.

DISCUSSION

TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials. We discuss some of the consequent problems and suggest how they may be mitigated.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN40586372.