Use of mind-body therapies in psychiatry and family medicine faculty and residents: attitudes, barriers, and gender differences

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Who Benefits Most? Interactions between Personality Traits and Outcomes of Four Incremental Meditation and Yoga Treatments

Mind-Body Medicine (MBM) includes a broad range of interventions with proven preventive and clinical value, such as yoga and meditation. However, people differ in their preferences and response to different MBM treatments and it remains unclear who benefits most from what type of practice. Thus, finding moderators of treatment outcome seems to be a promising approach. This was the aim of the present study. We conducted a single-case multiple-baseline study investigating the outcomes and moderators of four different MBM treatments. Fifty-seven healthy participants with no prior experience were randomly assigned to three baselines (7, 14, and 21 days) and four eight-week treatments: mantra meditation alone, meditation plus physical yoga, meditation plus ethical education and meditation plus yoga and ethical education. We analysed the data using effect size estimation, multiple regression and cluster analyses. High anxiety, high absorption, low spirituality, low openness and younger age were associated with a range of positive outcomes, such as increased wellbeing or decentering and decreased mind wandering. Receiving ethical education consistently improved wellbeing, while engaging in physical yoga reduced mind wandering. In the cluster analysis, we found that participants with a more maladaptive personality structure enhanced their emotion regulation skills more. Consequently, people do differ in their response to MBM interventions and more vulnerable people, or those high in absorption, seem to benefit more. These findings could support the development of custom-tailored MBM interventions and help clinicians to make scientifically sound recommendations for their patients.

Do Palliative Care Providers Use Complementary and Integrative Medicine? A Nationwide Survey

CONTEXT

Given the high prevalence of burdensome symptoms in palliative care (PC) and increasing use of complementary and integrative medicine (CIM) therapies, research is needed to determine how often and what types of CIM therapies providers recommend to manage symptoms in PC.

OBJECTIVES

To document recommendation rates of CIM for target symptoms and assess if, CIM use varies by provider characteristics.

METHODS

Nationwide survey's of physicians (MD and DO), physician assistants, and nurse practitioners in PC.

RESULTS

Participants (N = 404) were mostly female (71.3%), physicians (74.9%), and cared for adults (90.4%). Providers recommended CIM an average of 6.82 times per-month (95% CI: 6.04-7.60) and used an average of 5.13 (95% CI: 4.90-5.36) out of 10 CIM modalities. Respondents recommended mind-body medicines (e.g., meditation, biofeedback) most, followed by massage, and acupuncture and/or acupressure. The most targeted symptoms included pain; followed by anxiety, mood disturbance, and distress. Recommendation frequencies for specific modality-for-symptom combinations ranged from little use (e.g., aromatherapy for constipation) to occasional use (e.g., mind-body interventions for psychiatric symptoms). Finally, recommendation rates increased as a function of pediatric practice, noninpatient practice setting, provider age, and proportion of effort spent delivering palliative care.

CONCLUSION

To the best of our knowledge, this is the first national survey to characterize PC providers' CIM recommendation behaviors and assess specific therapies and common target symptoms. Providers recommended a broad range of CIM but do so less frequently than patients report using CIM. These findings should be of interest to any provider caring for patients with serious illness.

U.S. Physician Recommendations to Their Patients About the Use of Complementary Health Approaches

Objective: There are no nationally representative studies using a probability sample that have been published examining whether physicians recommend complementary health approaches (CHAs) to their patients, as previous research has focused only on selected medical specialties or a particular U.S. region. This article fills a void in the current literature for robust data on recommendations for CHAs by office-based physicians in the United States. Design: Descriptive statistics and multivariable regression analyses of physician-level data were from the 2012 Physician Induction Interview of the National Ambulatory Medical Care Survey (NAMCS PII), a nationally representative survey of office-based physicians. Weighted response rate among eligible physicians sampled for the 2012 NAMCS PII was 59.7%. Setting/Location: United States. Outcome measures: Recommendations by physicians to their patients for any CHA, and individual CHAs: massage therapy, herbs/nonvitamin supplements, chiropractic/osteopathic manipulation, yoga, acupuncture, and mind-body therapies. Differences in recommendations by physician demographic characteristics were identified. Results: Massage therapy was the most commonly recommended CHA (30.4%), followed by chiropractic/osteopathic manipulation (27.1%), herbs/nonvitamin supplements (26.5%), yoga (25.6%), and acupuncture (22.4%). The most commonly recommended CHAs by general/family practice physicians were chiropractic/osteopathic manipulation (54.0%) and massage therapy (52.6%). Of all U.S. physicians, 53.1% recommended at least one CHA to patients during the previous 12 months. Multivariable analyses found physician's sex, race, specialty, and U.S. region to be significant predictors of CHA recommendations. Female physicians were more likely than male physicians to recommend massage therapy (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI] = 1.40-2.20), herbs/nonvitamin supplements (aOR = 1.85, 95% CI = 1.46-2.35), yoga (aOR = 2.16, 95% CI = 1.70-2.75), acupuncture (aOR = 1.65, 95% CI = 1.27-2.13), and mind-body therapies (aOR = 2.63, 95% CI = 2.02-3.41) to patients. Psychiatrists (aOR = 0.13, 95% CI = 0.07-0.23), OB/GYNs (aOR = 0.38, 95% CI = 0.24-0.60), and pediatricians (aOR = 0.26, 95% CI = 0.18-0.38) were all less likely to recommend chiropractic/osteopathic manipulation than general and family practitioners. Conclusions: Overall, more than half of office-based physicians recommended at least one CHA to their patients. Female physicians recommended every individual CHA at a higher rate than male physicians except for chiropractic and osteopathic manipulation. These findings may enable consumers, physicians, and medical schools to better understand potential differences in use of CHAs with patients.

The Feasibility and Effectiveness of Online Guided Imagery Training for Health Professionals

This study evaluated the feasibility and impact of brief online guided imagery training (up to 3 hours) for health professionals. Paired t tests were used to measure pre-to-post-training changes in stress (Perceived Stress Scale,), anxiety (Patient Reported Outcomes Measurement Information System-Anxiety Scale), empathy (Empathic Concern Scale, and Perspective-taking Scale), and self-efficacy (Self-Efficacy in providing Non-Drug Therapies Scale). Online guided imagery training attracted diverse health professionals and trainees (n = 273; 14% trainees; 34% registered nurses, 20% physicians, 14% social workers, 5% registered dititians, and 27% others). Participants reported small but significant pre-to-post-module improvements in stress (17.8 to 13.5), anxiety (T-scores 56.4 to 54.3), empathy (both empathic concern, 29.8 to 30.7, and perspective taking, 28.0 to 29.4), and self-efficacy in providing nondrug therapies for common symptoms (58.5 to 77.0) (P < .001 for all). Future studies will need to examine the clinical impact of online guided imagery training for health professionals.

Facilitators and Barriers to the Integration of Mind-Body Medicine into Primary Care

PURPOSE

To improve understanding of the facilitators and barriers affecting the integration of mind-body medicine (MBM) into primary care and describe the experiences of mind-body primary care providers.

METHODS

The authors conducted a qualitative analysis of semi-structured telephone interviews with mind-body primary care providers selected via a maximum variation sampling strategy.

RESULTS

Four main themes emerged: (1) MBM is an approach to patient care as well as a set of modalities, (2) time and reimbursement pose significant challenges to MBM, (3) support for MBM in one's practice setting is a key facilitator, and (4) commitment to MBM comes from personal experience. "Insufficient time" was the most highly ranked barrier among survey respondents. Interviewees described innovative strategies to overcome barriers, including customized intake forms, MBM training for staff, MBM group visits, and discounted referrals for low-income patients.

CONCLUSIONS

While increased MBM and self-care training for providers may facilitate the integration of MBM into primary care, systematic changes are needed to decrease time pressures on providers and incentivize patient wellness. Despite barriers, providers are using innovative strategies to provide mind-body primary care in diverse practice settings.

An adapted, four-week mind-body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care

OBJECTIVE

Despite the well-known stress of medical school, including adverse consequences for mental and behavioral health, there is little consensus about how to best intervene in a way that accommodates students׳ intense training demands, interest in science, and desire to avoid being stigmatized. The objective of this study, therefore, was to evaluate the feasibility, acceptability, and initial effectiveness of an adapted, four-week stress management and self-care workshop for medical students, which was based on the science and practice of mind-body medicine.

METHODS

The current study used a prospective, observational, and mixed methods design, with pretest and posttest evaluations. Participants (n = 44) included medical and physician-scientist (MD/PhD) students from a large, southeastern medical school. Feasibility was assessed by rates of workshop enrollment and completion. Acceptability was assessed using qualitative ratings and open-ended responses that queried perceived value of the workshop. Quantitative outcomes included students׳ ratings of stress and mindfulness using validated self-report surveys.

RESULTS

Enrollment progressively increased from 6 to 15 to 23 students per workshop in 2007, 2009, and 2011, respectively. Of the 44 enrolled students, 36 (82%) completed the workshop, indicating that the four-session extracurricular format was feasible for most students. Students reported that the workshop was acceptable, stating that it helped them cope more skillfully with the stress and emotional challenges of medical school, and helped increase self-care behaviors, such as exercise, sleep, and engaging in social support. Students also reported a 32% decrease in perceived stress (P < .001; d = 1.38) and a 16% increase in mindfulness (P < .001; d = 0.92) following the workshop. Changes in stress and mindfulness were significantly correlated (r = -0.42; P = .01).

CONCLUSION

Together, these findings suggest that a brief, voluntary mind-body skills workshop specifically adapted for medical students is feasible, acceptable, and effective for reducing stress, increasing mindfulness, and enhancing student self-care.

Meeting them where they are: Using the Internet to deliver behavioral medicine interventions for pain

Pharmacological and interventional pain medicine treatments are emphasized in the routine treatment of chronic pain despite strong evidence for the efficacy and safety of behavioral approaches. Most medical professionals have not incorporated behavioral pain treatments into their practices. Internet-based interventions have the potential to increase clinical use of these treatments. We discuss the strengths and weaknesses of current Internet-based behavioral pain management interventions, focusing on three broad intervention categories: therapist-guided interventions, unguided (automated) interventions, and pain-relevant applications for mobile platforms. Examples of each category are discussed, revealing a high degree of variation in approaches, user interfaces, and components as well as variability in the degree to which these interventions have been subjected to empirical testing. Finally, we highlight key issues for research and clinical implementation, with the goal of advancing this field so that it can meet its potential to increase access to evidence-based behavioral medicine treatments for chronic pain.

Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures

OBJECTIVES

A large body of research has demonstrated that patient factors are strong predictors of recovery from surgery. Mind-body therapies are increasingly targeted at pre-operative psychological factors. The objective of this paper was to evaluate the efficacy of pre-operative mind-body based interventions on post-operative outcome measures amongst elective surgical patients.

METHODS

A systematic review of the published literature was conducted using the electronic databases MEDLINE, CINAHL and PsychINFO. Randomised controlled trials (RCTs) with a prospective before-after surgery design were included.

RESULTS

Twenty studies involving 1297 patients were included. Mind-body therapies were categorised into relaxation, guided imagery and hypnotic interventions. The majority of studies did not adequately account for the risk of bias thus undermining the quality of the evidence. Relaxation was assessed in eight studies, with partial support for improvements in psychological well-being measures, and a lack of evidence for beneficial effects for analgesic intake and length of hospital stay. Guided imagery was examined in eight studies, with strong evidence for improvements in psychological well-being measures and moderate support for the efficacy of reducing analgesic intake. Hypnosis was investigated in four studies, with partial support for improvements in psychological well-being measures. Evidence for the effect of mind-body therapies on physiological indices was limited, with minimal effects on vital signs, and inconsistent changes in endocrine measures reported.

CONCLUSIONS

This review demonstrated that the quality of evidence for the efficacy of mind-body therapies for improving post-surgical outcomes is limited. Recommendations have been made for future RCTs.

A new paradigm for teaching behavior change: implications for residency training in family medicine and psychiatry

BACKGROUND

Primary care physicians (PCPs) provide ~50 % of all mental health services in the U.S. Given the widening gap between patient mental health needs and resources available to meet those needs, there is an increasing demand for family medicine and psychiatry trainees to master competencies in both behavioral medicine and primary care counseling during residency-if for no other reason than to accommodate the realities of medical practice given the oft present gap between the need for psychiatric services and the availability, quality, and/or affordability of specialized psychiatric care. To begin to address this gap, a skills-based, interactive curriculum based on motivational interviewing (MI) as a teaching method is presented.

METHODS

The curriculum described in this paper is a four-week block rotation taught in the second year of residency. Motivational interviewing (MI) is used as a teaching approach toward the goal of clinical behavior change. Residents' strengths, personal choice and autonomy are emphasized. Each week of the rotation, there is a clinical topic and a set of specific skills for mastery. Residents are offered a "menu" of skills, role modeling, role/real play, practice with standardized patients (SP), and direct supervision in clinic.

RESULTS

Thirty-nine residents have completed the curriculum. Based on residents' subjective reporting using pre-post scales (i.e., importance and confidence), all participants to date have reported substantial increases in confidence/self-efficacy using primary care counseling skills in their continuity clinic.

CONCLUSIONS

This paper presents an innovative, empirically based model for teaching the essential skills necessary for physicians providing care for patients with mental/emotional health needs as well as health-behavior change concerns. Implications for training in the broader context, particularly as it relates to multi-disciplinary and collaborative models of teaching/training are discussed.

Meditation for Quality Improvement of Medical Encounters: Single-Intervention, Vedanta-Based Meditation Effects on Vital Signs and Mood Indices

A 15-minute, single-intervention, individually guided, Vedanta-based meditation was evaluated for acute effects on vital signs and mood indices. This study included 99 volunteers. Subjects were led in meditations incorporating breathing techniques, relaxation exercises, mental imagery, and silent mantra repetition. Pre- and post-intervention vital signs and mood indices were assessed, including heart rate, respiratory rate, blood pressure, temperature, Beck Depression Inventory (BDI), and Likert scales for mood. The meditation was shown to have statistically significant effects in the immediate improvement of vital signs and mood indices. The most substantial effects occurred for blood pressure, respiratory rate, Beck Depression Inventory, depression, anxiousness, happiness, and peacefulness. Also, males experienced greater physiological benefit whereas females experienced greater psychological benefit. The results of this study could be useful in developing gender-specific meditations to improve vital signs and mood indices in acute settings.

Mind-body therapy: attitudes, beliefs and practices of graduate faculty and students from accredited marriage and family therapy programs in the U.S. and Canada

CONTEXT

Interest in CAM and mind-body therapies (MBT) among mental health professionals has increased over the last decade. Individuals seeking treatment for mental health concerns often use MBTs and expect clinicians to be aware of such treatments. Yet, current data reveal a critical gap in training, practice, and the needs of those seeking treatment.

OBJECTIVE

To determine the attitudes, beliefs, and practices of marriage and family therapists regarding MBTs.

DESIGN

Electronic survey method using Likert-type scale questions.

PARTICIPANTS

Clinical faculty members and graduate students (N = 140) from accredited Marriage and Family Therapy programs in the United States and Canada.

RESULTS

Findings revealed that a majority of respondents believed that graduate programs should introduce MBT topics during course of training and that MBTs are valuable in the treatment of various clinical problems. Respondents were familiar with at least one form of MBT and reported using such in personal and professional settings.

Perspective: Does medical education promote professional alexithymia? A call for attending to the emotions of patients and self in medical training

Emotions--one's own and others'--play a large role in the lives of medical students. Students must deal with their emotional reactions to intellectual and physical stress, the demanding clinical situations to which they are witness, as well as patients' and patients' family members' often intense feelings. Yet, currently few components in formal medical training--in either direct curricular instruction or physician role modeling--focus on the emotional lives of students. In this article, the author examines patients', medical students', and physician role models' emotions in the clinical context, highlighting challenges in all three of these arenas. Next, the author asserts that the preponderance of medical education continues to address the emotional realm through ignoring, detaching from, and distancing from emotions. Finally, she presents not only possible theoretical and conceptual models for developing ways of understanding, attending to, and ultimately "working with" emotions in medical education but also examples of innovative curricular efforts to incorporate emotional awareness into medical student training. The author concludes with the hope that medical educators will consider making a concerted effort to acknowledge emotions and their importance in medicine and medical training.

Fibromyalgia: diagnosis and treatment options

BACKGROUND

Fibromyalgia is a widespread, chronic pain disorder that includes a complex constellation of somatic and emotional symptoms. Controlled clinical trials for both medication and nonmedication therapies have led to sound, evidence-based recommendations for the care of patients with fibromyalgia.

OBJECTIVE

This review article was designed to provide updated information from database literature searches on fibromyalgia epidemiology, including gender differences, psychological comorbidity, and treatment with medication and nonmedication therapies.

METHODS

A literature review was performed by identifying fibromyalgia articles published in English from January 2000 to October 2008 using the PubMed and EMBASE databases. Search terms included fibromyalgia, exercise, gender, nonpharmacologic, placebo-controlled, randomized, and treatment.

RESULTS

New epidemiologic data support important differences in fibromyalgia symptom severity between the sexes and the important role of comorbid psychological distress. Physicians diagnose fibromyalgia in women at an approximately 3- to 6-fold rate compared with men. Well-conducted clinical trials and recently published treatment guidelines reinforce effective treatment with medication and nonpharmacologic therapy. The strongest evidence suggests effective treatment of fibromyalgia with duloxetine and milnacipran. Studies also report efficacy with gabapentin, pramipexole, pregabalin, tramadol, and IV tropisetron. Nonpharmacologic treatments should include fitness and strengthening exercise, as well as warm-water therapy and psychological pain management techniques.

CONCLUSIONS

Fibromyalgia is a common, disabling, chronic pain condition that predominantly affects women. Symptoms can be effectively treated using both drug and nondrug therapies. In general, treatment benefits in fibromyalgia appear largely independent of patient sex.

The salutogenesis-oriented session: creating space and time for healing in primary care

Primary care in America is in need of a rescue. Clinicians are asked to see more patients in a day that only allows time to focus on a physical symptom or disease process. They do not have time or space to use their humanism to develop insight toward what the patient needs for the symptom to resolve, and they are often forced to suppress it with technology. This results in a very expensive medical system that leads to frustration for a clinician who realizes that this is not the way toward facilitating health. This clinically focused paper proposes the incorporation of a healing-oriented session into the delivery of primary care to bring focus toward the creation of health (salutogenesis). A salutogenesis-oriented session (SOS) honors relationship-centered care and will provide a unit that can then be studied to see if it has a positive influence on cost, quality of care, and provider satisfaction.