Anxiety and depressive symptoms in first-time parents: A dyadic longitudinal study based on attachment theory

BACKGROUND

The aim of this study was to examine the temporal and dyadic associations between anxiety and depressive symptoms during the transition to parenthood (TTP), while exploring the antecedence of attachment insecurities in these associations.

METHOD

Couples of first-time parents (N = 211) completed the State-Trait Anxiety Inventory, the Edinburgh Postnatal Depression Scale, the Experiences in Close Relationships scale, and a sociodemographic questionnaire during the second trimester of pregnancy and at four and twelve months postpartum.

RESULTS

Both prenatal anxiety and depressive symptoms predicted postnatal depressive and anxiety symptoms. Prenatal attachment-related anxiety predicted higher postnatal anxiety and depressive symptoms whereas prenatal attachment-related avoidance predicted higher postnatal depressive symptoms only. Parents whose partners had a higher level of prenatal attachment-related anxiety experienced higher postnatal anxious and depressive symptoms via their own's prenatal depressive symptoms. Parents whose partners had a higher level of prenatal attachment-related avoidance experienced higher postnatal depressive symptoms via their own's prenatal anxious symptoms. No gender differences were found for these associations.

LIMITATIONS

The sample was predominantly composed of educated heterosexual French-Canadian Caucasian couples and all measures were self-reported.

CONCLUSIONS

Our original findings suggest that professionals should routinely screen for anxiety and depressive symptoms in both partners from pregnancy up to one year postpartum. Also, our findings suggest addressing attachment insecurities with both partners to prevent the development of future symptoms during pregnancy or after childbirth. Finally, our study supports the relevance of considering these symptoms at subclinical levels during the TTP.

Do perfectionism, body image concerns, and intimacy predict genitopelvic pain in the postpartum? A prospective study of new mothers

BACKGROUND

Genitopelvic pain following childbirth is common and likely to challenge the psychological, relational, and sexual well-being of new mothers. While genitopelvic pain generally decreases during the postpartum period, personal and interpersonal characteristics may explain why genitopelvic pain persists beyond the period of physical recovery in some mothers. Body image concerns, increased stress, and relationship challenges would be particularly salient during pregnancy and the postpartum period, which could put new mothers at greater risk of sexual difficulties. Also, mothers may display a negative appraisal regarding genitopelvic pain and doubt their ability to cope with it, which may contribute to the pain.

AIM

The current study aimed to examine the role of perfectionism, body image concerns, and perceived intimacy in the occurrence and change in genitopelvic pain in new mothers in postpartum.

METHODS

A total of 211 new mothers and their partners were recruited for a larger prospective dyadic study on the transition to parenthood.

OUTCOMES

Mothers completed a single item assessing genitopelvic pain, in addition to brief validated questionnaires measuring perfectionism, body image concerns, and perceived couple intimacy during pregnancy and at 4, 8, and 12 months postpartum.

RESULTS

Five multilevel modeling analyses revealed that adaptive perfectionism, maladaptive perfectionism, and body image concerns were associated with a higher occurrence of genitopelvic pain from 4 to 12 months postpartum. Mothers' and partners' perceived intimacy was not significantly related to new mothers' genitopelvic pain. None of the predictors modified the trajectory of genitopelvic pain over time.

CLINICAL IMPLICATIONS

Raising awareness among health care professionals regarding the role of perfectionism and body image concerns in genitopelvic pain may help them identify new mothers at risk of chronic genitopelvic pain, while offering a new avenue of intervention.

STRENGTHS AND LIMITATIONS

There has been little research examining the role of perfectionism, body image concerns, and intimacy in postpartum genitopelvic pain. Based on a longitudinal prospective approach, this study identified perfectionism and body image concerns as significant predictors of postpartum genitopelvic pain. However, prepregnancy genitopelvic pain, genitopelvic pain intensity, and sexual distress were not measured.

CONCLUSION

Adaptive and maladaptive perfectionism and body image concerns are associated with new mothers' genitopelvic pain up to 12 months postpartum.

Workers' Worries, Pain, Psychosocial Factors, and Margin of Manoeuvre, in Relation to Outcomes in a Return-to-Work Program: An Exploratory Study

PURPOSE

To explore the intensity and variation of workers' worries, pain, psychosocial factors, and margin of manoeuvre before and after a return-to-work program, and identified the psychosocial factors associated with non-return to work at the end of the rehabilitation program.

METHODS

A pre-post study design was used. A convenience sample of 80 workers starting a return-to-work program and having a compensated musculoskeletal injury that caused an absence of more than three months from their regular work was recruited. Data were collected at baseline and at the end of the rehabilitation program on the nature of the worries and maintenance factors defined in Dugas' generalized anxiety and worry model, using validated questionnaires. The margin of manoeuvre was assessed by the treating occupational therapist. A series of descriptive analyses were performed, as well as Generalized Estimating Equations analyses.

RESULTS

Workers' worries were work-related or disability-related 83% of the time at baseline. These worries were essentially based on the situation then occurring at work 90% of the time. For the Generalized Estimating Equations analyses on work status, the final model was significant, explaining 54% of the variance in non-return to work (Pseudo R2 = 0.54; p = 0.0001). Workers were 8.52 times less likely to return to work when the margin of manoeuvre was insufficient, and twice as likely not to return to work in the presence of intense worry. Worries were significantly associated with insufficient margin of manoeuvre.

CONCLUSION

A strong association between workers' lack of margin of manoeuvre at work and their worries about their return to work, and poor work outcomes, supports the importance of the worker-environment interaction in rehabilitation programs.

[An innovative process for sustaining and scaling up a school-based mental health promotion and anxiety prevention programs: The example of the HORS-PISTE program]

Context Anxiety disorders are among the most prevalent psychopathologies for children and adolescents in Quebec. The prevalence of anxiety disorders is very high and has been affecting a growing number of young people for the past 10 years. It is possible to observe an increased number of anxiety prevention programs for young people around the world. However, some authors point out that they are rarely faithfully implemented, sustained, and scaled up in several schools. Based on implementation science, this HORS-PISTE program was developed to address these important issues by preventing anxiety in Quebec high school students. Implemented in more than 100 schools, the program is now part of Action 4.3 (Promote the deployment of the HORS-PISTE program) of the new interdepartmental Action Plan on Mental Health of the Government of Quebec (2022). Purpose This article aims to describe how the Knowledge-to-Action (KTA) framework, derived of implementation science, was used to design, implement, sustain, evaluate, and scale up the HORS-PISTE program. This framework proposes a cyclical process in seven phases. Method A multi-method and multi-stakeholder approach was conducted with a grant from the Public Health Agency of Canada's Mental Health Promotion Innovation Fund, which has been supporting 20 innovative projects across Canada since 2019. It includes a pre-post evaluation protocol consisting of validated questionnaires, surveys (administered to students, parents, and teachers), semi-structured logbooks completed by program facilitators and implementation review meetings in each school. The different cycles of the program development, implementation and evaluation are discussed through the KTA framework phases. Results From 2017 to 2021, this methodology made it possible to evaluate and readjust the program each year to promote its adaptation and prepare its scaling up. This article highlights the data collected and analyzed in relation to the seven phases of the KTA framework. Conclusion This article demonstrates how implementation science can support designers of anxiety prevention programs who are concerned by scaling up and sustaining their programs. Issues in combining the scientific rigor of evaluation with the reality of the field are also raised.

The moderating and mediating role of telepresence and cognitive change in cognitive behaviour therapy delivered via videoconference

In this study, we combined the results of two controlled trials and examined the relationships between working alliance, telepresence, cognitive change and treatment outcome. Sixty-five participants with a primary diagnosis of generalized anxiety disorder (GAD) or panic disorder with agoraphobia (PDA) received cognitive behaviour therapy delivered via videoconference. Participants completed measures of working alliance and telepresence after three psychotherapy sessions. They also completed measures of treatment outcome and dysfunctional beliefs (cognitive change) specific to PDA and GAD at pretreatment and posttreatment. Results revealed that telepresence at the fifth session moderated the relationship between the working alliance at the first and fifth sessions. As telepresence increased, its impact on the working alliance diminished. Cognitive change mediated the relationship between the working alliance at the fifth session and treatment outcome.

Couple Adaptation to the Birth of a Child: The Roles of Attachment and Perfectionism

This study aims to examine two explanatory factors of relationship satisfaction and parental alliance among both parents of a new child, namely romantic attachment and perfectionism. A sample of 80 couples completed individual online questionnaires. Path analyses based on the Actor-Partner Interdependence Model were carried out to explore the actor and partner effects of each explanatory variable (attachment, perfectionism) on both partners' postnatal relationship satisfaction and parental alliance. Results revealed that attachment avoidance is negatively related to each partner's own relationship satisfaction and parental alliance, whereas attachment anxiety is related to their own lower parental alliance. Maladaptive perfectionism is negatively related to each partner's own relationship satisfaction, whereas adaptive perfectionism is positively related to each partner's own relationship satisfaction. These results extend the understanding of the factors contributing to parental and couple adaptation in the postnatal period. They highlight the role of attachment and perfectionism for improving postnatal professionals' interventions.

Self-help guided by trained lay providers for generalized anxiety disorder in older adults: study protocol for a randomized controlled trial

Background

Only a small proportion of older patients with generalized anxiety disorder (GAD) seek professional help. Difficulties in accessing treatment may contribute to this problem. Guided self-help based on the principles of cognitive-behavioral therapy (GSH-CBT) is one way of promoting access to psychological treatment. Moreover, because the therapist’s role in GSH-CBT is limited to supporting the patient, this role could be assumed by trained and supervised lay providers (LPs) instead of licensed providers. The main goal of this study is to evaluate the efficacy of GSH-CBT guided by LPs for primary threshold or subthreshold GAD in older adults.

Methods

We will conduct a multisite randomized controlled trial comparing an experimental group receiving GSH-CBT guided by LPs (n = 45) to a wait-list control group (n = 45). Treatment will last 15 weeks and will be based on a participant’s manual. Weekly telephone sessions with LPs (30 min maximum) will be limited to providing support. Data will be obtained through clinician evaluations and self-assessment questionnaires. Primary outcomes will be the tendency to worry and severity of GAD symptoms. Secondary outcomes will be anxiety symptoms, sleep difficulties, functional deficit, diagnosis of GAD, and cognitive difficulties. For the experimental group, measurements will take place at pre- and post-treatment and at 6 and 12 months post-treatment. For the control group, three evaluations are planned: two pre-treatment evaluations (before and after the waiting period) and after receiving treatment (post-treatment). The efficacy of GSH-CBT will be established by comparing the change in the two groups on the primary outcomes.

Discussion

This project will provide evidence on the efficacy of a novel approach to treat GAD in older adults. If effective, it could be implemented on a larger scale and provide many older adults with much needed mental health treatment through an expanded workforce.

Trial registration

The trial was registered at ClinicalTrials.gov, number NCT03768544, on December 7, 2018.

The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis

BACKGROUND

Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance.

OBJECTIVE

As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome.

METHODS

A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up.

RESULTS

The results revealed that the therapeutic bond did not predict treatment outcome (r=-0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=-0.42; P=.004 and r=-0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized β=-0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome.

CONCLUSIONS

These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027.

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory

OBJECTIVES

Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth.

METHOD

Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples.

RESULTS

Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore.

DISCUSSION

Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.

A Systematic Review of the Psychometric Properties of the Geriatric Anxiety Inventory

The Geriatric Anxiety Inventory (GAI) is a widely used self-report measure of anxiety symptoms in older adults. Although much research has been conducted on the psychometric properties of the GAI, previous reviews have examined only a small proportion of studies and have not evaluated the methodological quality of this work. In view of this, we conducted a systematic review of the psychometric properties of the GAI and it’s short form (GAI-SF). Relevant studies (N = 31) were retrieved through a search of electronic databases (Pubmed, PsycINFO, CINAHL, EMBASE and Google Scholar) and a hand search. The methodological quality of the included studies was assessed by two independent reviewers using the ‘‘COnsensus-based Standards for the selection of health status Measurement INstruments’’ (COSMIN) checklist. Based on the COSMIN checklist, internal consistency and test reliability were mostly rated as poorly assessed (63% and 72.7% of studies, respectively) and quality of studies examining structural validity was mostly fair (60% of studies). Both the GAI and GAI-SF showed adequate internal consistency and test-retest reliability. Convergent validity indices were highest with measures of generalized anxiety and lowest with instruments that include somatic symptoms. Substantial overlap with measures of depression was reported. While there is no consensus on the factorial structure of the GAI, the short version was found to be unidimensional. Our review therefore suggests that the GAI and GAI-SF have satisfactory psychometric properties while indicating that future efforts should aim to achieve a higher degree of methodological quality.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial

BACKGROUND

Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care.

METHODS

In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis.

RESULTS

A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79].

CONCLUSIONS

Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Six-month prevalence and correlates of generalized anxiety disorder among primary care patients aged 70 years and above: Results from the ESA-services study

OBJECTIVES

To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries.

METHODS/DESIGN

Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses.

RESULTS

The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression.

CONCLUSIONS

GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

A pragmatic randomized controlled trial of group transdiagnostic cognitive-behaviour therapy for anxiety disorders in primary care: study protocol

BACKGROUND

Anxiety disorders are the most common mental disorders in community settings, and they are associated with significant psychological distress, functional and social impairment. While cognitive behaviour therapy (CBT) is the most consistently efficacious psychological treatment for anxiety disorders, barriers preclude widespread implementation of CBT in primary care. Transdiagnostic group CBT (tCBT) focuses on cognitive and behavioural processes and intervention strategies common to different anxiety disorders, and could be a promising alternative to conventional CBT. This study aims to examine the effectiveness of a transdiagnostic group CBT for anxiety disorders program as a complement to treatment-as-usual (TAU) in primary mental health care.

METHODS/DESIGN

The trial is a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment, and follow-up at 4, 8 and 12-months design. Treatment and control groups. a) tCBT (12 weekly 2-h group sessions following a manualized treatment protocol); b) TAU for anxiety disorders. Inclusion criteria comprise meeting DSM-5 criteria for primary Panic Disorder, Agoraphobia, Social Anxiety Disorder and/or Generalized Anxiety Disorder. Patients are recruited in three regions in the province of Quebec, Canada. The primary outcome measures are the self-reported Beck Anxiety Inventory and the clinician-administered Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5); secondary outcome measures include treatment responder status based on the ADIS-5, and self-reported instruments for specific anxiety and depression symptoms, quality of life, functioning, and service utilisation.

STATISTICAL ANALYSIS

Intention-to-treat analysis. A mixed effects regression model will be used to account for between- and within-subject variations in the analysis of the longitudinal effects of the intervention.

DISCUSSION

This rigorous evaluation of tCBT in the real world will provide invaluable information to decision makers, health care managers, clinicians and patients regarding the effectiveness of the intervention. Widespread implementation of tCBT protocols in primary care could lead to better effectiveness, efficiency, access and equity for the large number of patients suffering from anxiety disorders that are currently not obtaining evidence-based psychotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02811458 .

Psychometric properties of the French Canadian version of the Geriatric Anxiety Inventory

BACKGROUND

The Geriatric Anxiety Inventory (GAI) and a short form of this instrument (GAI-SF) were developed to assess the severity of anxiety symptoms in older adults in order to compensate for the lack of validated screening tools adapted to the elderly population. This study examined the psychometric properties of the French Canadian version of the GAI, in its complete (GAI-FC) and short form (GAI-FC-SF).

METHOD

A total of 331 community-dwelling seniors between 65 and 92 years old participated in this study.

RESULTS

Both the GAI-FC and the GAI-FC-SF have sound psychometric properties with, respectively, a high internal consistency (α = .94 and .83), an adequate convergent validity (r = .50 to .86 with instruments known to evaluate constructs similar to the GAI or related to anxiety), a good test-retest reliability (r = .89 and .85), in addition to a single-factor structure.

CONCLUSIONS

The results support the use of both the GAI-FC and the GAI-FC-SF. The GAI-FC-SF seems to be an interesting alternative to the GAI-FC as a screening tool when time available for assessment is limited.

Design of PEG-grafted-PLA nanoparticles as oral permeability enhancer for P-gp substrate drug model Famotidine

Bioavailability of oral drugs can be limited by an intestinal excretion process mediated by P-glycoprotein (P-gp). Polyethylene glycol (PEG) is a known P-gp inhibitor. Dispersion of Famotidine (a P-gp substrate) within PEGylated nanoparticles (NPs) was used to improve its oral bioavailability. In this work, we evaluated the potential impact of NPs prepared from a grafted copolymer of polylactic acid and PEG on P-gp function by studying in vitro permeability of Famotidine across Caco-2 cells. Copolymers of PEG grafted on polylactic acid (PLA) backbone (PLA-g-PEG) were synthesised with 1 mol% and 5 mol% PEG vs. lactic acid monomer using PEG 750 and 2000 Da. The polymers were used to prepare Famotidine-loaded NPs and tested in vitro on Caco-2 cells. Significant decrease in basolateral-to-apical transport of Famotidine was observed when Famotidine was encapsulated in NPs prepared from PLA-g-PEG5%. NPs prepared from PLA-g-PEG5% are promising to improve oral bioavailability of P-gp substrates.

Reduction in Costs after Treating Comorbid Panic Disorder with Agoraphobia and Generalized Anxiety Disorder

BACKGROUND

Panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) are impairing and costly disorders that are often misdiagnosed and left untreated despite multiple consultations. These disorders frequently co-occur, but little is known about the costs associated with their comorbidity and the impact of cognitive-behavioral therapy (CBT) on cost reduction.

AIMS OF THE STUDY

The first objective of this study was to assess the mental health-related costs associated with the specific concomitance of PDA and GAD. The second aim was to determine whether there is a reduction in direct and indirect mental health-related costs following conventional CBT for the primary disorder only (PDA or GAD) or combined CBT adapted to the comorbidity (PDA and GAD).

METHODS

A total of 123 participants with a double diagnosis of PDA and GAD participated in this study. Direct and indirect mental health-related costs were assessed and calculated from a societal perspective at the pre-test, the post-test, and the three-month, six-month and one-year follow-ups.

RESULTS

At the pre-test, PDA-GAD comorbidity was found to generate a mean total cost of CADUSD 2,000.48 (SD = USD 2,069.62) per participant over a three-month period. The indirect costs were much higher than the direct costs. Both treatment modalities led to significant and similar decreases in all cost categories from the pre-test to the post-test. This reduction was maintained until the one-year follow-up.

DISCUSSION

Methodological choices may have underestimated cost evaluations. Nonetheless, this study supports the cost offset effects of both conventional CBT for primary PDA or GAD and combined CBT for PDA-GAD comorbidity.

IMPLICATIONS FOR HEALTHCARE PROVISION AND USE

Treatment of comorbid and costly disorders with evidence-based treatments such as CBT may lead to considerable economic benefits for society.

IMPLICATIONS FOR HEALTH POLICIES

Considering the limited resources of healthcare systems, it is important to make choices that will lead to better accessibility of quality services. The application of CBT for PDA, GAD or both disorders and training mental health professionals in this therapeutic approach should be encouraged. Additionally, it would be favorable for insurance plans to reimburse employees for expenses associated with psychological treatment for anxiety disorders.

IMPLICATIONS FOR FURTHER RESEARCH

In addition to symptom reduction, it would be of great pertinence to explore which factors can contribute to reducing direct and indirect mental health-related costs.

Guided self-help for generalized anxiety disorder in older adults

OBJECTIVE

The main objective of this study was to examine the efficacy of a guided self-help treatment based on cognitive behavioral principles (CBT-GSH) for generalized anxiety disorder (GAD) in older adults.

METHODS

Three older adults aged from 66 to 70 and diagnosed with GAD were included in a single-case experimental multiple-baseline protocol. Data were collected using daily self-monitoring, standardized clinician ratings, and self-report questionnaires at pretest, posttest, and 6-month and 12-month follow-ups. Treatment consisted of awareness training, worry interventions, relaxation training, pleasant activities scheduling, and relapse prevention. Participants used a manual presenting weekly readings and at-home practice exercises. They also received weekly supportive phone calls from a therapist.

RESULTS

At posttest, participants showed improvement on worries and GAD severity, on psychological process variables targeted by treatment (intolerance of uncertainty, negative problem orientation, cognitive avoidance, and perceived usefulness of worry), and on secondary variables associated with GAD (anxiety, depression, sleep difficulties, cognitive functioning, and disability). These results were generally maintained at 12 months after the end of treatment. Participants had favorable opinions toward the treatment.

CONCLUSION

The results of this study suggest that CBT-GSH is both feasible and effective for the treatment of GAD in older adults.

Mortality and morbidity peaks modeling: An extreme value theory approach

Hospitalizations and deaths belong to the most studied health variables in public health. Those variables are usually analyzed through mean events and trends, based on the whole dataset. However, this approach is not appropriate to comprehend health outcome peaks which are unusual events that strongly impact the health care network (e.g. overflow in hospital emergency rooms). Peaks can also be of interest in etiological research, for instance when analyzing relationships with extreme exposures (meteorological conditions, air pollution, social stress, etc.). Therefore, this paper aims at modeling health variables exclusively through the peaks, which is rarely done except over short periods. Establishing a rigorous and general methodology to identify peaks is another goal of this study. To this end, the extreme value theory appears adequate with statistical tools for selecting and modeling peaks. Selection and analysis for deaths and hospitalizations peaks using extreme value theory have not been applied in public health yet. Therefore, this study also has an exploratory goal. A declustering procedure is applied to the raw data in order to meet extreme value theory requirements. The application is done on hospitalization and death peaks for cardiovascular diseases, in the Montreal and Quebec metropolitan communities (Canada) for the period 1981–2011. The peak return levels are obtained from the modeling and can be useful in hospital management or planning future capacity needs for health care facilities, for example. This paper focuses on one class of diseases in two cities, but the methodology can be applied to any other health peaks series anywhere, as it is data driven.

[Fear of childbirth among nulliparous women: Relations with pain during delivery, post-traumatic stress symptoms, and postpartum depressive symptoms]

OBJECTIVE

Fear of childbirth is common in women who are pregnant with their first child and is associated with important consequences such as abortions and miscarriages. Twenty percent of nulliparous women seem to exhibit a mild or moderate fear, while 6% present an excessive and irrational fear known as tocophobia. Tocophobia is suggested to be associated with many negative consequences such as postpartum depression (PPD) and Post-traumatic stress (PTS). However, there is little empirical evidence to support these relationships. Recently, Fairbrother and Woody (2007) did not observe a link between the fear of childbirth and symptoms of PPD and PTS in nulliparous women. Some results, near the significance level, could be explained by a lack of statistical power. The present study focused on the link between the fear of childbirth and the process of delivery, the perception of pain, PPD and PTS. More specifically, it aimed to test three hypotheses: (i) fear of childbirth will be linked to the process of delivery, especially regarding the perception of pain, the use of anaesthesia and the use of Caesarean section; (ii) a high level of fear of childbirth will be associated with more negative postpartum consequences (namely PPD/PTS symptoms); (iii) the process of delivery and pain will also be related to post-delivery symptoms. Mediation effects were tested.

METHOD

Data from a longitudinal study were used to meet the hypotheses. A total of 176 nulliparous pregnant women responded to questionnaires at two time measurements (during pregnancy and at 5weeks postpartum).

RESULTS

Fear of childbirth is related to the perception of pain at birth among women delivering vaginally, in the absence of anaesthesia. It is also linked to symptoms of PPD and PTS, regardless of whether or not anaesthesia was used. Fear of childbirth also appears to be strongly associated to symptoms of PTS in women who have experienced an unplanned caesarean section. Thus, symptoms of postpartum PTS could play a mediating role in the link between fear of childbirth and PPD.

CONCLUSIONS

These results support the relevance of taking into account the fear of childbirth and perception of pain in connection with symptoms of PTS and PPD in nulliparous women. The unplanned caesarean section (including emergency caesarean) also appears to be important in the study of the relationship between fear and symptoms of PTS. Fear of childbirth could render the experience of childbearing more negative and predispose to PTS and PPD. Enabling psychological vulnerabilities could also be an interesting avenue for understanding these links. Limitations are discussed.

The systemic control of circadian gene expression

The mammalian circadian timing system consists of a central pacemaker in the brain's suprachiasmatic nucleus (SCN) and subsidiary oscillators in nearly all body cells. The SCN clock, which is adjusted to geophysical time by the photoperiod, synchronizes peripheral clocks through a wide variety of systemic cues. The latter include signals depending on feeding cycles, glucocorticoid hormones, rhythmic blood-borne signals eliciting daily changes in actin dynamics and serum response factor (SRF) activity, and sensors of body temperature rhythms, such as heat shock transcription factors and the cold-inducible RNA-binding protein CIRP. To study these systemic signalling pathways, we designed and engineered a novel, highly photosensitive apparatus, dubbed RT-Biolumicorder. This device enables us to record circadian luciferase reporter gene expression in the liver and other organs of freely moving mice over months in real time. Owing to the multitude of systemic signalling pathway involved in the phase resetting of peripheral clocks the disruption of any particular one has only minor effects on the steady state phase of circadian gene expression in organs such as the liver. Nonetheless, the implication of specific pathways in the synchronization of clock gene expression can readily be assessed by monitoring the phase-shifting kinetics using the RT-Biolumicorder.

The Effect of a Combined Versus a Conventional Cognitive-Behavioral Therapy on Quality of Life for Comorbid Panic Disorder With Agoraphobia and Generalized Anxiety Disorder

Concurrent panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) are the most common diagnostic occurrences among anxiety disorders. This particular comorbidity is associated with significant impairments in quality of life (QOL). The current study sought to investigate the efficacy of a combined cognitive-behavioral psychotherapy that addressed both conditions compared with a conventional psychotherapy, which attends solely to the primary disorder. The hypotheses postulated firstly, that both treatment conditions would lead to improvements in participants’ QOL and secondly, that the combined therapy would lead to greater QOL ameliorations. Twenty-five participants with comorbid PDA/GAD diagnoses were evaluated with a number of clinical interviews and self-report questionnaires, and were provided with either conventional or combined cognitive-behavioral psychotherapy, which consisted of 14 one-hour weekly sessions. Participants were once again evaluated in the same fashion 2-weeks after the completion of the psychotherapy. The results revealed that both conditions led to significant improvements in participants’ QOL, but that the two groups did not significantly differ in terms of the effect on QOL. The results also reveal that the two conditions did not significantly differ in terms of their effect on PDA and GAD symptomatology or psychiatric comorbidity. The results demonstrate that the combined psychotherapy, which addresses both conditions simultaneously, is similar to the conventional psychotherapy employed for the primary disorder in terms of QOL enhancement, symptom severity, and comorbidity reduction.

Secular trends of hip fractures in Québec, Canada

This study examined the secular trends of hip fracture incidence among individuals 50 years and older in Québec between 1993 and 2004. Age-standardized rates decreased at both the provincial and regional levels. The largest relative decrease was observed among younger females, and rates declined more slowly in the elderly.

INTRODUCTION

The population of the province of Québec is among the oldest in North America. Before the trend rupture reported in the late 1990s in several countries, hip fracture (HF) incidence rates did not show a secular trend (between 1981 and 1992). This study examined the secular trends of HF incidence at the provincial level and in two of the most important urban areas of the province, Montréal and Québec City, between 1993 and 2004.

METHODS

All hospitalisations of individuals 50 years and older living in the province of Québec between 1993 and 2004 with a main diagnosis of HF were included. Standardized rates of HF incidence were calculated for females and males, 50-74 years and 75 years and older.

RESULTS

The Québec City area showed a strong decreasing trend in HF rates for younger females, but the other groups did not show an obvious trend. Although our models did not support the existence of significant differences in trends between both areas, the rates of HF of younger males and, to a lesser extent, of older women in the Montréal area were significantly higher than in the Québec City area.

CONCLUSIONS

Differences observed in hip fracture rates as well as in secular trends between age groups and gender emphasise the need for decision makers to rely on results based on age-specific and sex-specific analyses.

Influence of drying procedure and of low degree of substitution on the structural and drug release properties of carboxymethyl starch

The aim of this study was to investigate the influence of drying methods and low range of degrees of substitution (DS) on the structural, physicochemical, and drug-release properties of carboxymethyl high-amylose starch (CMS). CMS with three DS of 0.03, 0.14, and 0.25 was synthesized and dried by either solvent precipitation (SP), spray drying (SD), or lyophilization (Ly). DS had an influence on the crystalline structure of CMS. It was found that a DS of 0.14 or higher induced a modification of polymorphism. The drying method and the DS had both an impact on the physical properties of the CMS powder which can further influence the formulation characteristics and drug-release properties from monolithic tablets. The CMS with DS of 0.14 and 0.25 dried by SP or SD presented good excipient properties in terms of compressibility. With acetaminophen (20%) as tracer, the monolithic CMS tablets showed controlled drug release over 17 h for DS of 0.14 and 10 h for DS of 0.25, almost independent of pH, suggesting interesting properties for sustained release applications.

Evaluation of intolerance of uncertainty: development and validation of a new self-report measure

Intolerance of uncertainty represents an important risk factor for development of anxiety disorders. However, few measures have been developed in order to evaluate this construct. Four studies were conducted in order to validate a new instrument evaluating intolerance of uncertainty: the Intolerance of Uncertainty Inventory (IUI). The first study described the questionnaire's development and evaluated the psychometric properties of its preliminary version. Study 2 examined the reliability and the factorial validity of the final version of the questionnaire, while Study 3 mainly addressed its convergent validity. Finally, Study 4 examined the questionnaire's temporal stability. Factorial analyses confirmed the IUI's validity. Results also supported the IUI's reliability, convergent validity, and temporal stability. The IUI is the first instrument that offers the possibility of measuring intolerance of uncertainty as a tendency to consider uncertainties to be unacceptable, as well as in terms of cognitive and behavioral manifestations.

Cognitive variables related to worry among adolescents: Avoidance strategies and faulty beliefs about worry

Studies aiming to better understand worry have neglected children and adolescents. This constitutes an important limitation considering that excessive worry is frequent among adolescents and that patients suffering from excessive worries associate the beginning of their disorder with adolescence. This study evaluates the cognitive variables associated with worry in a sample of 777 adolescents. It attempts to determine whether cognitive avoidance and false beliefs about the usefulness of worries are present and associated with worries in adolescence. The results showed that participants with a high level of worry used more avoidance strategies and held more beliefs about worry. The results also revealed that avoidance of stimuli that trigger unpleasant thoughts and thought substitution were the major avoidance strategies related to worry among adolescents. The belief that worry helps to avoid future negative events was also related to worry. These findings may suggest that adolescents' worries are maintained by processes similar to those observed among adults.

Self-Exclusion Program: A Longitudinal Evaluation Study

Few self-exclusion programs have been evaluated and their long-term impact remains unknown. This study has two main goals: (1) to assess changes in gambling behaviour and gambling problems for self-excluded patrons, and (2) to follow self-excluded gamblers for a two-year period (during and after the self-exclusion period). Individuals who excluded themselves (N = 161 at the initial stage) participated in telephone interviews after signing the self-exclusion agreement and were followed at 6, 12, 18 and 24-months. Results show that according to the DSM-IV, 73.1% of the participants were pathological gamblers. The self-exclusion program has many positive effects. During the follow-ups, the urge to gamble was significantly reduced while the perception of control increased significantly for all participants. The intensity of negative consequences for gambling was significantly reduced for daily activities, social life, work, and mood. The DSM score was significantly reduced over time. This reduction also took place between the baseline and the 6-month follow-up. The clinical implications of the results are discussed in relation to the effectiveness of the program. Suggestions are provided in order to increase compliance of self-excluded patrons.

Benzodiazepine discontinuation among adults with GAD: A randomized trial of cognitive-behavioral therapy

This study evaluated the specific effectiveness of cognitive-behavior therapy (CBT) combined with medication tapering for benzodiazepine discontinuation among generalized anxiety disorder (GAD) patients by using a nonspecific therapy control group. Sixty-one patients who had used benzodiazepines for more than 12 months were randomly assigned to the experimental conditions. Nearly 75% of patients in the CBT condition completely ceased benzodiazepine intake, as compared with 37% in the control condition. Results of the 3-, 6-, and 12-month follow-ups confirmed the maintenance of complete cessation. Discontinuation rates remained twice as high in the CBT condition. The number of patients who no longer met GAD criteria was also greater in the CBT condition. The addition of specific CBT components thus seemed to facilitate benzodiazepine tapering among patients with GAD.

Physicochemical evaluation of carbamazepine microparticles produced by the rapid expansion of supercritical solutions and by spray-drying

PURPOSE

To compare the physical and physicochemical characteristics of carbamazepine microparticles prepared using two different methods: (1) the rapid expansion of supercritical solutions (RESS) and (2) the spray-drying process.

METHODS

For both processes, microparticles were produced over a range of different temperatures (35 to 100 degrees C). For the RESS method, carbon dioxide was the solvent used over a pressure range of 2500 to 3500 psi. As for the spray-drying method, different organic solvents were used at atmospheric pressure. Comparison was based on morphology, crystalline structure, mean particle size, and size distribution of processed particles. The influence of process parameters on microparticles' characteristics was also investigated. Particles were analyzed using scanning electron microscopy (SEM), X-ray powder diffraction (XRPD), thermogravimetric analyzer (TGA), and differential scanning calorimetry (DSC).

RESULTS

The carbamazepine particles used as unprocessed starting material had a mean diameter of approximately 85 microm with a size distribution range between 15 and 336 microm. Microparticles produced by either the RESS or spray-drying method had a mean diameter smaller than 2 microm and a narrower size distribution range between 0.25 and 2.5 microm. SEM photomicrographs, X-ray diffractograms, and DSC spectra revealed that modification of crystal morphology was dependent on the operating conditions.

CONCLUSIONS

Significant reduction in mean particle size and size distribution range of carbamazepine particles was observed by RESS and spray-drying methods. The results also demonstrate that the crystalline nature of carbamazepine particles depends on the method of production and on the operating parameters of pressure and temperature.

Echinoderms as bioindicators, bioassays, and impact assessment tools of sediment-associated metals and PCBs in the North Sea

The study assessed the occurrence, possible toxicity, and impact of sediment-associated metals and PCBs in the coastal zone of the southern North Sea using echinoderms as representatives of the macrobenthos. Metals and PCBs were analyzed in the sediments and in the body compartments of the starfish Asterias rubens from 11 stations. The general toxicity of sediment-associated contaminants was assessed by bioassays using embryonic and larval developments of both A. rubens and the sea urchin Psammechinus miliaris. The impact of contamination was assessed by measuring cellular immune responses of A. rubens collected in the same stations. Contamination of the starfish by metals and PCBs closely reflected that of the sediments. However, bioaccumulation was element-specific for metals and depended on the chlorination pattern for PCBs. The sediment-associated contaminants appeared to be toxic in both the A. rubens and P. miliaris developmental assays. Moreover, metals were shown to affect the immune responses of starfishes living in contaminated stations. The most significant effects on biological responses were recorded in the plumes of the Scheldt/Rhine/North Sea Canal and the Elbe/Weser Rivers.

[Etiological factors of generalized anxiety disorder]

Generalized Anxiety disorder (GAD) is a widespread psychiatric syndrome involving significant consequences on people's health. However, recent data show that this disorder has received little attention when compared to other anxiety disorders. A review of the publication on GAD also stated that the majority of research has been conducted on descriptive issues, whereas etiological factors received lower rates of publication. This may be explained by the fact that changes in the conceptualization of GAD slowed down the progression of researches focussing on the identification of factors implicated in the development and the maintenance of its symptoms. For example, in the third version of the Diagnostic and Statistical Manual of Mental disorders (DSM) published in 1980, GAD could only be assigned if patients had a persistent anxiety without reporting specific symptoms of other anxiety disorders (eg Specific Phobias, Panic Disorder, Obsessive-Compulsive Disorder). With DSM III-R and DSM IV, excessive worry became the central feature of GAD, which increased its diagnostic validity. Taking that into account, where do we stand in the comprehension of GAD? What are the etiological factors identified as playing a role in the development and the maintenance of GAD and its central feature, excessive and uncontrollable worry? The goal of this article consists to provide answers to these questions by reviewing the literature of the current knowledge of GAD and examining various theories and explanatory models available. Firstly, many studies suggest that environmental factors are implicated in the development and maintenance of GAD. However, the majority of researches rests on an out-of-date conceptualization of GAD. Furthermore, the nature of experimental designs used in researches limits their conclusion. The first environmental factor documented is negative life events. Researchers noted that the occurrence of one or more negative life events being significant and appearing in an unexpected way was associa-ted with an increase in the risk to develop a GAD (eg. Familial problems (eg conflicts, abuses), considered as chronic stress-inducing situations, have also been suggested as etiological factor of GAD. Among the other environmental factors identified are separation during childhood, role inversion during childhood, lack of social interactions, poor life satisfaction, and modeling of a relative having an anxiety disorder. The cognitive and behavioral approach has been widely used during the last two decades to precise the etiology of GAD. First of all, some studies have pointed out the function of worry, which is to suppress images associated with negative thoughts (eg. Thus, GAD patients seem to develop excessive worries in order to prevent more negative feeling associated with the images of a thought. Other authors suggested that a deficit of attention might be responsible of excessive worry. Finally, some cognitive variables such as intolerance of uncertainty, false beliefs about worry, negative problem orientation and cognitive avoidance have been suggested as playing a determinant role in the development and maintenance of GAD. In order to resume the empirical findings available in the literature, an etiological model gathering the cognitive, behavioral, and environmental factors implicated in GAD is proposed. This model suggests that GAD is the result of a psychological vulnerability activated by a tension resulting from a negative event. Finally, recommendations are brought concerning future researches on GAD and its central characteristic, excessive and uncontrollable worry.

[Benzodiazepine withdrawal in patients with generalized anxiety disorder: efficiency of a behavioral and cognitive intervention]

Benzodiazepine medication is often prescribed for the short-term treatment of generalized anxiety disorder. The chronic nature of generalized anxiety disorder entails a prolonged use of these psychotropic medication on several months and several years, entailing also a psychological and physical addiction. The current study aims at determining if the combination of a behavioral and cognitive therapy and gradual withdrawal facilitate interrupting the use of benzodiazepine in patients with generalized anxiety disorder. In total, five participants have received the combined intervention according to an experimental protocol of unique case with multiple levels. Four among them have completed the withdrawal plan and have demonstrated important clinical improvements. Data collected during the 3rd and 6th month indicate the preservation of therapeutic gain. These results suggest that behavioral and cognitive therapy facilitates stopping the use of benzodiazepine medication in patients with generalized anxiety disorder by significantly reducing anxious symptoms.

[Study of psychometric properties of two new questionnaires assessing beliefs in hypochondriasis in a non-clinical population]

Most instruments focussing on hypochondriasis symptoms do not have for goal to assess beliefs specifically. Instead, these instruments are used to measure specific behaviors. To assess underlying beliefs with these kinds of instruments, you have to extract false beliefs by deduction. In cognitive therapy, it is important to target erroneous beliefs in order to change them. On the other hand, existing instruments are not really suitable to target erroneous health beliefs. Even if some questionnaires are built to assess beliefs directly, it seems that they only measure the conviction of having an illness and do not assess the general health beliefs present in excessive health worriers. However, many researchers argue that this other kind of beliefs are the ones responsible in maintaining hypochondriasis symptoms. Presently, researchers assume that erroneous beliefs can maintain worries about illness among people with hypochondriasis symptoms like false beliefs about worry maintain worries in people with General Anxiety Disorder (GAD). Even if the importance of false beliefs in the maintenance of pathological worries is now recognized, most instruments on hypochondriasis symptoms do not have for goal to assess erroneous beliefs concerning worry about health. For instance, although the questionnaire Why do people worry? (WW) shows good psychometric properties and measures beliefs related to general worries, this questionnaire is not specific enough to correctly evaluate beliefs associated to health worry. A new questionnaire has to emerge in order to assess false beliefs associated to worry about health. This manuscript presents the development and the validation of a new questionnaire: the General Health Beliefs Questionnaire (GHBQ) that assesses general health beliefs, and also presents the development and the validation of a new questionnaire assessing beliefs associated to worry about health: the Why do people Worry about Health? (WW-H) . In this study, the GHBQ's and the WW-H's psychometric qualities and the factorial structure were assessed. More precisely, this study examined the factorial structure, the temporal stability, the convergent, divergent and criteria validities of the GHBQ and the WW-H. Four hundred and twenty nine French-speaking university students (non-clinical participants) completed a battery of questionnaires at the beginning of a class. The questionnaires were: The General Health Beliefs Questionnaire (GHBQ), the Why do people Worry about Health (WW-H), the Illness Worry Scale (IWS), the Beck Depression Inventory-short form (BDI-short form) and the Beck Anxiety Inventory (BAI). A second administration took place three weeks later with the same sample to test the temporal stability of the GHBQ and the WW-H. The principal component analysis with orthogonal rotation (varimax) supports a five components solution for the GHBQ: 1) magical thinking, 2) health, 3) consequences, 4) responsibility, and 5) vulnerability. The principal component analysis with oblique rotation (direct oblimin) (d=0) found a two components solution for the WW-H: 1) utility and 2) magical thinking associated to worries about health. The internal consistency of the GHBQ and the WW-H is excellent (a=.80 and a=.90, respectively). A correlation of 0.49 was found between the GHBQ and the WW-H. The correlation between the GHBQ and the IWS who evaluates the tendency to worry (r=.50) and between the WW-H and the IWS (r=.49) showed that the convergent validity of these questionnaires is adequate. On a three weeks interval, the GHBQ (r=.70) and the WW-H (r=.71) showed a satisfying temporal stability. The means of the high worriers (80 superior percentile at the IWS) (M=38.8, ET=8.93) and the means of the moderate worriers (between the 40 and the 60 percentile at the IWS) (M=32.8, ET=8.00) on the GHBQ have been compared. A significant difference has been found between the two groups [F(1,181)=23,129, p<0,001]. Also, the means of the high worriers (M=27.3, ET=8.59) and the means of the moderate worriers (M=23.8, ET=8.56) on the WW-H haveave been compared. An ANOVA has found a significant difference between these two groups [F(1,180)=7,396, p=0,007]. These results show that general health beliefs and false beliefs associated to worry about health are more often present in high worriers than in moderate worriers. The GHBQ and the WW-H allow psychologists, physicians and psychiatrists to do a quicker and more exhaustive evaluation of general health beliefs and false beliefs associated to worry about health, in less costs. These questionnaires will improve the chances of success of the hypochondriasis' treatment by helping clinicians to detect and correct false beliefs more easily.