Effects of a Virtual Reality Game on Children's Anxiety During Dental Procedures (VR-TOOTH): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Dental fear and anxiety (DFA) is a condition that affects approximately one-quarter of children and adolescents. It is a significant cause for pediatric patients to avoid dental care later in adulthood. Lack of patient cooperation due to DFA can create an environment of stress, often obligating dentists to end appointments prematurely and consider alternative pharmacological treatment options. Virtual reality (VR) use during dental care, providing an immersive experience through sensory stimuli, is potentially an additional nonpharmacologic tool to better manage DFA in children with special health care needs (SHCN) undergoing dental procedures.

OBJECTIVE

This pilot study aims to assess the feasibility and acceptability of VR immersion as a tool to reduce DFA in pediatric special needs patients undergoing dental procedures. The study also aims to gain insight on parent and health care provider perspectives on the use of VR during dental appointments.

METHODS

This pilot randomized controlled trial study will follow a parallel design including 2 groups: a control group (clinic's standard care using a wall TV) and an experimental group (using a VR game). We will randomize 20 participants to either group. Recruitment will be carried out at the dental clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary-quaternary care center that mostly serves pediatric patients with SHCN. The primary outcome will be patient recruitment rates and completion rates of planned procedures. DFA in children will be assessed using both an observation-based proxy assessment with the Venham Anxiety and Behavior Rating Scale and physiological assessments using parameters such as change in heart rate and levels of salivary alpha-amylase as a stress biomarker before and 10 minutes after the procedure. Sociodemographic characteristics, measures of the levels of parent and health care professional satisfaction, occurrence of side effects, and any deviation from normal procedure length will also be collected. Descriptive statistics, nonparametric tests, and effect sizes will be used for demographic and clinical variables and to present parent and health care professional satisfaction levels as well as procedural time.

RESULTS

This study will be conducted from May 2023 to May 2024, with results expected to be available in December 2024.

CONCLUSIONS

The pilot study will provide insight on the feasibility and acceptability of VR use in clinical dentistry to reduce DFA for pediatric patients with SHCN. This study will guide future research on VR use in pediatric dentistry and can serve as a framework for a larger randomized clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05898100; https://classic.clinicaltrials.gov/ct2/show/NCT05898100.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49956.

Add-On Intermittent Theta Burst Stimulation Improves the Efficacy of First-Episode and Recurrent Major Depressive Disorder: Real-World Clinical Practice

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based treatment for major depressive disorder (MDD). This retrospective study aimed to explore the efficacy of add-on iTBS treatment in MDD in real-world clinical practice.

METHODS

One hundred and fifty-nine inpatients with MDD in a general hospital were included in this study. These patients were treated with at least 8 sessions of iTBS, in addition to antidepressants and supportive psychotherapy. Symptoms of depression and anxiety were assessed with the Hamilton Depression Rating Scale (HDRS) and the Hamilton Rating Scale for Anxiety (HAMA) at baseline and after 2-4 weeks of treatment. The improvement degree of depressive and anxious symptoms was compared between the first-episode MDD (n=107) and recurrent MDD (n=52) groups.

RESULTS

Depressive and anxious symptoms were reduced significantly after the add-on iTBS treatment; the response and remission rates in the first-episode MDD group were 55.14% and 28.97%, which were 63.46% and 28.85% for the recurrent MDD group, respectively (P>0.05). The response rate and remission rate of anxiety in the first-episode MDD group was 64.13% and 57.45% for HAMA, and 66.67% and 62.50% for the recurrent MDD group (P>0.05).

CONCLUSION

Our findings indicated that antidepressant and anti-anxiety efficacy of add-on iTBS treatment remains equivocal in real-world clinical practice, regardless of a first-episode depression diagnosis or recurrent depression.

Smartphone addiction, gender and interpersonal attachment: A cross-sectional analytical survey in Taiwan

Overview

Smartphone use has dramatically increased worldwide, contributing to a profound change in interpersonal interactions. They have become the primary medium of human interaction, and smartphone addiction, consequently, has become a modern-day reality. Recent research on smartphone addiction has provided diverse explanations regarding the correlation between gender and addiction. Therefore, this study aims to analyse the correlation and variance among smartphone addiction, gender and interpersonal attachment.

Methods

The participants included Taiwanese citizens and the questionnaires were randomly distributed; 1190 valid questionnaires (534 males, 656 females) were collected. Descriptive statistics were computed to observe the average value and standard deviation between interpersonal attachment and gender. Next, Spearman's ρ was conducted to interpret the correlation among smartphone addiction, gender and interpersonal attachment. Finally, the participants were divided into three groups based on their pre-determined level of smartphone addiction: high, moderate and low addictions. The Analysis of variance (ANOVA) was performed based on interpersonal attachment as the independent variable to determine any statistically significant difference among the three levels.

Results

There are four patterns of interpersonal attachment: secure, avoidant, dismissing and anxious attachments. The correlation analysis revealed a significant positive correlation between interpersonal attachment and smartphone addiction (p > 0.000), while revealing no relationship between gender and smartphone addiction or gender and interpersonal attachment. Additionally, the ANOVA indicated the difference was statistically significant in the groups of high and moderate addictions; no statistical significance was identified in the group of low addiction (p < 0.204).

Conclusion

This study revealed that there was no correlation between gender and smartphone addiction, but rather, a positive correlation between smartphone addiction and interpersonal attachment. This positive correlation suggests both high and moderate addiction groups display insecurity in their interpersonal attachment. Therefore, to lower the prevalence of unhealthy smartphone addiction, maintaining healthy interpersonal relationships is suggested.

Anxiety among patients undergoing various dental procedures

Dental Anxiety (DA) was the most frequent problem which can lead to the avoidance of treatment. Therefore, is to evaluate the DA level among patients of different treatments. A questionnaire was distributed among the participants. The Modified Corah Dental Anxiety Scale (MDAS) was used to measure dental anxiety. In gender differences, it has been found that females were more anxious than male participants. The younger age group (18-30 years) was less anxious than the older age groups (P < 0.05). Most of the participants in all conditions were slightly anxious. Male participants exhibited less dental anxiety than females. This might be due to males being more stable emotionally.

TNF-α, IL-6 and hsCRP in patients with melancholic, atypical and anxious depression: an antibody array analysis related to somatic symptoms

Background

The association between inflammation and major depressive disorder (MDD) remains poorly understood, given the heterogeneity of patients with MDD.

Aims

We investigated inflammatory markers, such as interleukin (IL)-6, high-sensitivity C reactive protein (hsCRP) and tumour necrosis factor-α (TNF-α) in melancholic, atypical and anxious depression and explored whether baseline inflammatory protein levels could indicate prognosis.

Methods

The sample consisted of participants (aged 18-55 years) from a previously reported multicentre randomised controlled trial with a parallel-group design registered with ClinicalTrials.gov, including melancholic (n=44), atypical (n=37) and anxious (n=44) patients with depression and healthy controls (HCs) (n=33). Subtypes of MDD were classified according to the 30-item Inventory of Depressive Symptomatology, Self-Rated Version and the 17-item Hamilton Depression Rating Scale. Blood levels of TNF-α, IL-6 and hsCRP were assessed using antibody array analysis.

Results

Patients with MDD, classified according to melancholic, atypical and anxious depression subtypes, and HCs did not differ significantly in baseline TNF-α, IL-6 and hsCRP levels after adjustment. In patients with anxious depression, hsCRP levels increased significantly if they experienced no pain (adjusted (adj.) p=0.010) or mild to moderate pain (adj. p=0.038) compared with those with severe pain. However, the patients with anxious depression and severe pain showed a lower trend in hsCRP levels than patients with atypical depression who experienced severe pain (p=0.022; adj. p=0.155). Baseline TNF-α (adj. p=0.038) and IL-6 (adj. p=0.006) levels in patients in remission were significantly lower than those in patients with no remission among the participants with the atypical depression subtype at the eighth-week follow-up.

Conclusions

This study provides evidence of differences in inflammatory proteins in patients with varied symptoms among melancholic, atypical and anxious depression subtypes. Further studies on the immunoinflammatory mechanism underlying different subtypes of depression are expected for improved individualised therapy.

Trial registration number

NCT03219008.

Nomophobia and temperaments in Lebanon: Results of a national study

OBJECTIVES

Assess the association between nomophobia and temperaments in the Lebanese population.

METHODS

The cross-sectional study was conducted between January and July 2019 (N = 2260).

RESULTS

A total of 1089 of the participants (48.3%) appeared to have moderate nomophobia while 349 (15.5%) were found to exhibit severe nomophobia. Multivariable analysis showed that higher hyperthymic temperament (β = -0.34) was associated with less nomophobia, whereas higher irritable temperament (β = 0.43) was associated with more nomophobia.

PRACTICAL IMPLICATIONS

The findings obtained from our study showed that a more irritable temperament was significantly associated with a more severe nomophobia, while hyperthymic temperament was associated with less nomophobia. They open up new perspectives for the evaluation of the temperaments among nomophobics with a better focus on the personality model and how they can predict nomophobia.

The Nasopharynx Swab Test for Coronavirus Disease-2019 Is Mild and Will Not Cause Significant Pain and Anxiety: A Cross-Sectional Study Based on Psychiatrists

Background

Laboratory viral nucleic acid testing (NAT), such as the nasopharyngeal swab test, is now recommended as the gold standard for the diagnosis of Coronavirus disease-2019 (COVID-19). However, the nasopharyngeal swab testing process may cause some discomfort.

Objective

To investigate the influence of nasopharyngeal swab tests on the anxiety and pain felt by psychiatric medical staff.

Methods

A total of 174 psychiatric medical staff (namely 97 doctors, 68 nurses, and nine administrators) and 27 controls were included in the current study. A self-designed questionnaire was used to collect their general demographic information (age, gender, marriage, occupation, profession, smoking history, alcohol consumption history, tea drinking history, previous history of anxiety and depression) as well as their subjective experience, such as nausea, vomiting, coughing, worry, fear, etc, during nasopharyngeal swab collection. The Numerical Rating Scale (NRS) and the State-Trait Anxiety Inventory (STAI) were used to assess the subjects’ pain and state anxiety, respectively.

Results

There were no statistical differences (p>0.05) in age, marriage, smoking history, a history of anxiety and depression, pain scores, and anxiety scores between different professions and genders. The results of partial correlation analysis (controlled for gender and history of depression or anxiety) indicated that the male gender was negatively correlated with being anxious (r=-0.148, p=0.037) and nervous (r=-0.171 p=0.016), although there was no significant difference in pain and anxiety between men and women. In addition, marriage might help women resist negative emotions.

Conclusions

1) There will be mild discomfort during nucleic acid testing, but not enough to cause pain and anxiety; 2) women are more likely to be anxious and nervous during the nucleic acid testing.

Anxiety and Leisure-Domain Physical Activity Frequency, Duration, and Intensity During Covid-19 Pandemic

This study investigated relationships between state anxiety and leisure-domain physical activity levels during Covid-19 pandemic. We used frequency, duration, and intensity as key variables of physical activity. Trait anxiety, state anxiety before pandemic, age, gender, and education level were also included in the analysis. Our general hypothesis was that participants who declared doing more physical activity levels would exhibit lower levels of anxiety during the Covid-19 pandemic. A convenient sample of 571 volunteer adults (mean age 39 ± 14 years) was drawn mainly from São Paulo State (89.2% of the sample), the epicenter of Covid-19 pandemic in Brazil. To obtain the participants’ levels of anxiety (trait, state before pandemic, and state during pandemic) we used a validated short-version of the State and Trait Anxiety Inventory. Levels of physical activity were measured via questions from VIGITEL, a validated questionnaire about the individual’s habits on risk factors. Answers were given regarding the first week of March 2020 (before pandemic) and at the very moment the participant was filling in the electronic form (June 2020). Data analyses were conducted through descriptive and inferential techniques, with the use of non-parametric tests and linear regression models. Overall, participants’ responses indicate that anxiety levels were higher during the pandemic compared to the period that preceded the pandemic, and that frequent and long physical activity in the leisure-domain reduced anxiety, regardless its intensity. The regression models revealed an inverse relationship between physical activity and anxiety (the more physical activity, the less anxiety) and independent of gender, age, education level, trait anxiety, and physical activity before pandemic.

The Differential Effects of Insecure Attachment on Post-Traumatic Stress: A Systematic Review of Extant Findings and Explanatory Mechanisms

It is well-documented that insecure attachment poses substantial risks to post-trauma recovery. Although attachment anxiety reliably predicts and is associated with elevated post-traumatic stress symptoms (PTSS), the attachment avoidance-PTSS link has been far less consistent. This suggests both attenuating and enhancing connections between attachment difficulties and post-trauma outcomes. The goal of this study is 2-fold: (a) to review and summarize extant evidence concerning the relation between insecure attachment and PTSS and (b) to review mechanism(s) underlying attachment anxiety and attachment avoidance that may explain the development of PTSS. Following a systematic review of the empirical literature investigating attachment, trauma, and post-trauma reactions, a total of 138 studies were identified and summarized. The review further identifies explanatory mechanisms underlying the association between insecure attachment and PTSS, including stress appraisals, cognitive factors, self-esteem, emotion regulation strategies, social factors, and trauma-specific factors (i.e., type of trauma, extreme stress). Implications for practice, policy, and research are discussed.

Affective temperaments (TEMPS-A) in panic disorder and healthy probands: Genetic modulation by 5-HTT variation

OBJECTIVES

Temperamental traits as ascertained by the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-Questionnaire (TEMPS-A) have been suggested as promising intermediate phenotypes of mental disorders. In anxiety disorders, however, TEMPS scales and their genetic underpinnings are still understudied.

METHODS

TEMPS-A scores in 109 patients with panic disorder (PD) were compared to a sample of 536 healthy probands. All participants were genotyped for serotonin transporter gene variation (5-HTTLPR/rs25531).

RESULTS

PD patients displayed significantly increased scores on the dysthymic, cyclothymic, irritable and anxious subscales, and lower scores on the hyperthymic subscale, respectively (all ps < 0.001) compared to healthy probands. In the total sample, the less active 5-HTTLPR/rs25531 S/L_G alleles were associated with higher scores on the dysthymic, cyclothymic, irritable and anxious temperaments (all ps < 0.01), but not the hyperthymic subscale. Mediation analyses revealed anxious temperament in particular to mediate the relationship between 5-HTT genotype and PD.

CONCLUSIONS

Dysthymic, cyclothymic, irritable and notably anxious temperament could serve as valuable intermediate phenotypes in efforts to unravel neurobiological, particularly serotonin system related genetic pathomechanisms associated with PD and potentially contribute to a panel of vulnerability markers guiding early targeted preventive interventions.

Insecure Attachment and Therapeutic Bond as Mediators of Social, Relational, and Social Distress and Interpersonal Problems in Adult Females with Childhood Sexual Abuse History

Establishing trust is an important part of building the therapeutic relationships and achieving the goal of effective trauma treatment for individuals who have experienced childhood sexual abuse. The current study explored the associations between attachment style, therapeutic bond, distress, and interpersonal problems. This study investigated whether attachment style and therapeutic bond mediated the association between the level of early treatment emotional distress and later treatment interpersonal problems among two groups: clients reporting histories of childhood sexual abuse and clients not reporting histories of childhood sexual abuse. Research indicates that disruption of attachment security as well as the therapeutic relationship is common in survivors of childhood sexual abuse. We explored the mediating role of insecure attachment and the therapeutic bond on the predictive relationship between early treatment emotional distress and the interpersonal difficulties that one experiences in their daily life. For clients with histories of child sexual abuse, the model showed that anxious attachment and avoidant attachment mediated the associations between emotional distress and interpersonal relations. Therapeutic bond was not a significant mediator. For clients without histories of sexual abuse, results showed significant association between emotional distress and interpersonal relations, but insecure attachment or therapeutic bond did not mediate this relationship.

Impact of the Use of Electronic Health Tools on the Psychological and Emotional Well-Being of Electronic Health Service Users (The Seventh Tromsø Study - Part 3): Population-Based Questionnaire Study

Background

Electronic health (eHealth) has been described as a silver bullet for addressing how challenges of the current health care system may be solved by technological solutions in future strategies and visions for modern health care. However, the evidence of its effects on service quality and cost effectiveness remains unclear. In addition, patients’ psychological and emotional reactions to using eHealth tools are rarely addressed by the scientific literature.

Objective

This study aimed to assess how the psychological and emotional well-being of eHealth service users is affected by the use of eHealth tools.

Methods

We analyzed data from a population-based survey in Norway, conducted in the years 2015-2016 and representing 10,604 eHealth users aged over 40 years, to identify how the use of eHealth tools was associated with feeling anxious, confused, knowledgeable, or reassured. Associations between these four emotional outcomes and the use of four types of eHealth services (Web search engines, video search engines, health apps, and social media) were analyzed using logistic regression models.

Results

The use of eHealth tools made 72.41% (6740/9308) of the participants feel more knowledgeable and 47.49% (4421/9308) of the participants feel more reassured about their health status. However, 25.69% (2392/9308) reported feeling more anxious and 27.88% (2595/9308) reported feeling more confused using eHealth tools. A high level of education and not having a full-time job were associated with positive reactions and emotions (feeling more knowledgeable and reassured), whereas low self-reported health status and not having enough friends who could provide help and support predicted negative reactions and emotions (ie, feeling anxious and confused). Overall, the positive emotional effects of eHealth use (feeling knowledgeable and reassured) were relatively more prevalent among users aged over 40 years than the negative emotional effects (ie, feeling anxious and confused). About one-fourth of eHealth users reported being more confused and anxious after using eHealth services.

Conclusions

The search for health information on the internet can be motivated by a range of factors and needs (not studied in this study), and people may experience a range of reactions and feelings following health information searching on the Web. Drawing on prior studies, we categorized reactions as positive and negative reactions. Some participants had negative reactions, which is challenging to resolve and should be taken into consideration by eHealth service providers when designing services (ie, including concrete information about how users can get more help and support). There is a need for more studies examining a greater range of reactions to online health information and factors that might predict negative reactions to health information on the Web.

The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis

Anxiety, although as common and arguably as debilitating as depression, has garnered less attention, and is often undetected and undertreated in the general population. Similarly, anxiety among medical students warrants greater attention due to its significant implications. We aimed to study the global prevalence of anxiety among medical students and the associated factors predisposing medical students to anxiety. In February 2019, we carried out a systematic search for cross-sectional studies that examined the prevalence of anxiety among medical students. We computed the aggregate prevalence and pooled odds ratio (OR) using the random-effects model and used meta-regression analyses to explore the sources of heterogeneity. We pooled and analyzed data from sixty-nine studies comprising 40,348 medical students. The global prevalence rate of anxiety among medical students was 33.8% (95% Confidence Interval: 29.2–38.7%). Anxiety was most prevalent among medical students from the Middle East and Asia. Subgroup analyses by gender and year of study found no statistically significant differences in the prevalence of anxiety. About one in three medical students globally have anxiety—a prevalence rate which is substantially higher than the general population. Administrators and leaders of medical schools should take the lead in destigmatizing mental illnesses and promoting help-seeking behaviors when students are stressed and anxious. Further research is needed to identify risk factors of anxiety unique to medical students.

Who stays in addiction treatment groups? Anxiety and avoidant attachment styles predict treatment retention and relapse

Attachment styles have been shown to be an important predictor of relationship quality and well-being. They have also been linked with ability to function well in groups. Insecure attachment styles are thought to be an underlying cause of addiction and represent a target for change in one-to-one therapy. How attachment styles themselves affect group therapy for addiction is understudied. The current study addresses this gap by examining the effects of attachment styles on relapse and treatment retention amongst a population of people attending addiction therapy groups. Fifty-eight individuals in such groups completed measures of attachment anxiety and avoidance. Participants were followed up 4 weeks later, and their continued treatment attendance and relapse status were recorded. In terms of treatment retention, high anxiety/high avoidant participants had the highest retention. In terms of relapse, low anxiety/high avoidant participants had the lowest rates. These results are discussed in terms of the potentially protective effects of avoidant attachment styles during group therapy and the role of anxiety attachment in the continued maintenance of both protective and risky personal relationships.

Prevalence and predictors of anxiety in an African sample of recent stroke survivors

OBJECTIVES

Studies considering emotional disturbances in the setting of stroke have primarily focused on depression and been conducted in high-income countries. Anxiety in stroke survivors, which may be associated with its own unique sets of risk factors and clinical parameters, has been rarely investigated in sub-Saharan Africa (SSA). We assess the characteristics of anxiety and anxiety-depression comorbidity in a SSA sample of recent stroke survivors.

MATERIALS AND METHODS

We assessed baseline data being collected as part of an intervention to improve one-year blood pressure control among recent (≤1 month) stroke survivors in SSA. Anxiety in this patient population was measured using the Hospital Anxiety and Depression Scale (HADS), while the community screening instrument for dementia was used to evaluate cognitive functioning. Independent associations were assessed using logistic regression analysis.

RESULTS

Among 391 participants, clinically significant anxiety (HADS anxiety score≥11) was found in 77 (19.7%). Anxiety was comorbid with depression in 55 (14.1%). Female stroke survivors were more likely than males to have anxiety (OR=2.4, 95% CI=1.5-4.0). Anxiety was significantly associated with the presence of cognitive impairment after adjusting for age, gender and education (OR=6.8, 95% CI=2.6-18.0).

CONCLUSIONS

One in five recent stroke survivors in SSA has clinically significant anxiety, and well over 70% of those with anxiety also have depression. Future studies will need to determine what specific impact post-stroke anxiety may have on post-stroke clinical processes and outcomes.

Implementation of a brief anxiety assessment and evaluation in a Department of Veterans Affairs geriatric primary care clinic

Anxiety disorders are common and debilitating in older individuals, yet anxiety is often not formally assessed in primary care. We conducted a quality improvement project to examine the feasibility of implementing a brief anxiety assessment, the Geriatric Anxiety Inventory (GAI), in a Department of Veterans Affairs geriatric primary care clinic. We compared the GAI with a depression assessment, the 15-item Geriatric Depression Scale (GDS-15). Fifty older Veterans (mean = 78.5 +/- 7.4 yr) completed the GAI and GDS-15. Mean completion time and feedback to patients was brief (6.20 min; n = 10). Good internal consistency (alpha = 0.82) was found for GAI scores. Patients with psychiatric diagnoses obtained significantly higher GAI scores (mean = 4.73 +/- 1.15) compared with patients without psychiatric diagnoses (mean = 1.15 +/- 1.86, t(11.46) = -3.10, p = 0.01). Findings suggest that the GAI is acceptable to patients but may not be suitable for differentiating anxiety symptoms or disorders from depression. Interdisciplinary team members continued to implement the GAI after project completion to screen for and track anxiety symptoms in our geriatric primary care patients. Detecting anxiety with the GAI had the benefit of allowing providers to initiate conversations about available treatments and track symptoms as part of noting treatment progress.