Web-Based Mindfulness Meditation as an Adjunct to Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Mixed Methods Feasibility Evaluation Study

BACKGROUND

Public safety personnel (PSP) are individuals who work to ensure the safety and security of communities (eg, correctional workers, firefighters, paramedics, and police officers). PSP have a high risk of developing mental disorders and face unique barriers to traditional mental health treatments. The PSP Wellbeing Course is a transdiagnostic, internet-delivered cognitive behavioral therapy (iCBT) course tailored to assist PSP with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). The initial course outcomes are promising, but some clients report some challenges with learning skills and recommend adding additional resources. Mindfulness meditations, which help people to experience the world and their reactions to the world in open and nonjudgmental ways, may complement the existing PSP Wellbeing Course.

OBJECTIVE

This study aims to examine the feasibility of mindfulness meditations in iCBT tailored for PSP. Information was gathered to evaluate engagement and client experiences with mindfulness meditations, symptom change, and the relationship between mindfulness meditation use and symptom change.

METHODS

A mixed methods study was conducted on PSP enrolled in the PSP Wellbeing Course who were offered 5 mindfulness meditations during the program (ie, 1/lesson). Clients completed questionnaires on depression, anxiety, PTSD, anger, insomnia, resilience, and mindfulness at pretreatment and at 8 weeks; an 8-week treatment satisfaction questionnaire; and brief weekly measures of mindfulness meditation engagement. We used paired sample t tests (2-tailed) to assess changes in outcomes over time and partial correlations to assess whether mindfulness meditation use predicted outcomes at posttreatment. A total of 12 clients were interviewed about their perceptions of the mindfulness meditations, and interviews were analyzed using directed content analysis.

RESULTS

Among the 40 clients enrolled, 27 (68%) reported using the mindfulness meditations, practicing for an average of 4.8 (SD 8.1) minutes each week. Most interviewees described the mindfulness meditations as beneficial but also reported challenges, such as discomfort while sitting with their feelings. Clients provided suggestions for better integration of mindfulness into iCBT. Overall, clients who completed the PSP Wellbeing Course with mindfulness meditations experienced statistically significant improvements in symptoms of anxiety (P=.001), depression (P=.001), PTSD (P=.001), and anger (P=.001) but not insomnia (P=.02). Clients also experienced improvements in resilience (P=.01) and mindfulness (P=.001). Self-reported time spent meditating was not associated with changes in symptoms over time.

CONCLUSIONS

This study provides new insight into the integration of mindfulness meditations with iCBT for PSP. It demonstrates the partial feasibility of adding mindfulness meditations to iCBT, revealing that some, but not all, PSP engaged with the meditations and reported benefits. PSP reported using the mindfulness meditations inconsistently and described challenges with the meditations. Improvements can be made to better integrate mindfulness meditation into iCBT, including offering mindfulness meditation as an optional resource, providing more psychoeducation on managing challenges, and offering shorter meditations.

Sustaining and Expanding Internet-Delivered Cognitive Behavioral Therapy (ICBT) for Public Safety Personnel across Canada: A Survey of Stakeholder Perspectives

Public safety personnel (PSP) experience an elevated risk of mental health problems and face barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) has been tailored to PSP to improve access to mental health care. In this study, we sought to investigate perceptions of ICBT, particularly among those with and without prior knowledge of ICBT and between PSP leaders and non-leaders. A survey was administered to 524 PSP from across Canada to identify (a) how PSP perceive ICBT, (b) the extent of organizational support for tailored ICBT in PSP organizations, particularly leadership's support, and (c) perceived facilitators and barriers to funding tailored ICBT. The results indicated that PSP perceive ICBT to have more advantages than disadvantages. PSP who had previously heard of tailored ICBT had more positive perceptions. PSP indicated that there is a need for ICBT, and PSP leaders indicated their support for the implementation of tailored ICBT. The study identified that there is a need for increasing awareness of the effectiveness of and need for ICBT in order to facilitate funding of services. Overall, the current study indicates that PSP support ICBT as a valued form of therapy and that policy makers and service providers seeking to provide ICBT to PSP may increase support for ICBT services through more education and awareness.

Assessing the Perceptions and Impact of Critical Incident Stress Management Peer Support among Firefighters and Paramedics in Canada

Relative to the general population, public safety personnel (PSP) appear at an increased risk of developing mental health challenges as a result of repeated exposure to potentially psychologically traumatic events (PPTEs). To help mitigate the impact of PPTEs on PSP mental health, many PSP agencies have implemented diverse peer support despite limited empirical evidence. The current study was designed to expand the empirical evidence surrounding peer support by investigating one of the most widely used and structured peer support resources: Critical Incident Stress Management (CISM). Specifically, the current study with integrated firefighters and paramedics assessed (a) the prevalence of mental disorders; (b) perceptions of high fidelity CISM peer support; and (c) the comparative associations of CISM with high fidelity (n = 91) versus unknown fidelity (n = 60) versus no CISM (n = 64) and mental health. Results indicated that (a) mental disorders are prevalent among PSP irrespective of gender, age, and years of service; (b) participants perceived CISM peer support as offering beneficial and valuable tools (e.g., skills and coping strategies); and (c) high fidelity CISM environments offer some mental health benefits to individuals who screen positive for alcohol use disorder and generalized anxiety disorder. Overall, the current study offers novel information that can inform future directions for evidence-based peer support and policy decisions designed to support the mental health of PSP.

Why Do Public Safety Personnel Seek Tailored Internet-Delivered Cognitive Behavioural Therapy? An Observational Study of Treatment-Seekers

First responders and other public safety personnel (PSP) experience elevated rates of mental disorders and face unique barriers to care. Internet-delivered cognitive behavioural therapy (ICBT) is an effective and accessible treatment that has demonstrated good treatment outcomes when tailored specifically for PSP. However, little is known about how PSP come to seek ICBT. A deeper understanding of why PSP seek ICBT can inform efforts to tailor and disseminate ICBT and other treatments to PSP. The present study was designed to (1) explore the demographic and clinical characteristics, motivations, and past treatments of PSP seeking ICBT, (2) learn how PSP first learned about ICBT, and (3) understand how PSP perceive ICBT. To address these objectives, we examined responses to online screening questionnaires among PSP (N = 259) who signed up for an ICBT program tailored for PSP. The results indicate that most of our sample experienced clinically significant symptoms of multiple mental disorders, had received prior mental disorder diagnoses and treatments, heard about ICBT from a work-related source, reported positive perceptions of ICBT, and sought ICBT to learn skills to manage their own symptoms of mental disorders. The insights gleaned through this study have important implications for ICBT researchers and others involved in the development, delivery, evaluation, and funding of mental healthcare services for PSP.

Effects of anxiety sensitivity, disgust, and intolerance of uncertainty on the COVID stress syndrome: a longitudinal assessment of transdiagnostic constructs and the behavioural immune system

Excessive fear and worry in response to the COVID-19 pandemic (e.g., COVID stress syndrome) is prevalent and associated with various adverse outcomes. Research from the current and past pandemics supports the association between transdiagnostic constructs-anxiety sensitivity (AS), disgust, and intolerance of uncertainty (IU)-and pandemic-related distress. Recent research suggests a moderating effect of disgust on the relationship of AS-physical concerns and COVID-19-related distress, suggesting that transdiagnostic constructs underlie individual differences in activation of the behavioral immune system (BIS). No previous study has examined the independent and conjoint effects of pre-COVID-19 AS-physical concerns, disgust propensity (DP), disgust sensitivity (DS), and IU in this context; thus, we did so using longitudinal survey data (N = 3,062 Canadian and American adults) with simple and moderated moderations controlling for gender, mental health diagnosis, and COVID-19 diagnosis. Greater AS-physical concerns, DP, and DS predicted more severe COVID stress syndrome assessed one month later. Either DP or DS further amplified the effect of AS-physical concerns on COVID stress syndrome, except danger and contamination fears. IU did not interact with AS-physical concerns and DS or DP. Theoretical and clinical implications pertaining to delivery of cognitive behavioural therapy for pandemic-related distress are discussed.

Worry, avoidance, and coping during the COVID-19 pandemic: A comprehensive network analysis

BACKGROUND

Many psychological factors play a role in the COVID-19 pandemic, including various forms of worry, avoidance, and coping. Adding to the complexity, some people believe the threat of COVID-19 is exaggerated. We used network analysis to investigate how these diverse elements are interrelated.

METHODS

A population-representative sample of 3075 American and Canadian adults completed an online survey, including measures of COVID-19-related worry, avoidance, self-protective behaviors, and other variables.

RESULTS

The network contained three major hubs, replicated across gender and age groups. The most important hub centered around worries about the dangerousness of COVID-19, and formed the core of the previously identified COVID Stress Syndrome. The second most important hub, which was negatively correlated with the first hub, centered around the belief that the COVID-19 threat is exaggerated, and was associated with disregard for social distancing, poor hand hygiene, and anti-vaccination attitudes. The third most important hub, which was linked to the first hub, centered around COVID-19-related compulsive checking and reassurance-seeking, including self-protective behaviors such as panic buying and use of personal protective equipment.

CONCLUSION

Network analysis showed how various forms of worry, avoidance, coping, and other variables are interrelated. Implications for managing disease and distress are discussed.

Reactions to COVID-19: Differential predictors of distress, avoidance, and disregard for social distancing

BACKGROUND

Recent psychological research into the effects of COVID-19 has focused largely on understanding excessive fear reactions ("over-responses"). Equally important, but neglected phenomena concern "under-responses", in which people downplay the significance of COVID-19. People who do not take the pandemic seriously may be less likely to adhere to social distancing policies. The present study is, to our knowledge, the first to investigate the differential predictors of over- and under-responses to COVID-19.

METHODS

A large community sample from the United States and Canada (N = 6,854) completed measures of beliefs associated with over- and under-responses, along with measures of distress, excessive avoidance, and nonadherence to social distancing. Over-response beliefs were assessed by scales measuring beliefs about the dangerousness of COVID-19 (personal health and socio-economic threats) and COVID-19-related xenophobia (beliefs that foreigners are spreading the virus). Under-response beliefs were assessed by scales measuring beliefs that the threat of COVID-19 has been exaggerated, and beliefs that one is sufficiently healthy to be robust against the effects of COVID-19.

RESULTS

In regression analyses, medium or large effects were obtained whereby over-response beliefs predicted distress (including distress associated with self-isolation) and excessive avoidance during the pandemic, whereas under-response beliefs predicted the disregard for social distancing.

LIMITATIONS

This study relied on self-reported cross-sectional data and focused on extreme forms of disregard for social distancing guidelines, CONCLUSION: : It is important to understand under-responses to COVID-19 and how these relate to distress, excessive avoidance, and nonadherence to social distancing. Implications for addressing the problems of over- and under-response are discussed.

A Proactive Approach for Managing COVID-19: The Importance of Understanding the Motivational Roots of Vaccination Hesitancy for SARS-CoV2

Importance

Vaccination hesitancy—the reluctance or refusal to be vaccinated—is a leading global health threat (World Health Organization, 2019). It is imperative to identify the prevalence of vaccination hesitancy for SARS-CoV2 in order to understand the scope of the problem and to identify its motivational roots in order to proactively prepare to address the problem when a vaccine eventually becomes available.

Objective

To identify (1) the prevalence of vaccination hesitancy for a SARS-CoV2 vaccine, (2) the motivational roots of this hesitancy, and (3) the most promising incentives for improving the likelihood of vaccination uptake when a vaccine does become available.

Design, Setting, and Participants

A cross-sectional sample of 3,674 American and Canadian adults assessed during the COVID-19 pandemic in May 2020.

Main Outcomes

Measures of vaccination intention (i.e., “If a vaccine for COVID-19 was available, would you get vaccinated?”), attitudes toward vaccines in general and specific to SARS-CoV2 using the Vaccination Attitudes Examination Scale, and incentives for getting vaccinated for those who reported they would not get vaccinated.

Results

Many American (25%) and Canadian (20%) respondents said that they would not get vaccinated against SARS-CoV2 if a vaccine was available. Non-adherence rates of this magnitude would make it difficult or impossible to achieve herd immunity. Vaccine rejection was most strongly correlated with mistrust of vaccine benefit, and also correlated with worry about unforeseen future effects, concerns about commercial profiteering from pharmaceutical companies, and preferences for natural immunity. When asked about incentives for getting vaccinated, respondents were most likely to report that evidence for rigorous testing and safety of the vaccine were of greatest importance.

Conclusions and Relevance

Vaccination hesitancy is a major looming problem for COVID-19. To improve vaccine uptake, it is imperative that the vaccine is demonstrated to the public to be rigorously tested and not perceived as rushed or premature in its dissemination.

Fear and avoidance of healthcare workers: An important, under-recognized form of stigmatization during the COVID-19 pandemic

BACKGROUND

During past disease outbreaks, healthcare workers (HCWs) have been stigmatized (e.g., shunned, ostracized) by members in their community, for fear that HCWs are sources of infection. There has been no systematic evaluation of HCW stigmatization during the COVID-19 pandemic.

METHODS

Non-HCW adults from the United States and Canada (N = 3551) completed an online survey, including measures of HCW stigmatization, COVID Stress Syndrome, and avoidance.

RESULTS

Over a quarter of respondents believed that HCWs should have severe restrictions placed on their freedoms, such as being kept in isolation from their communities and their families. Over a third of respondents avoided HCWs for fear of infection. Participation in altruistic support of HCWs (i.e., evening clapping and cheering) was unrelated to stigmatizing attitudes. Demographic variables had small or trivial correlations with HCW stigmatization. People who stigmatized HCWs also tended to avoid other people, avoid drug stores and supermarkets, and avoid leaving their homes. Factor analysis suggested that HCW stigmatization is linked to the COVID Stress Syndrome.

CONCLUSION

Fear and avoidance of HCWs is a widespread, under-recognized problem during the COVID-19 pandemic. It is associated with the COVID Stress Syndrome and might be reduced by interventions targeting this syndrome.

Do pre-existing anxiety-related and mood disorders differentially impact COVID-19 stress responses and coping?

BACKGROUND

People with pre-existing mental health conditions may be more susceptible to stressors associated with COVID-19 relative to the general population; however, no studies have assessed whether susceptibility differs between classes of mental health disorders. We assessed COVID-19-related stress, self-isolation stressors, and coping in those with a primary anxiety-related disorder diagnosis, a primary mood disorder diagnosis, and no mental health disorder.

METHODS

Adults from a population-representative sample from the United States and Canada who reported current (past year) anxiety-related (n = 700) or mood (n = 368) disorders were compared to a random sample of respondents who did not report a current mental health diagnosis (n = 500) on COVID-19-related stress, self-isolation stress, and coping.

RESULTS

The anxiety-related disorders group exhibited higher COVID Stress Scales total scores and higher scores on its fears about danger and contamination, socioeconomic consequences, xenophobia, and traumatic stress symptoms scales than the other groups. The mood disorders group had higher scores on the traumatic stress symptoms and socioeconomic consequences scales than those with no current mental disorder. Those with current anxiety-related or mood disorders were more likely to voluntarily self-isolate and were more likely to report greater self-isolation stressors and distress than those without a mental health disorder. Yet, there were no major differences in perceived effectiveness of coping strategies across groups.

CONCLUSION

People with anxiety-related or mood disorders were more negatively affected by COVID-19 compared to those with no mental health disorder; however, adding to psychological burden, those with anxiety-related disorders reported greater fears about danger and contamination, socioeconomic consequences, xenophobia, and traumatic stress symptoms than the other groups. These findings suggest the need for tailoring COVID-19-related mental health interventions to meet the specific needs of people with pre-existing mental health conditions.

COVID stress syndrome: Concept, structure, and correlates

BACKGROUND

Research shows that the COVID Stress Scales have a robust multifactorial structure, representing five correlated facets of COVID-19-related distress: (a) Fear of the dangerousness of COVID-19, which includes fear of coming into contact with fomites potentially contaminated with SARSCoV2, (b) worry about socioeconomic costs of COVID-19 (e.g., worry about personal finances and disruption in the supply chain), (c) xenophobic fears that foreigners are spreading SARSCoV2, (d) traumatic stress symptoms associated with direct or vicarious traumatic exposure to COVID-19 (nightmares, intrusive thoughts, or images related to COVID-19), and (e) COVID-19-related compulsive checking and reassurance seeking. These factors cohere to form a COVID stress syndrome, which we sought to further delineate in the present study.

METHODS

A population-representative sample of 6,854 American and Canadian adults completed a self-report survey comprising questions about current mental health and COVID-19-related experiences, distress, and coping.

RESULTS

Network analysis revealed that worry about the dangerousness of COVID-19 is the central feature of the syndrome. Latent class analysis indicated that the syndrome is quasi-dimensional, comprising five classes differing in syndrome severity. Sixteen percent of participants were in the most severe class and possibly needing mental health services. Syndrome severity was correlated with preexisting psychopathology and with excessive COVID-19-related avoidance, panic buying, and coping difficulties during self-isolation.

CONCLUSION

The findings provide new information about the structure and correlates of COVID stress syndrome. Further research is needed to determine whether the syndrome will abate once the pandemic has passed or whether, for some individuals, it becomes a chronic condition.

Development and initial validation of the COVID Stress Scales

Research and clinical observations suggest that during times of pandemic many people exhibit stress- or anxiety-related responses that include fear of becoming infected, fear of coming into contact with possibly contaminated objects or surfaces, fear of foreigners who might be carrying infection (i.e., disease-related xenophobia), fear of the socio-economic consequences of the pandemic, compulsive checking and reassurance-seeking regarding possible pandemic-related threats, and traumatic stress symptoms about the pandemic (e.g., nightmares, intrusive thoughts). We developed the 36-item COVID Stress Scales (CSS) to measure these features, as they pertain to COVID-19. The CSS were developed to better understand and assess COVID-19-related distress. The scales were intentionally designed so they could be readily adapted for future pandemics. The CSS were developed and initially validated in population-representative samples from Canada (N = 3479) and the United States (N = 3375). A stable 5-factor solution was identified, corresponding to scales assessing COVID-related stress and anxiety symptoms: (1) Danger and contamination fears, (2) fears about economic consequences, (3) xenophobia, (4) compulsive checking and reassurance seeking, and (5) traumatic stress symptoms about COVID-19. The scales performed well on various indices of reliability and validity. The scales were intercorrelated, providing evidence of a COVID Stress Syndrome. The scales offer promise as tools for better understanding the distress associated with COVID-19 and for identifying people in need of mental health services.

Abstract P5-11-07: The significance of androgen receptor co-expression in ER+ metastatic breast cancer patients treated with palbociclib

Background: The PALOMA-1 and PALOMA-3 studies demonstrated a significant progression-free survival (PFS) advantage for palbociclib, a CDK4/6 inhibitor, in combination with letrozole or fulvestrant in the first or second line setting compared to these therapies alone in estrogen receptor (ER)+, HER2-negative metastatic breast cancer (MBC). Recent studies have revealed preliminary efficacy signals for androgen receptor (AR) blockade in MBC, predominately in AR+, triple negative patients. We sought to further evaluate AR expression and its significance in ER+ MBC patients treated with palbociclib early in their metastatic treatment course.

Methods: A retrospective review identified 22 patients treated with palbociclib for ER+, HER2- MBC after its FDA approval between January 1st, 2015 and October 1st, 2016 at our center with available pre-treatment tumor samples for analysis. Records were reviewed and clinical characteristics for each patient were analyzed. Archival tumor tissue was tested for AR, phosphorylated retinoblastoma (pRb), CDK6, p16, and CyclinE1 by immunohistochemistry assay for each patient. For AR, nuclear staining >0% was considered positive. For all other IHC studies, intensity of staining >2+ or staining in >10% of cells was considered positive.

Results: The median age was 63.5 years (range 34-84); 23% were ≥ age 70. Our cohort was 35% African American, 60% Caucasian, and 5% Asian American. 64% of patients were post-menopausal and 59% had visceral metastases. 45% of patients were on their first line of treatment, 23% second line, and 32% third line. 68% of patients were on an aromatase inhibitor. Median follow up was 18.7 months (95% CI 13.9, 23.3 months). The AR was expressed in 59% of patients; 55% had expression >10% and 41% had expression >20%. AR+ patients were significantly more likely to experience event-free survival (EFS) (HR 0.26, p=0.01), with a median EFS of 18.8 months (AR- median EFS 5.4 months). AR expression was significantly associated with expression of pRb (100% of AR+ patients, p=0.02). CDK6, p16, and CyclinE1 expression were not associated with AR expression or EFS.

Conclusions: Our data show preliminary evidence of the significance of ER and AR co-expression in ER+, HER2- MBC. ER+, AR+ patients have significantly improved EFS when treated with palbociclib and endocrine therapy as compared with AR-, ER+ patients. There is evidence that AR expression is associated with pRB expression, which may represent a mechanism by which cell cycle inhibition with palbociclib is particularly efficacious in these patients. AR expression rates in ER+, HER2- MBC are significant, and may provide rationale for combining CDK4/6 inhibitors with AR targeting as a subsequent line of targeted therapy in these patients before cytotoxic chemotherapy is initiated. Further studies based on these results are underway.

Citation Format: Landry CA, Ru M, Jaffer S, Dimitrova M, Tiersten A. The significance of androgen receptor co-expression in ER+ metastatic breast cancer patients treated with palbociclib [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-11-07.

Long term hypoxia suppresses reproductive capacity in the estuarine fish, Fundulus grandis

Human nutrient input has significantly altered dissolved oxygen (DO) cycles in coastal waters such that summertime hypoxia (DO <2 mg/L) and anoxia of bottom water are common worldwide. Prolonged hypoxia usually reduces metabolic rate in fish and potentially reduces reproduction, particularly in a spring and summer spawning species such as the Gulf killifish, Fundulus grandis. To evaluate the effects of long term hypoxia on reproduction, Gulf killifish were subjected to either normoxia (6.68+/-2.1 mg/L DO) or hypoxia (1.34+/-0.45 mg/L DO) for one month. Fecundity, growth, gonadosomatic index (GSI), circulating sex steroids (testosterone, T; 11-ketotestosterone, 11KT; and estradiol-17beta, E2), and egg yolk protein (vitellogenin, VTG) were measured. Hypoxia significantly reduced growth and reproduction. E2 was 50% lower in females and 11KT was 50% lower in males, although the precursor hormone T was unchanged in either sex after hypoxic exposure. Hypoxia-exposed females produced significantly fewer eggs and initiated spawning later than control fish. Plasma VTG concentration was unchanged, suggesting that hypoxia may delay VTG uptake by oocytes. Long term laboratory exposure clearly suppressed reproductive capacity in Gulf killifish. Wild populations experience cyclic hypoxia which could have equivalent effects if daily hypoxic periods are long and frequent - a potential consequence of anthropogenic nutrient enrichment in marsh systems.