Editorial: Transdisciplinary Innovation

This special issue includes a rich and nuanced set of takeaways for practitioners, academics, and members of the public or third sectors. We highlight four of them here, regarding learning, spaces, levels of impact, and partner selection. We nonetheless strongly encourage you to read the entire set of articles to make sure you get a balanced overview of different ways in which transdisciplinary innovation occurs

The Doctor and the Market: About the Influence of Market Reforms on the Professional Medical Ethics of Surgeons and General Practitioners in The Netherlands

To explore whether market reforms in a health care system affect medical professional ethics of hospital-based specialists on the one hand and physicians in independent practices on the other. Qualitative interviews with 27 surgeons and 28 general practitioners in The Netherlands, held 2–3 years after a major overhaul of the Dutch health care system involving several market reforms. Surgeons now regularly advertise their work (while this was forbidden in the past) and pay more attention to patients with relatively minor afflictions, thus deviating from codes of ethics that oblige physicians to treat each other as brothers and to treat patients according to medical need. Dutch GPs have abandoned their traditional reticence and their fear of medicalization. They now seem to treat more in accordance with patients’ preferences and less in accordance with medical need. Market reforms do affect medical professional principles, and it is doubtful whether these changes were intended when Dutch policy makers decided to introduce market elements in the health care system. Policy makers in other countries considering similar reforms should pay attention to these results

Measuring Dysfunctional Attitudes in the General Population: The Dysfunctional Attitude Scale (form A) Revised

The Dysfunctional Attitude Scale (DAS) was designed to measure the intensity of dysfunctional attitudes, a hallmark feature of depression. Various exploratory factor analytic studies of the DAS form A (DAS-A) yielded mixed results. The current study was set up to compare the fit of various factor models. We used a large community sample (N = 8,960) to test the previously proposed factor models of the DAS-A using confirmatory factor analysis. The retained model of the DAS-A was subjected to reliability and validity analyses. All models showed good fit to the data. Finally, a two-factor solution of the DAS-A was retained, consisting of 17 items. The factors demonstrated good reliability and convergent construct validity. Significant associations were found with depression. Norm-scores were presented. We advocate the use of a 17-item DAS-A, which proved to be useful in measuring dysfunctional beliefs. On the basis of previous psychometric studies, our study provides solid evidence for a two-factor model of the DAS-A, consisting of ‘dependency’ and ‘perfectionism/performance evaluation’

Analysis of Blood Stem Cell Activity and Cystatin Gene Expression in a Mouse Model Presenting a Chromosomal Deletion Encompassing Csta and Stfa2l1

The cystatin protein superfamily is characterized by the presence of conserved sequences that display cysteine protease inhibitory activity (e.g., towards cathepsins). Type 1 and 2 cystatins are encoded by 25 genes of which 23 are grouped in 2 clusters localized on mouse chromosomes 16 and 2. The expression and essential roles of most of these genes in mouse development and hematopoiesis remain poorly characterized. In this study, we describe a set of quantitative real-time PCR assays and a global expression profile of cystatin genes in normal mouse tissues. Benefiting from our collection of DelES embryonic stem cell clones harboring large chromosomal deletions (to be reported elsewhere), we selected a clone in which a 95-kb region of chromosome 16 is missing (Del16qB3Δ/+). In this particular clone, 2 cystatin genes, namely Csta and Stfa2l1 are absent along with 2 other genes (Fam162a, Ccdc58) and associated intergenic regions. From this line, we established a new homozygous mutant mouse model (Del16qB3Δ/16qB3Δ) to assess the in vivo biological functions of the 2 deleted cystatins. Stfa2l1 gene expression is high in wild-type fetal liver, bone marrow, and spleen, while Csta is ubiquitously expressed. Homozygous Del16qB3Δ/16qB3Δ animals are phenotypically normal, fertile, and not overtly susceptible to spontaneous or irradiation-induced tumor formation. The hematopoietic stem and progenitor cell activity in these mutant mice are also normal. Interestingly, quantitative real-time PCR expression profiling reveals a marked increase in the expression levels of Stfa2l1/Csta phylogenetically-related genes (Stfa1, Stfa2, and Stfa3) in Del16qB3Δ/16qB3Δ hematopoietic tissues, suggesting that these candidate genes might be contributing to compensatory mechanisms. Overall, this study presents an optimized approach to globally monitor cystatin gene expression as well as a new mouse model deficient in Stfa2l1/Csta genes, expanding the available tools to dissect cystatin roles under normal and pathological conditions

Quality of life in patients with personality disorders seen at an ordinary psychiatric outpatient clinic

BACKGROUND: Epidemiological studies have found reduced health-related quality of life (QoL) in patients with personality disorders (PDs), but few clinical studies have examined QoL in PDs, and none of them are from an ordinary psychiatric outpatient clinic (POC). We wanted to examine QoL in patients with PDs seen at a POC, to explore the associations of QoL with established psychiatric measures, and to evaluate QoL as an outcome measure in PD patients. METHODS: 72 patients with PDs at a POC filled in the MOS Short Form 36 (SF-36), and two established psychiatric self-rating measures. A national norm sample was compared on the SF-36. An independent psychiatrist diagnosed PDs and Axis-I disorders by structured interviews and rated the Global Assessment of Functioning (GAF). All measurements were repeated in the 39 PD patients that attended the 2 years follow-up examination. RESULTS: PD patients showed high co-morbidity with other PDs and Axis I mental disorders, and they scored significantly lower on all the SF-36 dimensions than age- and gender-adjusted norms. Adjustment for co-morbid Axis I disorders had some influence, however. The SF-36 mental health, vitality, and social functioning were significantly associated with the GAF and the self-rated psychiatric measures. Significant changes at follow-up were found in the psychiatric measures, but only on the mental health and role-physical of the SF-36. CONCLUSION: Patients with PDs seen for treatment at a POC have globally poor QoL. Both physical and mental dimensions of the SF-36 are correlated with established psychiatric measures in such patients, but significant changes in these measures are only partly associated with changes in the SF-36 dimensions

Social class and gender patterning of insomnia symptoms and psychiatric distress: a 20-year prospective cohort study

Background: Psychiatric distress and insomnia symptoms exhibit similar patterning by gender and socioeconomic position. Prospective evidence indicates a bi-directional relationship between psychiatric distress and insomnia symptoms so similarities in social patterning may not be coincidental. Treatment for insomnia can also improve distress outcomes. We investigate the extent to which the prospective patterning of distress over 20 years is associated with insomnia symptoms over that period.Methods: 999 respondents to the Twenty-07 Study had been followed for 20 years from approximately ages 36-57 (73.2% of the living baseline sample). Psychiatric distress was measured using the GHQ-12 at baseline and at 20-year follow-up. Gender and social class were ascertained at baseline. Insomnia symptoms were self-reported approximately every five years. Latent class analysis was used to classify patterns of insomnia symptoms over the 20 years. Structural Equation Models were used to assess how much of the social patterning of distress was associated with insomnia symptoms. Missing data was addressed with a combination of multiple-imputation and weighting.Results: Patterns of insomnia symptoms over 20 years were classified as either healthy, episodic, developing or chronic. Respondents from a manual social class were more likely to experience episodic, developing or chronic patterns than those from non-manual occupations but this was mostly explained by baseline psychiatric distress. People in manual occupations experiencing psychiatric distress however were particularly likely to experience chronic patterns of insomnia symptoms. Women were more likely to experience a developing pattern than men, independent of baseline distress. Psychiatric distress was more persistent over the 20 years for those in manual social classes and this effect disappeared when adjusting for insomnia symptoms. Irrespective of baseline symptoms, women, and especially those in a manual social class, were more likely than men to experience distress at age 57. This overall association for gender, but not the interaction with social class, was explained after adjusting for insomnia symptoms. Sensitivity analyses supported these findings.Conclusions: Gender and socioeconomic inequalities in psychiatric distress are strongly associated with inequalities in insomnia symptoms. Treatment of insomnia or measures to promote healthier sleeping may therefore help alleviate inequalities in psychiatric distress. © 2014 Green et al.; licensee BioMed Central Ltd

Professional Service Utilisation among Patients with Severe Mental Disorders

<p>Abstract</p> <p>Background</p> <p>Generally, patients with serious mental disorders (SMD) are frequent users of services who generate high care-related costs. Current reforms aim to increase service integration and primary care for improved patient care and health-care efficiency. This article identifies and compares variables associated with the use by patients with SMD of services offered by psychiatrists, case managers, and general practitioners (GPs). It also compares frequent and infrequent service use.</p> <p>Method</p> <p>One hundred forty patients with SMD from five regions in Quebec, Canada, were interviewed on their use of services in the previous year. Patients were also required to complete a questionnaire on needs-assessment. In addition, data were collected from clinical records. Descriptive, bivariate, and multivariate analyses were conducted.</p> <p>Results</p> <p>Most patients used services from psychiatrists and case managers, but no more than half consulted GPs. Most patients were followed at least by two professionals, chiefly psychiatrists and case managers. Care access, continuity of care, and total help received were the most important variables associated with the different types of professional consultation. These variables were also associated with frequent use of professional service, as compared with infrequent service use. In all, enabling factors rather than need factors were the core predictors of frequency of service utilisation by patients with SMD.</p> <p>Conclusion</p> <p>This study reveals that health care system organisation and professional practice - rather than patient need profiles - are the core predictors of professional consultation by patients with SMD. The homogeneity of our study population, i.e. mainly users with schizophrenia, recently discharged from hospital, may partly account for these results. Our findings also underscored the limited involvement of GPs in this patient population's care. As comorbidity is often associated with serious mental disorders, closer follow-up by GPs is needed. Globally, more effort should be directed at increasing shared-care initiatives, which would enhance coordination among psychiatrists, GPs, and psychosocial teams (including case managers). Finally, there is a need to increase awareness among health care providers, especially GPs, of the level of care required by patients with disabling and serious mental disorders.</p

Tailoring Adjuvant Endocrine Therapy for Postmenopausal Breast Cancer: A CYP2D6 Multiple-Genotype-Based Modeling Analysis and Validation

Purpose: Previous studies have suggested that postmenopausal women with breast cancer who present with wild-type CYP2D6 may actually have similar or superior recurrence-free survival outcomes when given tamoxifen in place of aromatase inhibitors (AIs). The present study established a CYP2D6 multiple-genotype-based model to determine the optimal endocrine therapy for patients harboring wild-type CYP2D6. Methods: We created a Markov model to determine whether tamoxifen or AIs maximized 5-year disease-free survival (DFS) for extensive metabolizer (EM) patients using annual hazard ratio (HR) data from the BIG 1-98 trial. We then replicated the model by evaluating 9-year event-free survival (EFS) using HR data from the ATAC trial. In addition, we employed two-way sensitivity analyses to explore the impact of HR of decreased-metabolizer (DM) and its frequency on survival by studying a range of estimates. Results: The 5-year DFS of tamoxifen-treated EM patients was 83.3%, which is similar to that of genotypically unselected patients who received an AI (83.7%). In the validation study, we further demonstrated that the 9-year EFS of tamoxifentreated EM patients was 81.4%, which is higher than that of genotypically unselected patients receiving tamoxifen (78.4%) and similar to that of patients receiving an AI (83.2%). Two-way sensitivity analyses demonstrated the robustness of the results

The course of untreated anxiety and depression, and determinants of poor one-year outcome: a one-year cohort study

<p>Abstract</p> <p>Background</p> <p>Little is known about the course and outcome of untreated anxiety and depression in patients with and without a self-perceived need for care. The aim of the present study was to examine the one-year course of untreated anxiety and depression, and to determine predictors of a poor outcome.</p> <p>Method</p> <p>Baseline and one-year follow-up data were used of 594 primary care patients with current anxiety or depressive disorders at baseline (established by the Composite Interview Diagnostic Instrument (CIDI)), from the Netherlands Study of Depression and Anxiety (NESDA). Receipt of and need for care were assessed by the Perceived Need for Care Questionnaire (PNCQ).</p> <p>Results</p> <p>In depression, treated and untreated patients with a perceived treatment need showed more rapid symptom decline but greater symptom severity at follow-up than untreated patients without a self-perceived mental problem or treatment need. A lower education level, lower income, unemployment, loneliness, less social support, perceived need for care, number of somatic disorders, a comorbid anxiety and depressive disorder and symptom severity at baseline predicted a poorer outcome in both anxiety and depression. When all variables were considered at the same time, only baseline symptom severity appeared to predict a poorer outcome in anxiety. In depression, a poorer outcome was also predicted by more loneliness and a comorbid anxiety and depressive disorder.</p> <p>Conclusion</p> <p>In clinical practice, special attention should be paid to exploring the need for care among possible risk groups (e.g. low social economic status, low social support), and support them in making an informed decision on whether or not to seek treatment.</p