An Interprofessional Approach to Teaching Advocacy Skills: Lessons from an Academic Medical-Legal Partnership

Medical students and educators recognize that preparing the next generation of health leaders to address seemingly intractable problems like health disparities should include advocacy training. Opportunities to acquire the knowledge and skills needed to effectively advocate at the policy level to promote systems-, community-, and population-level solutions are a critical component of such training. But formal advocacy training programs that develop and measure such skills are scarce. Even less common are interprofessional advocacy training programs that include legal and policy experts to help medical students learn such skills. This 2016–2017 pilot study started with a legislative advocacy training program for preclinical medical students that was designed to prepare them to meet with Capitol Hill representatives about a health justice issue. The pilot assessed the impact of adding an interprofessional education (IPE) dimension to the program, which in this case involved engaging law faculty and students to help the medical students understand and navigate the federal legislative process and prepare for their meetings. Results from the pilot suggest that adding law and policy experts to advocacy-focused training programs can improve medical students’ advocacy knowledge and skills and increase their professional identity as advocates

Web-Based Self-Compassion Training to Improve the Well-Being of Youth With Chronic Medical Conditions: Randomized Controlled Trial

Background:Up to one-third of young people live with chronic physical conditions (eg, diabetes, asthma, and autoimmune disease) that frequently involve recurrent pain, fatigue, activity limitations, stigma, and isolation. These issues may be exacerbated as young people transition through adolescence. Accordingly, young people with chronic illness are at a high risk of psychological distress. Accessible, evidence-based interventions for young people with chronic illnesses are urgently needed to improve well-being, support adaptation, and enhance daily functioning. Self-compassion, which is an adaptive means of relating to oneself during times of difficulty, is a promising intervention target for this population.Objective:This study aims to test the efficacy of a 4-week, self-guided, web-based self-compassion training program for improving well-being among young Australians (aged 16-25 years) living with a chronic medical condition. The primary outcomes were self-compassion, emotion regulation difficulties, and coping; the secondary outcomes were well-being, distress, and quality of life. We also sought to test whether changes in primary outcomes mediated changes in secondary outcomes and gather feedback about the strengths and limitations of the program.Methods:We conducted a single-blind, parallel-group, randomized controlled trial comparing a 4-week, fully automated, web-based self-compassion training program with a waitlist control. Participants were recruited via the internet, and outcomes were self-assessed at 4 (T1) and 12 weeks (T2) after the baseline time point via a web-based survey. A mixed methods approach was used to evaluate the program feedback.Results:Overall, 151 patients (age: mean 21.15, SD 2.77 years; female patients: n=132, 87.4%) were randomized to the intervention (n=76, 50.3%) and control (n=75, 49.7%) groups. The loss–to–follow-up rate was 47.4%, and program use statistics indicated that only 29% (22/76) of young people in the experimental group completed 100% of the program. The main reported barrier to completion was a lack of time. As anticipated, treatment effects were observed for self-compassion (P=.01; partial η2=0.05; small effect); well-being (P≤.001; partial η2=0.07; medium effect); and distress (P=.003; partial η2=0.054; small-medium effect) at the posttest time point and maintained at follow-up. Contrary to our hypotheses, no intervention effects were observed for emotion regulation difficulties or maladaptive coping strategies. Improvements in adaptive coping were observed at the posttest time point but were not maintained at follow-up. Self-compassion, but not emotion regulation difficulties or coping, mediated the improvements in well-being.Conclusions:Minimal-contact, web-based self-compassion training can confer mental health benefits on young people with chronic conditions. This group experiences substantial challenges to participation in mental health supports, and program engagement and retention in this trial were suboptimal. Future work should focus on refining the program content, engagement, and delivery to optimize engagement and treatment outcomes for the target group

The Academic Medical-Legal Partnership: Training the Next Generation of Health & Legal Professionals to Work Together to Advance Health Justice

As the national medical-legal partnership (MLP) movement grows, the need for doctors, nurses, social workers, other health professionals, and lawyers who have the knowledge, skills, and experience to collaborate effectively in this holistic healthcare approach is increasing. Given the unique role that institutions of higher education play in training students as they develop their professional identities, members of the Georgetown University Health Justice Alliance sought to build on prior efforts to define the MLP model by focusing on MLPs that exist in academic settings as a specific type of MLP. This report is based on the results of an environmental scan of MLPs that had evidence of engagement with a medical or law school and reflects the core elements of those MLPs as embodied by their objectives, activities, and unique features. The scan started with prior research conducted by the National Center for Medical-Legal Partnership, which categorized MLPs based on their targeted patient populations and identified eight core elements of infrastructure shared across MLPs. The Health Justice Alliance research team then collected data on the impact of interprofessional MLP learning on core undergraduate and graduate medical education knowledge, attitudes, and skill competencies sets for students. Other reports and articles describing specific MLP programs that create interprofessional education opportunities for law and medical students to learn and practice together also provided foundational background

Conceptualising wellbeing for Australian Aboriginal LGBTQA+ young people

It is likely that young people who are both Aboriginal and Torres Strait Islander and LGBTQA+ would be at increased risk for poor mental health outcomes due to the layered impacts of discrimination they experience; however, there is very little empirical evidence focused on the mental health and wellbeing of Aboriginal and Torres Strait Islander LGBTQA+ young people. The current study represents a qualitative exploration of wellbeing among Aboriginal LGBTQA+ young people. This study consisted of semi-structured interviews and focus groups with Aboriginal LGBTQA+ young people aged 14–25 years old in the Perth metropolitan area of Western Australia. Thematic analysis identified seven major themes that were significant to participants’ wellbeing: identity, family, community, visibility, services, stigma and navigating

Juegos serios para el tratamiento o la prevención de la depresión: una revisión sistemática

Serious games (computerised interventions which utilise gaming for serious purposes) have been shown to support improved outcomes in several health conditions. We aimed to review evidence regarding serious games for depression. We undertook electronic searches of PsycInfo, EMBASE and Medline, using terms relevant to computer games and depression. We included fulltext articles published in English in peer-reviewed literature since 2000, where the intervention was designed to treat or prevent depression and which included pre-and post-intervention measurement of depression. Nine studies relating to a total of six interventions met inclusion criteria. Most studies were small and were carried out by the developers of the programs. All were tested with young people (ages between 9 and 25 years). Most reported promising results with some positive impact on depression although one universal program had mixed results. Serious gaming interventions show promise for depression, however evidence is currently very limited.Se ha demostrado que los juegos serios (intervenciones computarizadas que utilizan juegos) mejoran los resultados en diferentes problemas de salud. Pretendemos examinar las evidencias de estos juegos para la depresión. Se realizaron búsquedas electrónicas en PsycINFO, EMBASE y Medline usando términos relacionados con juegos de ordenador y depresión. Se incluyeron artículos publicados desde el año 2000, donde se diseñó la intervención para tratar o prevenir la depresión incluyendo medidas pre- y post-intervención. Nueve estudios sobre un total de seis intervenciones cumplieron los criterios de inclusión. La mayoría de estos fueron pequeños y los llevaron a cabo los desarrolladores de los programas. Todos incluían población joven (9 - 25 años). La mayoría presentan resultados prometedores con un impacto positivo sobre la depresión aunque un programa universal tuvo resultados mixtos. Se concluye que las intervenciones basadas en juegos serios son prometedoras para la depresión, aunque la evidencia es todavía muy limitada

School-based depression and anxiety prevention programs for young people: A systematic review and meta-analysis

Depression and anxiety often emerge for the first time during youth. The school environment provides an ideal context to deliver prevention programs, with potential to offset the trajectory towards disorder. The aim of this review was to provide a comprehensive evaluation of randomised-controlled trials of psychological programs, designed to prevent depression and/or anxiety in children and adolescents delivered in school settings. Medline, PsycINFO and the Cochrane Library were systematically searched for articles published until February 2015. Eighty one unique studies comprising 31,794 school students met inclusion criteria. Small effect sizes for both depression (g = 0.23) and anxiety (g = 0.20) prevention programs immediately post-intervention were detected. Small effects were evident after 12-month follow-up for both depression (g = 0.11) and anxiety (g = 0.13). Overall, the quality of the included studies was poor, and heterogeneity was moderate. Subgroup analyses suggested that universal depression prevention programs had smaller effect sizes at post-test relative to targeted programs. For anxiety, effect sizes were comparable for universal and targeted programs. There was some evidence that externally-delivered interventions were superior to those delivered by school staff for depression, but not anxiety. Meta-regression confirmed that targeted programs predicted larger effect sizes for the prevention of depression. These results suggest that the refinement of school-based prevention programs have the potential to reduce mental health burden and advance public health outcome

Computerised cognitive behavioural therapy for gender minority adolescents: Analysis of the real-world implementation of SPARX in New Zealand

Objective: SPARX is a form of computerised cognitive behavioural therapy (CBT) in serious game format funded via the Ministry of Health to be freely available in New Zealand. At registration users identify themselves as male, female, transgender or another option. We aimed to establish whether adolescent transgender users of SPARX, compared to adolescent male and female users, were more likely to have high mental health needs at baseline and were more likely to complete SPARX. We also sought to determine transgender adolescents’ reductions in depressive symptoms after using SPARX. Methods: Quantitative analysis of five years of usage data from the nation-wide delivery of SPARX in New Zealand. Results: There were 9079 adolescents who completed the registration process and used SPARX, 2.3% (n=207) identified as transgender. The majority of transgender registrants (69.0%) completing a baseline Patient Health Questionnaire - modified for Adolescents (PHQ-A) were categorised as having high mental health needs, significantly more so than male and female registrants (p<0.001). Over half of SPARX registrants completed the first module of the program, with subsequently lower proportions of transgender registrants completing Module 4 (p=0.005) and Module 7 (i.e. the last module, p=0.048). Of those registrants completing a baseline and subsequent PHQ-A, both male (n=247) and female (n=630) registrants, on average, had improvements in their scores (2.68 and 3.15 respectively) whereas transgender registrants (n=14) did not (-0.43) (p=0.048). Conclusion: This is the first study describing the impact of an e-therapy on transgender young people. The analysis of data from this free self-help intervention suggests that: transgender adolescents seeking treatment for depression have particularly high mental health needs; and, an existing well tested tool may be less effective for them than it is for others. Taken together the results appear to suggest targeted efforts may be required for transgender adolescents

Anxiety, depression and swallowing disorders in patients with Parkinson’s disease

Swallowing disturbances (SDs), anxiety and depression are commonly present in Parkinson’s disease (PD) patients. We hypothesized that there is an association between the presence of SDs and the PD affective state. Sixty nine PD patients were assessed for the presence of SDs by undergoing cognitive screening with the Mini Mental State Examination (MMSE), completing three inventories: a swallowing disturbance questionnaire (SDQ), the Spielberger manual for the trait anxiety and Beck depression inventories. All patients underwent clinical swallowing evaluations by a speech and language pathologist (SLP). Patients diagnosed with SDs were also assessed by fiberoptic endoscopic evaluation of swallowing (FEES) performed by an ENT and SLP. Thirty eight patients experienced SDs, the other 31 did not. The clinical characteristics of the two groups were matched. Patients with SDs experienced increased anxiety and depression compared to patients without SDs. Comparisons between patients who scored in the two opposite ends of the anxiety and depression ranges demonstrated that the most anxious and depressed patients reported more swallowing difficulties (SDQ scores) compared with the least anxious and depressed ones. In addition, the most anxious patients had significantly increased disease severity and decreased MMSE scores compared with the least anxious patients. Disease severity was also increased in the most depressed patients compared with the least depressed ones. Advanced disease emerged as being associated with high anxiety levels and greater numbers of SDs. The contribution of anxiety or depression to the development or worsening of SDs and their role in treatment strategy warrant further investigation

Preventing Depression in Final Year Secondary Students: School-Based Randomized Controlled Trial

BACKGROUND: Depression often emerges for the first time during adolescence. There is accumulating evidence that universal depression prevention programs may have the capacity to reduce the impact of depression when delivered in the school environment. OBJECTIVE: This trial investigated the effectiveness of SPARX-R, a gamified online cognitive behavior therapy intervention for the prevention of depression relative to an attention-matched control intervention delivered to students prior to facing a significant stressor-final secondary school exams. It was hypothesized that delivering a prevention intervention in advance of a stressor would reduce depressive symptoms relative to the control group. METHODS: A cluster randomized controlled trial was conducted in 10 government schools in Sydney, Australia. Participants were 540 final year secondary students (mean 16.7 [SD 0.51] years), and clusters at the school level were randomly allocated to SPARX-R or the control intervention. Interventions were delivered weekly in 7 modules, each taking approximately 20 to 30 minutes to complete. The primary outcome was symptoms of depression as measured by the Major Depression Inventory. Intention-to-treat analyses were performed. RESULTS: Compared to controls, participants in the SPARX-R condition (n=242) showed significantly reduced depression symptoms relative to the control (n=298) at post-intervention (Cohen d=0.29) and 6 months post-baseline (d=0.21) but not at 18 months post-baseline (d=0.33). CONCLUSIONS: This is the first trial to demonstrate a preventive effect on depressive symptoms prior to a significant and universal stressor in adolescents. It demonstrates that an online intervention delivered in advance of a stressful experience can reduce the impact of such an event on the potential development or exacerbation of depression.This project was supported by an Australian National Health and Medical Research Council (NHMRC) project grant 1061072 to HC. HC is supported by an NHMRC John Cade fellowship (1056964). ALC and PJB are supported by NHMRC fellowships 1013199 and 108331

Characterization of Coding Synonymous and Non-Synonymous Variants in ADAMTS13 Using Ex Vivo and In Silico Approaches

Synonymous variations, which are defined as codon substitutions that do not change the encoded amino acid, were previously thought to have no effect on the properties of the synthesized protein(s). However, mounting evidence shows that these “silent” variations can have a significant impact on protein expression and function and should no longer be considered “silent”. Here, the effects of six synonymous and six non-synonymous variations, previously found in the gene of ADAMTS13, the von Willebrand Factor (VWF) cleaving hemostatic protease, have been investigated using a variety of approaches. The ADAMTS13 mRNA and protein expression levels, as well as the conformation and activity of the variants have been compared to that of wild-type ADAMTS13. Interestingly, not only the non-synonymous variants but also the synonymous variants have been found to change the protein expression levels, conformation and function. Bioinformatic analysis of ADAMTS13 mRNA structure, amino acid conservation and codon usage allowed us to establish correlations between mRNA stability, RSCU, and intracellular protein expression. This study demonstrates that variants and more specifically, synonymous variants can have a substantial and definite effect on ADAMTS13 function and that bioinformatic analysis may allow development of predictive tools to identify variants that will have significant effects on the encoded protein