Interpersonal mechanisms in recurrence of depression

Depression is serious disease, also because of its recurrent nature. Many people who have become depressed once, will become depressed more often. Moreover, the risk of depression seems to increase with every further episode. These observations underline the importance of gaining a better understanding of the mechanisms behind recurrence of depression. The present multidisciplinary project investigates 5 different types of risk factors for recurrence of depression (factors from the fields of personality, social cognition, interpersonal behavior, stress physiology, and interpersonal stress). The objective is to examine whether these factors jointly can explain why people recovered from a depressive episode often become depressed again. Starting point of our investigations is the personality dimension of neuroticism. Neuroticism refers to an assemblage of traits in the sphere of emotional instability, anxiety, sensitivity, moodiness, and worrying. This broad personality concept is intriguing, as it is very consistently associated with depression and various other kinds of distress while it is far from clear why. The present study aims at explicating this vague concept by relating it to factors from the 4 other fields of depression research. We expect that each of these factors explains part of the risk of depression associated with neuroticism. The factors of our interest are selected from an interpersonal point of view. Social factors play a major role in depression; in the development but particularly also in the recovery and the recurrence of the disease. We expect that interpersonal mechanisms also can serve to explain the link between neuroticism and depression. In the field of social cognition we focus on emotion perception. We investigate how patients whose depression is in remission interpret emotional expressions in faces and voices. It is known that depressives have problems with emotion perception; they often make mistakes and have a negative bias. In the field of interpersonal behavior we focus on nonverbal communication. We investigate the degree to which remitted patients and their interaction partners adjust their nonverbal behaviors to each other. People unconsciously tend to mirror each other’s behaviors and to adopt each other’s rhythms. Such matching and synchronization processes appear to be related to the quality of social interactions. Nonverbal adjustment also appears to be related to a more favorable course of the depression. In the field of stress physiology we concentrate on cortisol, the so-called “stress hormone”. Many depressed patients show elevated cortisol levels, as a result of alterations in the hypothalamic-pituitary-adrenal (HPA) axis. This hypercortisolism usually resolves upon remission. In some individuals, however, the HPA axis shows persistent dysregulations. The stress system of these individuals remains hypersensitive. These individuals also have a higher risk to develop another depressive episode. In the field of interpersonal stress we focus on “stressful life events”. These are grave experiences which tend to happen to people now and then. Stressful life events are notorious triggers of depression. Particularly stressful life events in the interpersonal sphere, like a relationship crisis or a death in the family, are known to catalyze the development of depression. Participants of this study were 104 outpatients from the Northern part of the Netherlands, treated for unipolar depression or dysthymia. These participants were subjected to a series of baseline measurements at the outset of the study, when the depression was in remission. These measurements consisted of self-report questionnaires, computer tasks, interviews, and a urine measure. After the baseline session participants were followed-up for 2 years. During this follow-up stressful life events were assessed. Participants also filled out a depression list every 4 weeks during the follow-up. Participants who scored beyond a critical value on this list at two times in succession were called for a diagnostic interview to verify whether the depression indeed had recurred. Results Our attempt to explicate the concept of neuroticism by translating it into more concrete factors from the fields of social cognition, interpersonal behavior, stress physiology, failed. Neuroticism was not related to negative emotion perception, poor nonverbal communication, or a hyperactive HPA axis. These factors (thus) could also not explain why neurotic people are more prone to experience stressful life events and why they have a higher risk of recurrence of depression. Poor nonverbal communication did contribute to the occurrence of stressful life events and –via this route- to the recurrence of depression, which was in accordance with our hypotheses. Also in line with our expectations was the finding that a hyperactive HPA axis and a negative bias in emotion perception reinforce each other and, in this way, increase the risk of recurrence. Separately, however, these factors were not predictive of recurrence

A good learning environment for nursing students in primary health care

Background: Clinical learning is a key part for developing nursingursing education. Previous studies concentrated on hospitals as placement sites. Research results reported in this dissertation identify factors that encourage good learning environments in primary health care (PHC) placements. Aims and methods: The overall aim of the present research was to identify factors that promote good clinical learning environments in PHC settings. Clinical learning environment was investigated from students 'and supervisors' perspectives and their perceptions of the clinical part of nursing education in PHC settings. The present research implemented three quantitative studies (I, II, III) and one qualitative study (IV). In study I investigated district nurses’ (DNs’) student supervision experiences in PHC units before and after implementation of a new supervision model; 98 of 133 DNs (74%) responded to a questionnaire before and 84 (65%) respondes after implementation. In study II validated the Clinical Learning Environment, Supervision, and Nurse Teacher (CLES+T) scale. In study III investigated students’ motivation, total satisfaction, and experience of professional role models associated with dimensions in clinical learning environments. In studies II and III collected data from undergraduate nursing students (n=356) using the CLES+T scale. In study IV interviewed six focus groups with 24 supervisors (DNs); these data provided understanding of student supervision in PHC units. Results: Study I revealed significant need for a new supervision model in PHC units. Supervisors had difficulties staying updated on changes in nursing curricula and experienced insufficient support from universities. They felt that they had to set aside time from their regular duties and get permission from unit managers to supervise students. The supervisors felt confident in the supervisory role, but few had formal educational and academic credentials. After the new supervision model implementation, several supervisors were more satisfied with the supervision organization. The model implementation resulted in improvements within PHC units. Study II confirmed good internal reliability in the CLES+T scale and demonstrated that the five-factor model within the scale is the best-fit model. Supervisory relationship was the most important factor and it strongly correlated with these factors: (i) pedagogical atmosphere and (ii) premises of nursing. Supervisory relationship was moderately correlated with the role of the nurse teacher, and leadership style correlated with PHC units. Study III revealed a statistically significant association between (i) students’ motivation, total satisfaction, and experiences of professional role models and (ii) five dimensions of clinical learning environments. The satisfaction factor had a statistically significant association (effect size was high) with the dimensions; this clearly indicated that students experienced satisfaction. Supervisory relationship and pedagogical atmosphere particularly influenced students’ satisfaction and motivation. Study IV revealed three themes related to supervisors’ experiences during student supervision in PHC units: abandonment, ambivalence, and sharing the holistic approach. Supervisors felt abandoned by their managers, colleagues, and nurse teachers rom universities. They were proud to be DNs and willing to share experiences with students – yet torn between being students’ supervisors and patients’ nurses. Conclusion: This dissertation reports six main factors for good learning environments in PHC units. Supervisors must be prepared and engaged, and students must be motivated. A close, reflective supervisory relationship is one of the most important factors for learning in PHC units. Successful supervision requires clear structure and organization. Adequate support and resources from PHC units are needed for supervisors. Collaboration and liaison between universities and PHC units are needed to link theoretical and practical parts of nurse education. PHC-unit circumstances contribute to holistic nursing care, which is an important factor for student learning. Furthermore, the CLES+T scale was shown to be a reliable tool to use for evaluating PHC settings as clinical learning environment

Seasonality of mood and affect in a large general population sample

Mood and behaviour are thought to be under considerable influence of the seasons, but evidence is not unequivocal. The purpose of this study was to investigate whether mood and affect are related to the seasons, and what is the role of neuroticism in this association. In a national internet-based crowdsourcing project in the Dutch general population, individuals were invited to assess themselves on several domains of mental health. ANCOVA was used to test for differences between the seasons in mean scores on the Positive and Negative Affect Schedule (PANAS) and Quick Inventory of Depressive Symptomatology (QIDS). Within-subject seasonal differences were tested as well, in a subgroup that completed the PANAS twice. The role of neuroticism as a potential moderator of seasonality was examined. Participants (n = 5,282) scored significantly higher on positive affect (PANAS) and lower on depressive symptoms (QIDS) in spring compared to summer, autumn and winter. They also scored significantly lower on negative affect in spring compared to autumn. Effect sizes were small or very small. Neuroticism moderated the effect of the seasons, with only participants higher on neuroticism showing seasonality. There was no within-subject seasonal effect for participants who completed the questionnaires twice (n = 503), nor was neuroticism a significant moderator of this within-subjects effect. The findings of this study in a general population sample participating in an online crowdsourcing study do not support the widespread belief that seasons influence mood to a great extent. For, as far as the seasons did influence mood, this only applied to highly neurotic participants and not to low-neurotic participants. The underlying mechanism of cognitive attribution may explain the perceived relation between seasonality and neuroticism

A Large Skull Defect Due to Gorham-Stout Disease: Case Report and Literature Review on Pathogenesis, Diagnosis, and Treatment

A 24-year old man was referred to the Erasmus MC Bone Center because of an asymptomatic increasing skull defect of the left parietal bone. The defect was first noticed at the age of six, and gradually increased over the years. His medical history was unremarkable, without any known trauma and a negative family history for bone diseases. Laboratory tests showed a low vitamin D level without other abnormalities. Particularly, there was no increase in markers of inflammation or bone turnover. CT-scans of the skull showed an osteolytic region of the parietal skull bone, with a two-centimeter increase in diameter over 9 years. Contrast enhanced MRI showed lymphangiogenic invasion, which was compatible with our suspicion of Gorham-Stout disease. The patient was referred to the neurosurgeon for treatment with a bone graft while considering additional drug treatment. Gorham-Stout or vanishing bone disease is a rare entity characterized by progressive osteolysis with lymphangiogenic bone invasion. Although already reported in 1838, currently the diagnosis and treatment of Gorham-Stout disease is still challenging. The underlying pathophysiology is not clarified yet and several theories exist. The disease usually affects persons younger than 40 years and the majority present with bone disease of the maxillofacial region, the upper extremities or the torso. The clinical presentation includes most frequently pain, swelling, and functional impairment of the affected region, but the disease can also be asymptomatic. Laboratory investigations are usually normal, and diagnosis is based upon imaging and sometimes pathology examination of affected bone tissue. Treatment is experimental and there is no general consensus about the best option due to lack of randomized controlled trials. Case reports showed patients treated with bisphosphonates, interferon-alpha, anti-VEGF therapy, mTOR inhibitors, and radiotherapy. There are some reports of surgery with prosthetic or bone grafts but no long-term follow-up data exist. This paper describes a unique case of Gorham-Stout disease of the parietal skull bone and discusses the current state of knowledge about this rare bone disease

Single-Subject Research in Psychiatry:Facts and Fictions

Scientific evidence in the field of psychiatry is mainly derived from group-based ("nomothetic") studies that yield group-aggregated results, while often the need is to answer questions that apply to individuals. Particularly in the presence of great inter-individual differences and temporal complexities, information at the individual-person level may be valuable for personalized treatment decisions, individual predictions and diagnostics. The single-subject study design can be used to make inferences about individual persons. Yet, the single-subject study is not often used in the field of psychiatry. We believe that this is because of a lack of awareness of its value rather than a lack of usefulness or feasibility. In the present paper, we aimed to resolve some common misconceptions and beliefs about single-subject studies by discussing some commonly heard "facts and fictions." We also discuss some situations in which the single-subject study is more or less appropriate, and the potential of combining single-subject and group-based study designs into one study. While not intending to plea for single-subject studies at the expense of group-based studies, we hope to increase awareness of the value of single-subject research by informing the reader about several aspects of this design, resolving misunderstanding, and providing references for further reading

A qualitative approach to guide choices for designing a diary study

Background: Electronic diaries are increasingly used in diverse disciplines to collect momentary data on experienced feelings, cognitions, behavior and social context in real life situations. Choices to be made for an effective and feasible design are however a challenge. Careful and detailed documentation of argumentation of choosing a particular design, as well as general guidelines on how to design such studies are largely lacking in scientific papers. This qualitative study provides a systematic overview of arguments for choosing a specific diary study design (e.g. time frame) in order to optimize future design decisions. Methods: During the first data assessment round, 47 researchers experienced in diary research from twelve different countries participated. They gave a description of and arguments for choosing their diary design (i.e., study duration, measurement frequency, random or fixed assessment, momentary or retrospective assessment, allowed delay to respond to the beep). During the second round, 38 participants (81%) rated the importance of the different themes identified during the first assessment round for the different diary design topics. Results: The rationales for diary design choices reported during the first round were mostly strongly related to the research question. The rationales were categorized into four overarching themes: nature of the variables, reliability, feasibility, and statistics. During the second round, all overarching themes were considered important for all diary design topics. Conclusions: We conclude that no golden standard for the optimal design of a diary study exists since the design depends heavily upon the research question of the study. The findings of the current study are helpful to explicate and guide the specific choices that have to be made when designing a diary study