Poor mental health places a burden on individuals and populations. Resilient persons are able to adapt to life's challenges and maintain high quality of life and function. Finding effective ...strategies to bolster resilience in individuals and populations is of interest to many stakeholders.
To synthesize the evidence for resiliency training programs in improving mental health and capacity in 1) diverse adult populations and 2) persons with chronic diseases.
Electronic databases, clinical trial registries, and bibliographies. We also contacted study authors and field experts.
Randomized trials assessing the efficacy of any program intended to enhance resilience in adults and published after 1990. No restrictions were made based on outcome measured or comparator used.
Reviewers worked independently and in duplicate to extract study characteristics and data. These were confirmed with authors. We conducted a random effects meta-analysis on available data and tested for interaction in planned subgroups.
The standardized mean difference (SMD) effect of resiliency training programs on 1) resilience/hardiness, 2) quality of life/well-being, 3) self-efficacy/activation, 4) depression, 5) stress, and 6) anxiety.
We found 25 small trials at moderate to high risk of bias. Interventions varied in format and theoretical approach. Random effects meta-analysis showed a moderate effect of generalized stress-directed programs on enhancing resilience pooled SMD 0.37 (95% CI 0.18, 0.57) p = .0002; I2 = 41% within 3 months of follow up. Improvement in other outcomes was favorable to the interventions and reached statistical significance after removing two studies at high risk of bias. Trauma-induced stress-directed programs significantly improved stress -0.53 (-1.04, -0.03) p = .03; I2 = 73% and depression -0.51 (-0.92, -0.10) p = .04; I2 = 61%.
We found evidence warranting low confidence that resiliency training programs have a small to moderate effect at improving resilience and other mental health outcomes. Further study is needed to better define the resilience construct and to design interventions specific to it.
PROSPERO #CRD42014007185.
The health care industry is increasingly driven by the pursuit of value. The author of this Invited Commentary believes this value is nothing more than a business rebranding of efficiency with little ...connection to care. Overclocked clinicians, increasingly impaired by symptoms of burnout and too focused on documenting, cannot see patients in high definition. The author shows that treatment which is blind to patients' contexts often overwhelms patients with medical errands, a topic absent from medical curricula. Care must not be the means by which health care satisfies its industrial mission but, rather, the end for which it mobilizes its means. In unhurried consultations, clinicians must appreciate and respond sensibly to patients' problematic situation, and care for and about them. Medical training must cultivate future clinicians who value caring over caring for value. Medical educators and trainees at all levels must turn away from industrial health care, toward careful and kind care for all.
Practice guidelines for the endocrine evaluation and treatment of pituitary incidentalomas are presented, including indications for surgery.
Objective:
The aim was to formulate practice guidelines ...for endocrine evaluation and treatment of pituitary incidentalomas.
Consensus Process:
Consensus was guided by systematic reviews of evidence and discussions through a series of conference calls and e-mails and one in-person meeting.
Conclusions:
We recommend that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. We recommend that patients with incidentalomas not meeting criteria for surgical removal be followed with clinical assessments, neuroimaging (magnetic resonance imaging at 6 months for macroincidentalomas, 1 yr for a microincidentaloma, and thereafter progressively less frequently if unchanged in size), visual field examinations for incidentalomas that abut or compress the optic nerve and chiasm (6 months and yearly), and endocrine testing for macroincidentalomas (6 months and yearly) after the initial evaluations. We recommend that patients with a pituitary incidentaloma be referred for surgery if they have a visual field deficit; signs of compression by the tumor leading to other visual abnormalities, such as ophthalmoplegia, or neurological compromise due to compression by the lesion; a lesion abutting the optic nerves or chiasm; pituitary apoplexy with visual disturbance; or if the incidentaloma is a hypersecreting tumor other than a prolactinoma.
Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to ...clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.
Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.
We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.
Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.
clinical trials.gov NCT00949611.
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