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BackgroundNon-invasive biomarkers of immune checkpoint inhibitor-associated acute tubulointerstitial nephritis (ICI-nephritis) are urgently needed. Because ICIs block immune checkpoint pathways that include cytotoxic T lymphocyte antigen 4 (CTLA4), we hypothesized that biomarkers of immune dysregulation previously defined in patients with congenital CTLA4 deficiency, including elevated soluble interleukin-2 receptor alpha (sIL-2R) and flow cytometric cell-based markers of B and T cell dysregulation in peripheral blood may aide the diagnosis of ICI-nephritis.MethodsA retrospective cohort of patients diagnosed with ICI-nephritis was compared to three prospectively enrolled control cohorts: ICI-treated controls without immune related adverse events, patients not on ICIs with hemodynamic acute kidney injury (hemodynamic AKI), and patients not on ICIs with biopsy proven acute interstitial nephritis from other causes (non-ICI-nephritis). sIL-2R level and flow cytometric parameters were compared between groups using Wilcoxon rank sum test or Kruskal-Wallis test. Receiver operating characteristic curves were generated to define the accuracy of sIL-2R and flow cytometric biomarkers in diagnosing ICI-nephritis. The downstream impact of T cell activation in the affected kidney was investigated using archived biopsy samples to evaluate the gene expression ofIL2RA, IL-2 signaling, and T cell receptor signaling in patients with ICI-nephritis compared to other causes of drug-induced nephritis, acute tubular injury, and histologically normal controls.ResultssIL-2R level in peripheral blood was significantly higher in patients with ICI-nephritis (N=24) (median 2.5-fold upper limit of normal [ULN], IQR 1.9-3.3), compared to ICI-treated controls (N=10) (median 0.8-fold ULN, IQR 0.5-0.9,PP=0.008). A sIL-2R cut-off point of 1.75-fold ULN was highly diagnostic of ICI-nephritis (AUC >96%) when compared to either ICI-treated or hemodynamic AKI controls. By peripheral blood flow cytometry analysis, lower absolute CD8+ T cells, CD45RA+CD8+ T cells, memory CD27+ B cells, and expansion of plasmablasts were prominent features of ICI-nephritis compared to ICI-treated controls. Gene expression forIL2RA, IL-2 signaling, and T cell receptor signaling in the kidney tissue with ICI-nephritis were significantly higher compared to controls.ConclusionElevated sIL-2R level and flow cytometric markers of both B and T cell dysregulation may aid the diagnosis of ICI-nephritis.Key MessagesWhat is already known on this topicThere are no non-invasive biomarkers of immune checkpoint inhibitor-associated nephritis (ICI-nephritis); kidney biopsy, the gold standard for diagnosing ICI-nephritis, can be challenging or even contraindicated given its periprocedural risk. There are mechanistic and clinicopathologic similarities between immune-related adverse events and congenital CTLA4 deficiency.What this study addsEstablished biomarkers of congenital CTLA4 deficiency, including elevated serum sIL-2R level and flow cytometric markers of both B and T cell dysregulation, are promising biomarkers for diagnosis of ICI-nephritis. These markers are not altered in patients treated with immune checkpoint inhibitors who are not experiencing immune-related adverse events.How this study might affect research, practice or policyProspective study with longitudinal sIL-2R and peripheral flow cytometry measurements are needed to validate the result and may limit the need for invasive diagnosis of ICI-nephritis.

BACKGROUND AND AIMS Immune checkpoint inhibitor (ICI) therapy has improved the outcome of advanced melanoma but can also lead to kidney injury. Anti-programmed cell death protein 1 (anti-PD-1) therapy is now used in adjuvant setting for stage 3 melanoma after curative intent surgery, and anti-PD-1 or a combination of anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4)/PD-1 therapy is used in stage 4 melanoma. We aimed to compare the incidence and predictors of adverse kidney outcomes in patients with stage 3 and stage 4 melanoma treated with ICIs. METHOD We conducted a retrospective cohort study including all patients diagnosed with advanced melanoma who initiated ICIs between January 2016 and December 2019 at Mass General Brigham. Acute kidney injury (AKI) was defined as a 1.5-fold rise in creatinine within 1 year of ICI initiation. Sustained AKI was defined as AKI that lasted for > 48 h, and acute interstitial nephritis (AIN) cases (diagnosed by biopsy or clinical criteria) were determined by chart review of all episodes of sustained AKI by two nephrologists. A composite outcome of chronic kidney disease (CKD) was defined by new onset estimated glomerular filtration rate (eGFR) RESULTS A total of 855 patients with advanced melanoma were treated with ICIs between 2016 and 2019. The risk of all-cause AKI was 16.6%. Patients with stage 4 melanoma receiving anti-CTLA-4/PD-1 combination therapy had the highest rates of all-cause AKI (27.2%) and AIN (5.7%). Patients with surgically resected stage 3 melanoma treated with adjuvant anti-PD-1 therapy has the lowest absolute risk of all-cause AKI (7.5%); but the aetiology of AKI was enriched for AIN in stage 3 melanoma (causing 62.5% of all cases of AKI sustained >48 h) (Fig. 1). In the multivariable Fine-Gray model, cancer stage and ICI treatment regimen were the top predictors of AKI. Patients with stage 4 melanoma treated with anti-PD-1 monotherapy were more than two times likely to develop AKI within the first year compared with patients with stage 3 melanoma [aHR 2.18, 95% confidence interval (95% CI) 1.29–3.74; P 4 years, 20% developed the composite CKD outcome. We identified a similar trend across the three cohorts for kidney and non-kidney irAEs: patients with stage 3 and stage 4 melanoma treated with anti-PD-1 monotherapy had similar rates of non-kidney irAEs (60% in stage 3 versus 52.7% in stage 4, P = .2), while patients with stage 4 melanoma treated with anti-CTLA-4/PD-1 combination therapy experienced higher rates of non-kidney irAEs (72%, P = .01). CONCLUSION Anti-CTLA-4/PD-1 combination therapy is associated with a higher risk of all-cause AKI and AIN. Incidence of AIN is similar between patients with stage 3 and stage 4 melanoma receiving anti-PD-1 monotherapy. Among patients with stage 3 melanoma, AKI aetiology is enriched for AIN. Survivors are at high risk of CKD regardless of cancer stage.

Immune checkpoint inhibitors (ICIs) have yielded remarkable responses in patients across multiple cancer types, but often lead to immune related adverse events (irAEs). Although a germline cause for irAEs has been hypothesized, no systematic genome wide association study (GWAS) has been performed and no individual variants associated with the overall likelihood of developing irAEs have yet been identified. We carried out a Genome-Wide Association Study (GWAS) of 1,751 patients on ICIs across 12 cancer types, with replication in an independent cohort of 196 patients and independent clinical trial data from 2275 patients. We investigated two irAE phenotypes: (i) high-grade (3-5) events defined through manual curation and (ii) all detectable events (including high-grade) defined through electronic health record (EHR) diagnosis followed by manual confirmation. We identified three genome-wide significant associations (p−8) in the discovery cohort associated with all-grade irAEs: rs16906115 near IL7 (combined p=1.6×10−11; hazard ratio (HR)=2.1), rs75824728 near IL22RA1 (combined p=6.6×10−9; HR=1.9), and rs113861051 on 4p15 (combined p=1.3×10−8, HR=2.0); with rs16906115 replicating in two independent studies. The association near IL7 colocalized with the gain of a novel cryptic exon for IL7, a critical regulator of lymphocyte homeostasis. Patients carrying the IL7 germline variant exhibited significantly increased lymphocyte stability after ICI initiation than non-carriers, and this stability was predictive of downstream irAEs and improved survival.

Immune checkpoint inhibitors (ICIs) have yielded remarkable responses but often lead to immune-related adverse events (irAEs). Although germline causes for irAEs have been hypothesized, no individual variant associated with developing irAEs has been identified. We carried out a genome-wide association study of 1,751 patients on ICIs across 12 cancer types. We investigated two irAE phenotypes: (1) high-grade (3-5) and (2) all-grade events. We identified 3 genome-wide significant associations (P 5 × 10

Introduction: Preclinical studies indicate that the concurrent use of inhibitors of the renin-angiotensin-aldosterone system (RAAS) may improve outcomes in broad groups of patients with cancer. There are limited data on the association between inhibitors of RAAS and outcomes among patients treated with immune checkpoint inhibitors (ICI). Hypothesis: RAAS inhibitors improve overall survival in patients treated with ICI. Methods: We performed a retrospective study of all patients treated with an ICI in a single academic network. Of 10,903 patients; 5,910 were on any anti-hypertensive medication. Of those on anti-hypertensive therapy, 3,426 were prescribed any RAAS inhibitor during ICI treatment and 2,484 were prescribed other anti-hypertensive medications. The primary outcome was overall survival in the entire cohort and in sub-groups by type of cancer. Results: Thoracic cancer (34%) and melanoma (16%) were the most common types of cancer and programmed cell death protein 1 inhibitor therapy was the most prescribed (76%). Those prescribed a RAAS inhibitor were older, more likely male and had more cardiovascular risk factors. In a Cox proportional hazard model, the concurrent use of RAAS inhibitors was associated with better overall survival (Figure). Among the different cancer types, there was a trend toward better overall survival among patients with gastrointestinal (Hazard Ratio (HR):0.82, [95% Confidence Interval (CI): 0.67-1.01], P=0.057) and genitourinary cancer (HR:0.81, [95% CI: 0.64-1.01], P=0.067). Conclusions: In this large retrospective study, patients who were concomitantly prescribed a RAAS inhibitor during ICI therapy had a better overall survival. The benefit of RAAS inhibitors was primarily noted among patients with gastrointestinal and genitourinary cancers. Prospective randomized trials are warranted to further evaluate and specify the benefit of RAAS inhibitors in cancer patients who receive ICI therapy.

Introduction: Immune checkpoint inhibitors (ICIs) treat an expanding range of cancers and the use of ICIs has been associated with an increase in atherosclerotic cardiovascular disease (ASCVD) events. The mechanisms involved in the increase in ASCVD with ICIs are incompletely understood. These same immune checkpoints targeted for cancer also regulate vascular function, yet there are no data testing the effect of ICIs on blood pressure. Hypothesis: Based on basic data on the role of these immune checkpoints in vascular function, we hypothesize that the use of ICIs would increase systolic and diastolic blood pressure. Methods: This was a single academic medical center study of 8,724 patients treated with an ICI. The primary analysis evaluated whether exposure to ICIs was associated with changes in blood pressure using repeated measures multivariate mixed linear regression models. The secondary analysis evaluated the effect of changes in blood pressure on all cause mortality using Cox proportional hazard models. Results: Of the 8,724 patients, 4,812 (55.2%) had a diagnosis of hypertension at ICI start. The average blood pressure at ICI start was 128.3±18.1/72.5±10.1mmHg. Among the entire cohort, there was a decrease of 2.9 mmHg in systolic blood pressure (95% CI: 2.70-3.02) after starting an ICI, and a drop of 1.6 mmHg (95% CI: 1.52-1.70) in diastolic blood pressure (adjusted, p Conclusions: Among a large cohort of patients, ICI therapy is associated with a drop in systolic and diastolic blood pressure. However, patients who had an increase of at least ≥20 mmHg in systolic blood pressure had lower risk of all-cause death.

Introduction: Myocarditis is as a major immune-related adverse event following the use of immune checkpoint inhibitors (ICI). Global radial strain (GRS) reflects both longitudinal and circumferential fiber shortening but no data exist regarding its utility for diagnosis and risk stratification of ICI-myocarditis. Hypothesis: We hypothesized that GRS from echocardiography data would be reduced in patients with ICI-myocarditis and its reduction would have prognostic implications. Methods: Leveraging a multicenter international registry, we measured GRS from 76 patients with myocarditis and 49 ICI treated patients with no myocarditis. Pre-ICI GRS values were available for 10 cases and 38 controls. Measures were performed in a central laboratory blinded to group and time (TomTec, Germany). Major adverse cardiac event was a composite of cardiogenic shock, cardiac arrest, complete heart block and cardiac death. Results: Groups had similar age (66±15 vs. 63±12 years; p=0.20), sex distribution (male: 72% vs. 61%; p= 0.27) and cancer type (p=0.07). Pre-ICI GRS values were similar between cases and controls (47.4±2.9 vs. 45.4±6.0; p=0.12). A total of 57% of myocarditis patients had LVEF of >50% at presentation. The GRS was lower in patients with myocarditis compared with controls (28.6±6.7 vs. 47±7.4; p Conclusions: Global radial strain is lower in ICI- myocarditis and the magnitude of the reduction is associated with a higher rate of events.

EXECUTIVE SUMMARY Hospitals, physician groups, and other healthcare providers are investing in improved patient care experiences. Prior reviews have concluded that better patient care experiences are associated with less healthcare utilization and better adherence to recommended prevention and treatment, clinical outcomes, and patient safety within hospitals. No comprehensive review has examined the business case for investing in patient experiences. This article reviews the literature on associations between patient experience-measured from the perspective of patients and families-and business outcomes, including patient allegiance and retention, complaints, lawsuits, provider job satisfaction, and profitability. We searched U.S. English-language peer-reviewed articles from January 1990 to July 2019. We followed the preferred reporting items for systematic reviews and meta-analyses guidelines and undertook a full-text review of 564 articles, yielding the inclusion of 40 articles. Our review found that patients with positive care experiences are more likely to return to the same hospital and ambulatory settings for future healthcare needs, retain their health plan, and voice fewer complaints. Associations between patient experiences and profitability or provider job satisfaction were limited/mixed. This suggests that providers can pursue better patient care experiences for the intrinsic value to patients, while also recognizing it is good for intermediate business outcomes: specifically increased recommendations, better patient retention, and fewer complaints. Nursing and physician care, broadly defined, are the only specific aspects of patient experience consistently associated with retention, with evidence pointing to communication and trust as parts of care linked to the intent to return. These aspects of patient experience are also the largest contributors to the overall ratings of a provider or facility.

Objective The purpose of the study was to determine whether resilience, defined by cognitive adaptation theory, predicted emerging adulthood outcomes among youth with and without type 1 diabetes. Methods Youth with ( n = 118) and without type 1 diabetes ( n = 122), who were part of a previous longitudinal study during adolescence, completed on-line questionnaires during their senior year of high school and one and two years later. They were average age 18, 53% female, and 93% white. Questionnaires assessed cognitive adaptation theory (CAT) indicators (self-esteem, mastery, optimism) and psychological, relationship, behavioral, vocational, and, for those with diabetes, diabetes outcomes. Results The CAT index at baseline predicted reduced psychological distress, enhanced psychological well-being, increased friend support, reduced friend conflict, the presence of romantic relationships, reduced likelihood of romantic breakups, higher GPA, higher work satisfaction, and lower work stress during the transition to emerging adulthood. Among those with diabetes, the CAT index predicted better self-care behavior and revealed a marginal relation to better glycemic control. Analyses controlled for baseline levels when appropriate. Findings were stronger one year than two years post high school graduation, and findings were stronger for those with than without diabetes. Youth with diabetes also scored lower on the CAT index than youth without diabetes. Conclusions These findings suggest that the implications of CAT include not only psychological health but also relationship, vocational, and diabetes outcomes. Those who score lower on CAT indicators should be identified as children so that interventions designed to enhance resilience can be implemented.

Objective To examine whether friendship and romantic relationships of emerging adults with type 1 diabetes differed from those of a comparison group, and to determine whether these relationships were associated with psychological and diabetes health outcomes. Methods High school seniors with (n = 122) and without (n = 118) type 1 diabetes were assessed annually for 3 years. Friend and romantic relationship variables, psychological distress, life satisfaction, eating disturbances, and, for those with diabetes, diabetes outcomes were assessed. Results Those with diabetes reported less friend support but similar friend conflict compared with controls. Aspects of romantic relationships and friend relationships were associated with health outcomes, but there were more effects involving romantic relationships. On some indices, romantic support was more beneficial for controls and romantic conflict was more troublesome for those with diabetes. Conclusions Both friendship and romantic relationships were associated with psychological and diabetes outcomes among emerging adults.

Objective To examine the relation of behavioral autonomy to psychological, behavioral, and physical health among emerging adults with and without type 1 diabetes. Methods High school seniors with (n = 118) and without type 1 diabetes (n = 122) completed online questionnaires for three consecutive years. Behavioral autonomy, psychological health, risk behaviors, and diabetes outcomes were assessed. Regression analyses were conducted to predict Time 2 and 3 outcomes, controlling for Time 1 outcomes. Results There were no group differences in behavioral autonomy. Behavioral autonomy predicted better psychological health but only for emerging adults without diabetes. Behavioral autonomy was related to increased risk behavior for both groups. Behavioral autonomy was unrelated to self-care but predicted better glycemic control for females. Conclusions Behavioral autonomy may be beneficial for psychological health, but is related to increased risk behavior. The implications of behavioral autonomy for emerging adults with type 1 diabetes require careful consideration.

There is a need to better understand the posttreatment concerns of the nearly 14 million survivors of cancer alive in the United States today and their receipt of care. Using data from 2,910 posttreatment survivors of cancer from the 2006 or 2010 LIVESTRONG Surveys, the authors examined physical, emotional, and practical concerns, receipt of care, and trends in these outcomes at the population level.89% of respondents reported at least one physical concern (67% received associated posttreatment care), 90% reported at least one emotional concern (47% received care), and 45% reported at least one practical concern (36% received care). Female survivors, younger survivors, those who received more intensive treatment, and survivors without health insurance often reported a higher burden of posttreatment concerns though were less likely to have received posttreatment care. These results reinforce the importance of posttreatment survivorship and underscore the need for continued progress in meeting the needs of this population. Efforts to increase the availability of survivorship care are extremely important to improve the chances of people affected by cancer living as well as possible in the posttreatment period.

Aims The goals of the study were to describe the transition of youth with Type 1 diabetes from paediatric to adult healthcare services, examine the link of this transition with self care and glycaemic control, and distinguish youth who received medical treatment from different physicians in terms of demographic and parent relationship variables. Methods Youth with Type 1 diabetes (n = 118) were enrolled in a prospective study that examined the transition from the paediatric to adult healthcare systems and were evaluated during their senior year of high school (time 1) and 1 year later (time 2). Data on self care, glycaemic control and parent relationship were collected. Results The majority of youth saw a paediatric endocrinologist at both assessments (n = 64); others saw an adult care physician at both assessments (n = 26) or transitioned from a paediatric endocrinologist to an adult care physician (n = 19). Nine youth saw no physician between time 1 and time 2. There were group differences in demographic and parent relationship variables and self-care behaviour and glycaemic control related to the transition of care. Youth who remained in the paediatric healthcare system had the best self care and did not experience declines in glycaemic control over time. Conclusions Early transition from the paediatric healthcare system to the adult healthcare system is associated with psychosocial variables and worse glycaemic control. Future research should identify factors that determine optimal timing and strategies to avoid deterioration of care and control during this transition.

Drug prescriptions need to accurately identify the medications that prescribers intend for pharmacists to dispense. However, the set of computer-interpretable identifiers currently used in electronic prescribing (e-prescribing) does not support the specific needs of the prescribers and pharmacists who conduct e-prescribing transactions. RxNorm, a drug nomenclature from the National Library of Medicine, assigns a rigorously derived, centrally maintained, and publicly available unique identifier to each clinically distinct drug. It therefore has the potential to greatly improve drug identification in e-prescribing transactions. Through laboratory research and pilot testing, the authors evaluated RxNorm's potential to improve how medications are represented in e-prescribing transactions. They found that RxNorm is highly complete for prescription drugs used in ambulatory practice that are within its scope and that it offers substantial efficiency and parsimony gains for communicating health plan formulary information to prescribers. The errors that arose during use were of low clinical significance. In live pilot testing, RxNorm identifiers were successfully added to prescription transactions sent between participating prescribers and pharmacies, and the pharmacies were able to use this information to check for dispensing errors or to disambiguate prescriptions. The authors found that RxNorm appears to provide drug identifiers that more accurately reflect the prescriber's intent than the drug identifier set currently used.

Major depressive disorder (MDD) is a prevalent condition associated with significant burden in terms of reduced quality of life, lower productivity, increased prevalence of other conditions and increased health care costs. We conducted a systematic review and qualitative summary of randomized controlled trials (RCTs) that assessed the effectiveness and safety of acupuncture for the treatment of MDD. We searched the databases PubMed, CINAHL, PsycINFO, Web of Science, Embase, CDSR, CENTRAL, clinicaltrials.gov, DARE, and PILOTS for English-language RCTs published through January 2015. Two independent reviewers screened the identified literature against inclusion and exclusion criteria, abstracted study level data, and assessed the risk of bias and methodological quality of included studies. The quality of the evidence was assessed using GRADE. Eighteen studies met inclusion criteria. Eleven assessed acupuncture as monotherapy, seven as adjunct depression treatment. Intervention approaches and comparators varied. Evidence on the effectiveness and comparative effectiveness of acupuncture to treat MDD for the outcomes depression improvement, measured as scale score differences and the number of responders, is very weak. Acupuncture may be superior to waitlist (low quality of evidence) but findings for effect estimates compared to other comparators are inconclusive. Few studies reported on patients achieving remission. The effect of acupuncture on relapse rates could not be determined. Too few studies assessed quality of life to estimate treatment effects. Reported adverse events were typically mild in nature, but the assessment lacked rigor and studies were not designed to detect rare events.

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

In the United States, many health care systems function independently from one another. Increasing coordination across systems has the potential to vastly improve services and patient outcomes, yet implementing these changes can be challenging, requiring increased communication, interaction, and coordination across systems that typically function independently. Parental depression is one health issue that could benefit greatly from a comprehensive systems approach. The Helping Families Raise Healthy Children initiative is a cross-system quality improvement initiative aimed at improving identification and treatment of families faced with the dual challenge of caregiver depression and early childhood developmental delays. Four main techniques were used to foster and sustain cross-system collaboration and communication: cross-system trainings, regular meetings of collaborative partners, a cross-system learning collaborative for service providers, and two cross-system facilitators. The initiative achieved successful cross-system collaboration, suggesting that these methods may be used in other initiatives to foster similar types of collaboration across systems.

It is not clear from the literature whether children with diabetes have more psychological difficulties than their peers.This study aims to use meta-analysis to determine if children with diabetes differ from children without a chronic illness in a variety of domains reflecting psychological well-being.A meta-analysis was undertaken of 22 studies that compared children with diabetes to a comparison group. Outcomes included depression, anxiety, behavioral problems, and related constructs.Children with diabetes were more likely than comparison groups to experience a variety of psychological difficulties. However, these effects were small to medium in magnitude and were typically smaller among more recent studies and studies with well-matched comparison groups.This meta-analysis suggests that children with diabetes are at slightly elevated risk for psychological difficulties. Future work will need to help identify children at the highest risk, and to identify factors associated with resilience.

Objective To examine the relation of adolescent and parent responsibility distribution for diabetes self-care to psychological and physical health. Methods We interviewed children (mean age 12 years) annually for 3 years and asked parents to complete a questionnaire. Both reported how diabetes self-care was distributed in the family. Amount of responsibility held by the child only, the parent only, and shared between child and parent was calculated. Psychological distress, competence, and diabetes outcomes were assessed at each wave. Results In both cross-sectional and longitudinal (lagged) analyses, multilevel modeling showed that shared responsibility was consistently associated with better psychological health, good self-care behavior, and good metabolic control, whereas child and parent responsibility were not. In some cases, links of shared responsibility to health outcomes were stronger among older adolescents. Conclusions These findings highlight the importance of shared responsibility for diabetes self-care through early to middle adolescence.

Objective To understand how primary care providers (PCPs) perceive barriers to adolescent depression care to inform strategies to increase treatment engagement. Study design We conducted semistructured interviews with 15 PCPs recruited from community pediatric offices with access to integrated behavioral health services (ie, low system-level barriers to care) who participated in a larger study on treating adolescent depression. Interviews addressed PCP perceptions of barriers to adolescents' uptake of care for depression. Interviews were audiorecorded, transcribed, and coded for key themes. Results Although PCPs mentioned several adolescent barriers to care, they thought parents played a critical role in assisting adolescents in accessing mental health services. Important aspects of the parental role in accessing treatment included transportation, financial support, and social support. PCPs perceived that parental unwillingness to accept the depression diagnosis, family dysfunction, and trauma were common barriers. PCPs contrasted this with examples of good family support they believed would enable adolescents to attend follow-up appointments and have a "life coach" at home to help monitor for side effects and watch for increased suicidality when starting antidepressants. Conclusions In this PCP population, which had enhanced access to mental health specialists, PCPs primarily reported attitudinal barriers to adolescent depression treatment, focusing mainly on perceived parent barriers. The results of these qualitative interviews provide a framework for understanding PCP perceptions of parental barriers to care, identifying that addressing complex parental barriers to care may be important for future interventions.

The current study examined the impact of interpersonal conflict on mood and physical symptoms for individuals who scored high on a personality characteristic called unmitigated communion (UC), as compared to individuals who did not score high in UC. UC is defined as a focus on others to the exclusion of the self. Forty-one undergraduate students participated in 7 consecutive nightly interviews. Participants described their social interactions, indicated whether the interaction involved interpersonal conflict, and indicated their distress and physical symptoms at the end of the day. Multilevel modeling analysis demonstrated that conflict adversely affected UC and non-UC individuals similarly on the same day, but had a more negative impact for UC individuals on the following day.

Adolescent depression is an under-recognized public health problem in the United States with serious consequences.1, 2 While almost 12% of all adolescents are diagnosed with major depression or dysthymia,3 only one-third of depressed adolescents receive mental health care.4 Although screening in primary care settings provides one route to identify and offer treatment for adolescents with depression,2, 5 other barriers may intervene to prevent successful treatment initiation, sufficient treatment engagement, and improved outcomes.6, 7 For primary care providers (PCPs) to effectively address adolescent depression and increase the likelihood for treatment initiation and engagement, strategies to better identify and address barriers to care are needed. Teens and parents in primary care settings identify a wide range of both external (e.g. transportation or access) and internal barriers (e.g. negative beliefs and attitudes) to depression care.8, 9 Depressed teens endorse internal barriers including fear of being identified as abnormal or a belief that they do not have a problem.8, 10 Parents may also face internal barriers such as not acknowledging that depression is a problem for the teen7, 9 or feeling guilty that the diagnosis is a result of poor parenting. Barriers most salient for parents differ from barriers identified by teens.9 A study on barriers to depression care among adolescents in primary care found that the top three barriers for parents of depressed teens were trouble making an appointment, high costs, and not wanting care.9 The top three barriers for depressed teens were personal responsibilities at school, home, or work, worry about family’s perceptions, and trouble making an appointment. Both parent and teen barriers predict poor uptake of depression care.7, 9 This study concluded that for PCPs to increase treatment uptake, they should identify and address teen and parent barriers to care. While several studies have investigated barriers to depression care for teens and parents,9–11 we are unaware of studies examining PCPs’ perceptions of these teen and parent barriers. Better understanding PCPs’ perceptions will assist in designing primary care interventions directed toward assisting PCPs in considering teen and parent needs, values, and preferences, thereby increasing initiation of and engagement with mental health care for adolescent depression. This exploratory study examined how PCPs perceive adolescents’ and parents’ beliefs about barriers to care, which may be important to improving the quality of shared decision-making in adolescent depression treatment decisions.

RAND developed a set of four tools to assist with understanding, evaluating, and improving performance of programs that address psychological health and traumatic brain injuries among service members.

Adolescent depression is a serious public health problem which is under-recognized as well as undertreated.1 The primary care setting may be a key place where adolescent mental health concerns can be addressed. Most adolescents have a usual place of health care,2 and up to one-third of adolescents presenting to primary care have an emotional problem, with 14% screening positive for depression.3, 4 Furthermore adolescents with mental health problems more frequently visit their primary care provider (PCP) than do adolescents without mental health problems.5 Understanding how PCPs make treatment decisions for depressed adolescents and identifying the factors that influence these decisions may help increase the initiation of depression treatment in the primary care setting. Current PCP guidelines for adolescent depression recommend active support and monitoring (or watchful waiting) for mild depression, and cognitive behavioral therapy (CBT) and/or selective serotonin reuptake inhibitors (SSRIs) for moderate or severe depression.6-8 CBT is recommended for first-line treatment in the primary care setting,9 especially for moderate depression which may respond to CBT alone.7, 8 SSRIs, which show a greater benefit for lowering depressive symptoms for severely depressed teens compared with moderate or mildly depressed teens, are the first-line treatment for patients with a severe major depressive disorder diagnosis with or without psychotherapy.7, 10 A mental health consultation is also strongly encouraged for severely depressed teens.7 Of note, a recent systematic review and meta-analysis found limited evidence for the effectiveness of antidepressants in children and adolescents, especially at follow-up,11 and there are a small number of trials with positive findings.12 However, many factors beyond treatment guidelines influence PCPs’ treatment decisions for adolescent depression, such as structural barriers to care including poor access to mental health specialists, insurance barriers, and insufficient training in depression management.13 For families in many parts of the United States, access to specialty pediatric mental health care is characterized by long waits for appointments associated with an insufficient and poorly distributed mental health workforce, particularly child psychiatrists.14-16 Many pediatric PCPs lack training in the treatment of depression, and therefore, may lack confidence to prescribe antidepressants independently.17-19 Indeed, studies suggest that only one quarter of pediatric PCPs had recently independently prescribed an SSRI for an adolescent.17, 19 PCPs are particularly likely to refer patients to mental health specialists when symptoms are severe,20, 21 and due to discomfort with prescribing antidepressants,17, 18, 22 may prefer to refer a more severely depressed adolescent to child psychiatry for medication management as opposed to initiating medication themselves. While prior studies have examined PCP treatment decisions for adolescent depression, in many cases structural barriers may have dominated PCP decision-making, reducing the ability to study other PCP-level factors that influence treatment decisions for depressed adolescents. For this reason, we sought to examine this issue in a practice environment with fewer structural barriers due to frequent access to on-site mental health therapists, PCP training in depression diagnosis and management, and communication between PCPs and mental health providers through an integrated electronic health record. The current work addresses this gap by examining PCP beliefs about adolescent depression treatment in a setting with few structural barriers, allowing a clearer perspective on the impact of PCP characteristics and beliefs on their intentions. We examined PCPs’ initial treatment decisions using adolescent depression scenarios, assessing the impact of depression severity and other related factors on these treatment decisions. These other factors were exploratory due to limited research in this area. We hypothesized that PCPs would be sensitive to the severity of adolescent depression, and would alter treatment decisions based on the clinical information available in structured vignettes. We also hypothesized that PCPs with better knowledge of depression and more positive attitudes toward managing psychosocial problems would be more likely to prescribe antidepressants.

Objective This longitudinal study compared emerging adults with and without type 1 diabetes on life path decisions, health behaviors, and psychological well-being during the transition out of high school. Methods Administered questionnaires during the senior year of high school and 1 year later to 117 emerging adults with diabetes and 122 emerging adults without diabetes. Comparisons were conducted with respect to health status, sex, and school status. Results Those with and without diabetes chose similar life paths and engaged in similar levels of risky behaviors, but disturbed sleep increased for males with diabetes only. Having diabetes was not associated with depressive symptoms, loneliness, or bulimic symptoms, but was associated with lower life satisfaction and lower life purpose over time. Conclusions Emerging adults with and without diabetes fare similarly on most dimensions studied during the first year out of high school.

The Helping Families Raise Healthy Children initiative addressed depression among parents of children with early childhood developmental delays, aligning the early intervention and behavioral health systems with a focus on relationship-based care.

Over the past decade, the number of people alive in the United States with a personal history of cancer has surpassed the 12 million mark. As the number of survivors has grown, accordingly, the field of psycho-oncology research and practice has increasingly focused on the post-treatment phase of the cancer trajectory. Post-treatment cancer survivors may experience numerous physical, emotional, and practical challenges that are distinct from the experiences people have earlier in the cancer trajectory near time of diagnosis or during treatment. Though post-treatment survivorship is an evolving field of inquiry and clinical care, there is evidence that psychological concerns are under-addressed in the post-treatment period, with estimates indicating that as many as half of post-treatment cancer survivors do not receive the help they need for emotional or psychological concerns. In this chapter, we review psychological factors in post-treatment cancer survivors and examine a unique data source, the 2010 LIVESTRONG Survey for People Affected by Cancer, to better understand the psychological experiences of post-treatment cancer survivors. The results of the survey suggest that emotional concerns among post-treatment cancer survivors are exceedingly common, and identify a gap between reports of emotional concerns and receipt of care for those concerns. We overview strategies for closing this gap using new innovations in survivorship care, such as survivorship care plans.

Provides overviews and detailed descriptions of 211 programs currently sponsored or funded by the Department of Defense to address psychological health and traumatic brain injury, along with recommendations to maximize program effectiveness.