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Students (N=40) whose loved one had died by suicide in the past two years, were assessed as to whether writing projects lessen their grief. All participants competed pre- and posttest measures of grief. Determined that writing about grief associated with suicide of a loved one appeared to reduce suicidal grief but did not extend to general grief or physical health. (Author/JDM)

To assess whether writing with cognitive change or exposure instructions reduces depression or suicidality, 121 undergraduates screened for suicidality wrote for 20 minutes on 4 days over 2 weeks. They were randomly assigned to reinterpret or to write and rewrite traumatic events/emotions, or to write about innocuous topics. The three groups (N-98) who completed pre-, post-, and 6week follow-up were not different on suicidality or depression. All subjects reported fewer automatic negative thoughts over the 2 weeks; they also reported higher self-regard but more health center visits at follow-up. Suicidal thoughts may be more resistant than physical health to writing interventions.

No-suicide contracts, in their various forms, can deepen commitment to a positive action, strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assessment, and document precautions. Conversely, they can anger or inhibit the client, introduce coercion into therapy, be used disingenuously, and induce false security in the clinician. Research on no-suicide contracts (frequency surveys, assessments of behavior after contracting, and opinions of users) has limitations common to naturalistic studies, and is now ready for more rigorous methods. Mental health professions should be trained to deal with suicidal individuals, including how to use no-suicide contracts. Good contracts are specific, individualized, collaborative, positive, context-sensitive, and copied. However, they are not a thorough assessment, a guarantee against legal liability, nor a substitute for a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute for sound clinical judgment.

To assess if writing projects lessen undergraduates' grief following a loved one's suicide, 40 students whose loved one died by suicide in the past 2 years wrote on four occasions over 2 weeks about profound topics (e.g., events and emotions surrounding the death) or trivial topics (e.g., description of the previous meal). All participants completed pre- and posttest measures of grief and self-reported health visits, and 75% completed the same measures at 6-week mailed follow-up. As expected, individuals in the profound condition reported less grief associated with suicide at follow-up than those in the trivial condition. However, the trivial and profound groups were not significantly different in general grief or health visits. Writing about grief associated with the suicide of a loved one appeared to reduce suicidal grief associated with this event. However, this benefit did not extend to general grief or physical health.

Writing about traumatic events produces improvement in an array of areas including physical and psychological functioning. To see if these improvements extended to improved bereavement recovery after the accidental or homicidal death of a loved one, 64 undergraduates (51 women, 13 men) began, and 44 completed, a writing project. At pretest, they completed measures of depression, anxiety, grief, impact, and nonroutine health visits. Then, they were randomly assigned to write about either the bereavement experience (profound condition), or innocuous topics (trivial condition). They wrote for 15 minutes a day for four days, then completed the same measures a second time (posttest). Six weeks later, they were mailed the same measures again (follow-up). A 2 (Condition: Profound versus Trivial) x 3(Time: Pre-, Post-, or Follow-up) MANOVA yielded a significant main effect for time, but no main effect for condition and no interaction. Follow-up ANOVAs indicated that, across conditions, from pretest to follow-up testing participants reported less anxiety and depression, less impact, greater grief recovery, but about the same health center visits. A 2 (Condition) x 4(Writing Day) MANOVA and follow-up tests indicated that those in the profound condition reported less subjective distress from Day 1 to Day 3, compared to those in the trivial condition. Combined with Kovac and Range (1999), present results suggest that writing projects may be more beneficial to those experiencing the unique bereavement of suicidal death, rather than those experiencing the nonintentional death of a loved one by accident or homicide.

Background: Known for excellence in care in the last days and hours of life, hospice programs can help individuals have a "good death" and lead to higher family satisfaction with quality of care. Our objective was to evaluate the effectiveness of a multicomponent palliative care intervention based on the best practices of home hospice and designed to improve the quality of care provided for patients dying in an acute care inpatient setting. Methods: This study was a before-after intervention trial conducted between 2001 and 2003. Participants included physician, nursing, and ancillary staff on inpatient services of an urban, tertiary care Veterans Affairs medical center. The palliative care intervention included staff education and support to identify patients who were actively dying and implement care plans guided by a comfort care order set template for the last days or hours of life. Data abstracted from computerized medical records of 203 veterans who died during a 6-month period before (n=108) and after (n=95) intervention were used to determine the impact of intervention on symptom documentation and 5 process of care indicators. Results: There was a significant increase in the mean (SD) number of symptoms documented from 1.7 (2.1) to 4.4 (2.7) (P<.001), and the number of care plans increased from 0.4 (0.9) to 2.7 (2.3) (P<.001). Opioid medication availability increased from 57.1% to 83.2% (P<.001), and do-not-resuscitate orders increased from 61.9% to 85.1% (P<.001). There were nonsignificant changes in the proportion of deaths that occurred in intensive care units (P=.17) and in the use of nasogastric tubes (P=.40), and there was a significant increase in the use of restraints (P<.001). Conclusion: Our results indicate that end-of-life care improved after the introduction of the palliative care program. [ABSTRACT FROM AUTHOR]

Objective: To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs)., Study Design: Controlled, cluster-randomized trial., Methods: Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering., Results: Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention., Conclusions: Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests.

Objective: Nonsteroidal antiinflammatory drug (NSAID) related gastrointestinal (GI) and renal adverse events are commonly reported. Although published guidelines recommend periodic laboratory monitoring, NSAID safety practices of physicians have not been investigated at a population level. We examined the associations of physician specialty and patient characteristics with NSAID safety practices., Methods: Using administrative data and medical record review from a regional managed care organization, we studied a retrospective cohort of 373 frequent NSAID users (> or = 3 consecutive NSAID prescriptions and > or = 1 month of continuous NSAID use and followup). NSAID safety measures included: complete blood count (CBC) testing, creatinine testing, use of GI cytoprotective agents, and lack of simultaneous prescriptions for different NSAID (NSAID overlap)., Results: The mean duration of cumulative NSAID use was 14.4 +/- 7.7 months/patient, patient age was 62.0 +/- 11.4 years, and 63% were women. About two-thirds of patients received CBC (238, 63.8%) and creatinine monitoring (263, 70.5%), one-third (120, 32.2%) were prescribed cytoprotective agents, and one-fourth (97, 26%) had at least one NSAID overlap. After multivariable adjustments, concomitant use of disease-modifying antirheumatic drugs (OR 2.5, 95% CI 1.1-5.8), longer NSAID exposure (OR 1.3, 95% CI 1.1-1.4), and a greater number of physician visits/year (OR 1.1, 95% CI 1.0-1.2) were significantly associated with receipt of a CBC. A history of hypertension (OR 2.0, 95% CI 1.2-3.2), longer NSAID exposure (OR 1.3, 95% CI 1.2-1.4), and more physician visits/year (OR 1.1, 95% CI 1.0-1.2) were significantly associated with serum creatinine testing. Rheumatologists, and to a lesser extent internists, trended toward more NSAID toxicity monitoring than family/general practitioners. However, family/general practitioners and internists were more likely to monitor creatinine than rheumatologists among patients with renal risk factors., Conclusion: While rheumatologists and internists trended toward more CBC and creatinine testing, visit frequency, duration of NSAID use, and comorbidities were the factors most consistently associated with safety monitoring.