Browsing by Author "Hirsh, Adam"

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    A Systematic Approach to Developing Virtual Patient Vignettes for Pediatric Health Equity Research
    (Mary Ann Liebert, 2022-11-22) Mulchan, Siddika S.; Miller, Megan; Theriault, Christopher B.; Zempsky, William T.; Hirsh, Adam; Psychology, School of Science
    Objective: The aim of this study was to describe a systematic approach to developing virtual patient (VP) vignettes for health equity research in pediatric pain care. Methods: VPs were initially developed to depict the body posture and movements of actual children experiencing pain. Researchers and clinicians with expertise in pediatric pain worked closely with a professional animator to portray empirically supported pain expression in four, full-motion, virtual male characters of two races (i.e., White and Black). Through an iterative process, VPs were refined to (1) appear realistic in a clinical setting and (2) display archetypal pain behavior and expression during a 1-min video clip without sound. Text vignettes were developed with consultation from experts in pain care and presented alongside VPs to assess clinical decision-making. VP vignettes were piloted in a sample of pediatric providers (N=13). Results: Informed by the literature and expertise of stakeholders, several revisions were made to improve VPs' facial grimacing and realism before piloting. VPs appeared to accurately capture important aspects of pain expression and behavior common among pediatric patients with pain disorders. Additional refinements to the text vignettes were made based on provider feedback to improve clarity and clinical relevance. Conclusions: This article presents a working framework to facilitate a systematic approach to developing VP vignettes. This framework is a first step toward advancing health equity research by isolating psychosocial and interpersonal factors affecting provider behavior and decision-making. Future research is needed to validate the use of VP vignettes for assessing provider behavior contributing to health inequities for youth with pain disorders.
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    Assessing the Efficacy of Acceptance and Commitment Therapy in Reducing Schema-enmeshment in Fibromyalgia Syndrome
    (2014-09-04) Steiner, Jennifer Leah; Hirsh, Adam; Bigatti, Silvia M.; Ashburn-Nardo, Leslie; Stewart, Jesse C.; Grahame, Nicholas J.
    The presence of a chronic pain condition can have a profound impact on one’s self-concept. Some individuals may have had to make major lifestyle changes. As a result, some people may start to define themselves in terms of their pain, such that their self-schema and pain-schemas become intertwined in a process termed schema-enmeshment. It is thought that schema-enmeshment is related to psychological distress making it a prime target for intervention. Little research has been conducted on interventions to reduce schema-enmeshment. Acceptance-based interventions may be especially appropriate in reducing schema-enmeshment or the connection between self and illness symptoms as these interventions tend to emphasize learning to live with pain and other symptoms and to work toward important life goals rather than continually fighting against the condition and allowing it to control their life. This study is a randomized trial comparing Acceptance and Commitment Therapy (ACT) to education about pain management in a sample of women with Fibromyalgia Syndrome (FMS). The primary aim of this study was to assess the efficacy of ACT in reducing schema-enmeshment between self and pain, as well as enmeshment between self and other symptoms and FMS as a whole. In addition, this study also explored the role of pain acceptance, specifically activity engagement as a mediator of the relationship between treatment group membership and changes in schema-enmeshment. The data was analyzed as an intent-to-treat analysis using the “last measure carried forward” method. Results indicated that the ACT group reported statistically significant differences in self schema-enmeshment with FMS, fatigue, and cognitive symptoms, but not with pain, following the intervention, compared to the educational control group. In each of these cases, the ACT group experienced greater reductions in schema-enmeshment compared to the education group. Interestingly, no statistically significant differences were observed for schema-enmeshment with pain. Statistically significant group differences were also observed for acceptance of pain following the intervention. Finally, a mediational model in which changes in activity engagement (a form of pain acceptance) served as the mediator of the relationship between treatment group and changes in schema-enmeshment with FMS was tested. The model was tested using a bootstrapping method, and results revealed a trend toward a significant indirect effect of changes in activity engagement leading to changes in schema-enmeshment with FMS. Taken together, the results of this study indicate that ACT may be a promising intervention for targeting maladaptive beliefs about the self in relation to illness, especially schema-enmeshment of self with illness and illness symptoms. Additionally, there is evidence that ACT may target key constructs such as activity engagement, which may be related to other cognitive and behavioral changes. Future directions for research and clinical practice related to ACT as an intervention for FMS are discussed in depth.
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    Bias in pain care: What patient variables do providers report as influencing their treatment decisions?
    (2024-10) Rose-McCandlish, Margaret; Hirsh, Adam; Mosher, Catherine; Stewart, Jesse
    Racialized and low socioeconomic status (SES) patients are often under-treated for chronic pain, despite reporting more pain on average. This disparity is likely due to multiple systemic factors, including healthcare provider bias. Providers often treat patients differently for chronic pain depending on the patient’s race and SES, but little is known about providers’ awareness of the extent to which patient demographic variables influence their pain treatment decisions. The present study examined the variables that providers report as influencing their pain treatment decisions, whether these variables group together to form distinct factors, and whether providers who demonstrate racial or socioeconomic bias in their treatment decisions report different patient variables or factors as influencing their treatment decisions compared to providers who did not demonstrate biases. Four hundred thirty-two United States-based physician residents and fellows (“providers”) made treatment decisions for 12 computer-simulated patients with chronic pain who varied by race (Black/White) and SES (high/low). Providers then rated the level to which 15 different variables influenced their treatment decision-making. Robust repeated measures ANOVAs indicated that providers rated patient sex/gender, age, and race as the least influential variables in their pain treatment decisions for the simulated patients. For the factor analysis, I sequentially omitted variables to achieve proper model fit and reliability and arrived at a three-factor solution; I labelled these factors Demographic, Biomedical, and Psychosocial, according to the variables’ conceptual overlap. Robust repeated measures ANOVAs found that reported use of variables did not differ between the providers who demonstrated bias and those who did not demonstrate bias, nor did factor scores for the three factors. The present study suggests that providers have low awareness of the extent to which patient race and SES may influence their clinical decision-making in pain care. Results can help inform future research to improve interventions to reduce the impact of racial and socioeconomic bias on providers’ treatment decisions for patients with chronic pain.
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    Can Hope and Optimism Interventions Be Delivered Online? A Pilot Study in College Students
    (2024-08) Ahamadeen, Naheeda; Rand, Kevin L.; Hirsh, Adam; Salyers, Michelle
    Hope and optimism are associated with many positive life outcomes, including better physical functioning (Cherry et al., 2017), less psychological dysfunction (Shanahan et al., 2021), and general well-being and better academic achievement in college students (Rand et al., 2020). College students in particular are known to struggle with a variety of issues and could benefit from increased hope and optimism. Interventions have been developed to increase hope and optimism, but these have largely been delivered in person. The purpose of this pilot study was to examine the feasibility and acceptability of delivering hope and optimism interventions in an online format to college students. There was mixed evidence of feasibility, but results did suggest online hope and optimism interventions are acceptable to college students. Although 94.3% of participants were retained, only 23% of participants met the active engagement word count requirement across conditions, and only 52.2% of participants adhered to intervention instructions in the hope condition. Acceptability was met across conditions with most participants reporting engagement (89.6%), vividly imagining their scenario (94.3%), thinking carefully about the prompt (95.4%), and putting effort into the task (93.1%). Examining the preliminary efficacy of these interventions showed no differential changes in state measures across conditions, although there were overall changes for hope and optimism across all conditions. Thus, it may be useful to examine these findings further in a fully powered study to determine the efficacy of these interventions.
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    Development of a Patient Centered Outcome Questionnaire for Advanced Lung Cancer Patients
    (2020-05) Krueger, Ellen F.; Mosher, Catherine; Hirsh, Adam; McGrew, John
    Symptom research with advanced lung cancer patients has primarily focused on symptom severity, frequency, and distress; yet, little is known about advanced lung cancer patients’ priorities and success criteria for symptom improvement. To address these gaps in the literature, this study examined these outcomes using a modified Patient Centered Outcomes Questionnaire (PCOQ), which has largely been used with adults with chronic pain. Advanced lung cancer patients (N = 102) were recruited from the Indiana University Simon Cancer Center to participate in a one-time self-report survey, including demographic and medical questionnaires, symptom treatment history, standardized measures of symptom severity and quality of life, and the modified PCOQ focused on eight common symptoms in advanced lung cancer. Cancer information was collected from medical records. My primary aim was to evaluate the construct validity of the PCOQ. As hypothesized, symptom severity ratings on the PCOQ were positively correlated with standardized assessments of the same symptoms as well as functional status. Greater severity of most symptoms on the PCOQ was also correlated with worse quality of life, and greater severity of four symptoms was correlated with having more medical comorbidities. Positive, moderate correlations were found between the severity and importance of seeing improvement in cough, fatigue, sleep problems, and pain on the PCOQ. Patients considered low levels of symptom severity to be acceptable following symptom treatment; no differences were found across the eight symptoms. Latent profile analysis identified four patient subgroups based on the importance of seeing improvement in each of the symptoms: (1) those who rated all symptoms as low in importance (n = 12); (2) those who rated bronchial symptoms and sleep problems as low in importance and all other symptoms as moderately important (n = 29); (3) those who rated nausea and emotional distress as low in importance and all other symptoms as moderately important (n = 23); and (4) those who rated all symptoms as highly important (n = 33). These subgroups were unrelated to demographic and clinical factors, except for functional status. Findings suggest that symptom severity and importance are related yet distinct aspects of the advanced lung cancer symptom experience. Furthermore, patients have heterogeneous priorities for symptom management, which has implications for tailoring treatment.
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    Do health behaviors mediate the relationships between loneliness and health outcomes in caregivers of cancer patients?
    (2013-11-06) Adams, Rebecca Nichole; Mosher, Catherine E.; Rand, Kevin L.; Hirsh, Adam; Grahame, Nicholas J.
    Greater levels of loneliness have shown consistent associations with poorer mental and physical health; however, the reason for these relationships is unknown. Engagement in poorer health behaviors among individuals with higher levels of loneliness is one potential explanation for this relationship. Self-regulation theory suggests that coping with feelings of loneliness may impair attempts to control health behaviors. Caregivers of cancer patients have been found to have poor health behaviors (e.g., inadequate exercise) and high levels of loneliness. Thus, the aim of the study is to examine whether health behaviors mediate the relationships between loneliness and mental and physical health outcomes among caregivers of cancer patients. Methods: A secondary data analysis was conducted using data from a longitudinal study of cancer patients and their family caregivers who were staying at the American Cancer Society’s Hope Lodge. Participants completed self-report questionnaires measuring levels of loneliness, engagement in health behaviors (i.e., exercise and fruit and vegetable consumption), mental and physical health, and demographic and medical characteristics at three time points over a 4-month period. A bootstrapping macro was used to examine the indirect effect of loneliness on mental and physical health via health behaviors. Results: Contrary to hypotheses, exercise and fruit and vegetable consumption did not mediate the relationships between loneliness and physical and mental health among cancer patients’ caregivers. Additional research is needed to determine whether health behaviors partially account for the relationships between loneliness and health outcomes or whether alternate explanations for these relationships should be considered.
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    Effect of Depression Treatment on Health Behaviors and Cardiovascular Risk Factors Among Primary Care Patients with Depression: Data from the eIMPACT Trial
    (2023-12) Schuiling, Matthew D.; Stewart, Jesse; Hirsh, Adam; Wu, Wei
    Background. Although depression is a risk factor for cardiovascular disease (CVD), few clinical trials in people without CVD have examined the effect of depression treatment on CVD-related outcomes. It’s unknown if successful depression treatment improves indicators of CVD risk, such as CVD-relevant health behaviors, traditional CVD risk factors, and CVD events. Methods. We examined data from eIMPACT trial, a phase II randomized controlled trial conducted from 2015-2020. Depressive symptoms, CVD-relevant health behaviors (self-reported CVD prevention medication adherence, sedentary behavior, and sleep quality) and traditional CVD risk factors (blood pressure and lipid fractions) were assessed. Incident CVD events over four years were identified using a statewide health information exchange. Results. The intervention group exhibited greater improvement in depressive symptoms (p < 0.01) and sleep quality (p < 0.01) than the usual care group, but there was no intervention effect on systolic blood pressure (p = 0.36), low-density lipoprotein cholesterol (p = 0.38), high-density lipoprotein cholesterol (p = 0.79), triglycerides (p = 0.76), CVD prevention medication adherence (p = 0.64), or sedentary behavior (p = 0.57). There was an intervention effect on diastolic blood pressure that favored the usual care group (p = 0.02). CVD-relevant health behaviors did not mediate any intervention effects on traditional CVD risk factors. Twenty-two participants (10%) experienced an incident CVD event. The likelihood of an CVD event did not differ between the intervention group (12.1%) and the usual care group (8.3%; HR = 1.45, 95% CI: 0.62-3.40, p = 0.39). Conclusions. Successful depression treatment alone improves self-reported sleep quality but is not sufficient to lower CVD risk of people with depression. Alternative approaches may be needed reduce CVD risk in depression. Trial Registration: ClinicalTrials.gov Identifier: NCT02458690
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    Effect of Depression Treatment on Somatic Depressive Symptoms and Cardiometabolic Biomarkers among People without Diabetes
    (2022-05) Shell, Aubrey Lynn; Stewart, Jesse; Hirsh, Adam; Cyders, Melissa; Considine, Robert
    While depression is a risk factor for type 2 diabetes, little is known about the effect of depression treatment on diabetes risk markers. Using data from the recently completed eIMPACT trial (NCT02458690, supported by R01 HL122245), I examined if depression intervention improves diabetes risk markers and if improvements in somatic depressive symptoms mediate potential intervention effects. 216 participants (primary care patients ≥50 years with depression and elevated cardiovascular disease risk from a safety net healthcare system) were randomized to 12 months of the eIMPACT intervention (modernized collaborative care intervention involving internet cognitive-behavioral therapy [CBT], telephonic CBT, and/or select antidepressants; n=107) or usual primary care for depression (primary care providers supported by embedded behavioral health clinicians and affiliated psychiatrists; n = 109). Given my focus on diabetes risk, I excluded participants who did not attend the post-treatment visit (n = 17) or who had a diabetes history at pre-treatment (n = 73), leaving a final sample of 126 (n=66 intervention, n=60 usual care; Mage = 58 years, 79% women, 50% Black, 47% with income <$10k/year). I computed depressive symptom severity variables from the Hopkins Symptom Checklist-20 (SCL-20) items: hyperphagia (“overeating” item), poor appetite (“poor appetite”), hypersomnia (“sleeping too much”), disturbed sleep (“sleep that is restless or disturbed”) and SCL-15 (mean of items not pertaining to appetite or sleep). I calculated insulin resistance from fasting plasma glucose and insulin using the Homeostasis Model Assessment for Insulin Resistance (HOMA-IR)-2 calculator, body mass index (BMI) from measured height and weight, and plasma concentrations of high-sensitivity C-reactive protein (hsCRP), leptin, and ghrelin using ELISA kits. Parallel mediation analyses revealed that 12 months of modernized collaborative care for depression improved both directions of sleep symptoms but did not improve poor appetite or hyperphagia – the somatic symptom most consistently linked with increases in HOMA-IR, BMI, hsCRP, and leptin. Of the five cardiometabolic biomarkers examined, the eIMPACT intervention decreased only hsCRP and ghrelin. There were no intervention effects on HOMA-IR, BMI, or leptin. In addition, no somatic depressive symptoms mediated intervention effects on the cardiometabolic biomarkers, nor did race moderate any mediation effects. Further research is warranted to determine best practices for targeting hyperphagia and reducing cardiometabolic disease risk among people with depression.
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    Examining the Effects of Contextually-Imposed Cognitive Load on Providers' Chronic Pain Treatment Decisions for Racially and Socioeconomically Diverse Patients
    (2022-08) Anastas, Tracy; Hirsh, Adam; Salyers, Michelle; Stewart, Jesse; Kroenke, Kurt
    Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.
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    Factors underlying metastatic breast cancer patients' perceptions of symptom importance: a qualitative analysis
    (Wiley, 2018-01) Mosher, Catherine E.; Daily, Susan; Tometich, Danielle; Matthias, Marianne S.; Outcalt, Samantha D.; Hirsh, Adam; Johns, Shelley A.; Rand, Kevin; Schneider, Bryan; Mina, Lida; Storniolo, Anna Maria; Newton, Erin; Miller, Kathy; Psychology, School of Science
    The symptom literature in cancer has primarily examined symptom severity, frequency and distress. Assessing cancer patients' perceptions of symptom importance-how important it is for them to see improvement in a symptom following an intervention-and factors influencing these judgments would also inform patient-centred care, but this analysis has not been undertaken. This qualitative study aimed to identify factors underlying perceptions of symptom importance among 25 symptomatic metastatic breast cancer (MBC) patients. Participants were recruited from a cancer centre in the Midwestern USA. Semi-structured interviews focused on patients' rationale for considering common symptoms (i.e., anxiety, sadness, sleep problems, pain or fatigue) to be important. Thematic analyses revealed five interrelated factors underlying MBC patients' perceptions of symptom importance: activity restriction, concentration difficulties, exacerbation of other physical symptoms, symptom-related long-term health concerns and negative impact on their relationships with others. Patients most frequently stated that a physical or psychological symptom was important because of the resulting activity restriction. Additionally, some patients considered pain to be important because it signalled potential long-term health concerns, such as worsening metastatic disease. Findings suggest that clinicians should take into account MBC patients' perceptions of symptom importance and factors underlying these judgments when making shared treatment decisions.