Integrating Wellness Programs
into Care of the Chronically Ill
McGrady 2012
What is a Wellness Group?
• Psycho-educational interventions that attempt
to develop motivation, build skills, and
empower patients to improve their physical,
emotional and spiritual health
• Useful to participants with physical or
emotional illness or those currently in good
health
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Why Wellness Groups?
• Behavioral choices are leading
contributors to morbidity and
mortality in the United States
(American Dietetic Association, 2002;; O’Donnell, 2004)
•
Programs are needed that focus
on helping people make positive
lifestyle changes
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Relevance of unhealthy lifestyle ***
• Heart disease
• Cancer
• Stroke
• Respiratory diseases
• Accidents
• Diabetes
*** account for 75% of all
deaths***
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Wellness Areas
Interpersonal
Wellness: Social
Cogntive Wellness:
Mental Stimulation
Emotional and
Spiritual Wellness:
Positive Psychology.
Spirituality
Environmental
Wellness:
Community
Physical
Wellness: Body
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Family Practice Setting
• Setting: Family Medicine Clinic
• Participants: Patients who were in the practice for at least
one year were screened with the Social Readjustment Scale
(SRRS; Holmes & Rahe, 1967)
– Twenty-three patients scored equal to or above 300 (indicating high
risk); signed consent and were randomized
– (Intervention and Control).
• Intervention: Two 90 minute sessions of relaxation and
problem solving
• Results: The intervention group had significantly lower
anxiety scores compared to control.
• (McGrady, Lynch, & Alvarez, 2004)
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Beck Anxiety Inventory
20
18
16
14
12
Baseline
3 months
10
8
6
4
2
0
Treatment
Control
ANCOVA: F(1,21 = 5.2; p < .034)
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Wellness in the Chronically Ill
•
•
•
•
•
Decrease focus on illness
Promote mindfulness
Decrease definition by illness
Increase sense of personal control
Build positive psychology skills
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Sample Techniques
• Educate on effects of stress on symptoms
• Teach mindfulness
• Count blessings instead of burdens
(Emmons, 2003)
• Use simple biofeedback devices
• Practice problem solving
• Increase awareness
• Build on strengths and manage vulnerabilities
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What can be learned from studies
of normal subjects under stress?
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Wellness Programs for Medical Students
Acknowledgements
Julie Brennan, Ph.D.
Kary Whearty, LSW, Paul Schaeffer, M.D.
Daniel Rapport, M.D. Denis Lynch Ph.D.
Funding
David C. and Lura L. Lovell Foundation, Tuscon AZ
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Objectives
1. Discuss the rationale for
implementing wellness programs for
medical students
2. Describe the programs for first &
third year students
3. Summarize the results of the
interventions
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Distress in Medical Students
• Depressive symptoms: 12.9% (higher in
women than in men) (Dahlin et. al. 2005)
• Mental health problems “in need of
treatment”: 14% (Midtgaard et al. 2008).
• Decrements in health behaviors were
predictive of emotional adjustment to medical
school (Ball and Bax 2002)
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Dreams and Reality – the First Year
•
•
•
•
•
Emotional exhaustion
Low sense of accomplishment
Fewer self care behaviors
Depression
Anxiety
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The clinical year
•
•
•
•
•
Increased time demands
Irregular schedules
Compromised self efficacy
Emotional demands of patients
Making a career choice
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Wellness Program at Toledo
• Randomized, controlled study; IRB approved
• Purpose is to
– Determine the effects of a structured wellness
program on measures of depression, anxiety
– Promote healthy behaviors that can be continued
in residency, practice and everyday life.
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Program offered to students
N = 671; 369 men; 302 women
Refused: n = 222
Agreed n = 449
Control group
Intervention
group
August
Post Intervention
Dec.
Follow-up
May
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Post control
Intervention
Refused
Wellness Program
• Structure: 8 sessions
• Session content: self awareness, relaxation,
positive coping, mindfulness.
• Students complete assessment
measures pre and
post intervention and control.
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Assessment Tools
•
•
•
•
Beck Depression Inventory (BDI-II)
Beck Anxiety Inventory (BAI)
Social Readjustment Rating Scale
Evaluation of program
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Session Structure
•
•
•
•
•
Explain purpose of session
Complete worksheet
Discuss worksheet
Emphasize key points
Teach and practice relaxation skill
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Survival Thinking
This session focuses on learning to refute negative, catastrophic,
maladaptive thoughts and development of healthy realistic thinking.
ABC Model
Activating event, Belief pattern, Consequence
The Belief pattern leads to the Consequence, not the Activating event
Self Talk
Positive self talk is useful in keeping up motivation and decreasing fatigue
Worksheet
Negative Thoughts
Effective Counters
I am going to fail.
I will do my best.
I am not as good as that person.
I am proud of my
accomplishments.
Don’t get nervous.
________________
I should have studied more.
________________
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Total
Sample (n=445)
BDI-II
August
BAI
WLE
M (SD)
M (SD)
M (SD)
5.4 (5.3)
5.8 (5.8)
201.5 (139)
BDI-II*
Females (n = 228)
BAI**
WLE
6.1 (5.7)
6.7 (6.2)
208.5 (143)
BDI-II*
Males (n = 215)
BAI**
WLE
4.7 (4.8)
4.8 (5.2)
193.3 (133)
Comparison of males and females
ANOVA *p<.005; **p<.01
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Identification
of the High Risk Group
• Beck Depression Inventory (BDI-II)
– Scores 1 SD above the mean
• Beck Anxiety Inventory (BAI)
– Scores 1 SD above the mean
• Social Readjustment Rating Scale
– Scores 1 SD above the mean
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Comparison of subjects with WLE scores
greater than and not greater than 1 SD
above the mean
BDI-II*
M (SD)
BAI*
M (SD)
WLE≤341
5.0 (4.7) n= 369 5.3 (5.2)
WLE>341
8.6 (7.5) n = 60 9.5 (8.0)
ANOVA:
BDI-II, BAI *p<.001
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Results - Comparisons
• experimental and control groups pre and post
intervention (control)(Aug. vs Dec.)
• high risk group experimental and controls pre
and post intervention (control) (Aug. Vs Dec.)
• experimental group (complete and high risk)
pre, post to follow-up (Aug. vs Dec. vs May)
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BDI-II Experimental vs Control
All Participants – WLE as covariate
BDI-II pre
August
BDI-II post
December
Experimental
Group
5.2 (4.8)
7.6 (5.6)
Control Group
5.7 (5.7)
9.1 (7.4)
Significant group difference
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ANCOVA: p = 0.045
BAI Experimental vs Control
All Participants – WLE as covariate
BAI pre
August
BAI post
December
Experimental
Group
5.7 (5.6)
8.2 (6.3)
Control Group
6.2 (5.8)
7.3 (7.5)
ANOVA: not significant
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BDI-II Experimental vs Control
High Risk Group
BDI-II pre
August
BDI-II post
December
Experimental
Group
9.5 (5.4)
7.8 (5.6)
Control Group
10.9 (7.1)
13.5 (9.7)
ANOVA: significant group difference p = 0.003
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BDI-II Complete Group
Pre
Post Follow-up
Aug.
Dec.
May
Experimental
Group
5.3 (5.7
6.9 (5.5)
5.2 (8.4) *
Control Group
5.4 (5.4)
8.3 (7.1)
6.0 (5.5)*
Control Group: paired t-test: Dec. to May: p < 0.05
Experimental Group: paired t-test: Dec. to May: p < .05
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BDI-II High Risk Group
Pre
Post Follow-up
Aug.
Dec.
May
Experimental
Group
7.3 (5.3)
5.9 (4.5)
4.1 (2.9) *
Control Group
11.4 (7.0)
13.0 (10.5) 7.3 (6.4)*
Control Group: paired t-test: Dec. to May: p < 0.05
Exp. Group: paired t-test: Dec. to May: p < .05
Exp. and Control Groups: Aug. to May: P < .05
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Reasons for dropout
“right now, my
grades are more
important than
my health”.
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Discussion
• This wellness program was beneficial to first
year students.; particularly to those at risk.
• Cumulative life events was an important
predictor of anxiety and depressed mood
• The major effects were on the measure of
depression and not on anxiety, perhaps due
to insufficient relaxation practice.
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Third Year Wellness Session
– Objectives
• Explain the types of stress that third-year
clerks frequently encounter
• Increase awareness of stress responses
and the warning signs of overload
• Learn simple relaxation to build on
existing psychological coping skills
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Increasing Awareness
• Individual response devices were used to answer
questions anonymously
• Data:
*Stress Response
*Self-care habits
*Finger temperature
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*Tension in body
*PHQ-2, GAD-2
Social Norms
• Students were given feedback and information
– How the group scored on each question through
use of bar graphs
– Cut-off scores for PHQ-2 and GAD-2
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24% had a GAD-2 score > 4
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16% had a PHQ-2 score > 4
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Brief Intervention
• 8 to 10 minute relaxation exercise including
mindful breathing followed by progressive
(slow tense-relax) relaxation
• Assessed the following before and after the
brief relaxation exercise:
– Perceived intensity of tension
– Perceived level of relaxation
– Skin temperature.
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Results of Brief Intervention
Pre Mean
(SD)
N
Post Mean
(SD)
N
Level of
Relaxation
6.20 (2.44)*
256
6.70 (2.92)*
153
Intensity of
Tension****
4.55 (2.05)**
266
3.30 (2.18)**
166
Finger
Temperature
84.68 (5.77)***
223
86.44 (6.15)***
169
*c2 (4, N = 409) = 33.46, p <.01
**c2 (4, N = 432) = 61.46, p <.01
***c2 (4, N = 392) = 14.66, p <.01
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****Lower scores reflect better outcomes.
Program Evaluation
Satisfaction with First Year Program (n=198)
Likert Scale, 1= unsatisfied, 5= very satisfied
– Program: Mean= 4.4; Presenters: Mean=4.6
The third year session was well organized and the
presenter was well prepared
• 180 Strongly Agreed; 99 Agreed; 2 Disagreed
– The content presented during this session will be
useful in my clinical rotations
• 118 Strongly Agreed; 159 Agreed; 4 Disagreed
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Program Evaluation Comments
“It helped me identify my behaviors/thoughts that
added to my stress and ways to change these”.
“I try to balance my life… and be happy with the
outcome, even if it is not perfect”.
“I am very happy and thankful to have signed up for this
session. The presentations were practical and helpful
to me, not only as a medical student, but as a mom
and wife. Thank you.”
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Conclusions
• Wellness groups seem to be promising in a
variety of settings by decreasing medical
symptoms, improving mental health, or
decreasing medical utilization.
• In healthy people during stressful conditions,
wellness can provide new ways of coping and
build a sense of empowerment.
• Components of wellness can be incorporated
in the care of the chronically ill.
McGrady 2012
References
Ball,S. & Bax, A. (2002). Self-care in medical education:
effectiveness of health habits interventions for first year
medical students. Academic Medicine, 77(9):911-917.
Beck, A.T. & Steer, R.A. (2001). Beck Depression Inventory II. San
Antonio, TX: Psychological Corp., Harcourt Brace Jovanovich,
Inc.
Beck, A.T. (1990). Beck Anxiety Inventory. San Antonio, TX:
Psychological Corp., Harcourt Brace Jovanovich, Inc.
Dahlin, M., Joneberg, N. & Runeson, B. (2005). Stress and
depression among medical students: a cross-sectional study.
Med Ed, 39:594-604.
Dyrbye, L. N. et al. (2010). Factors associated with resilience to
and recovery from burnout: a prospective, multi-institutional
study of US medical students. Med Ed, 44:1016-1026.
McGrady, Brennan et al. 2012 Appl. Psycho. Biofeed. In press
Paro, H., Morales, N., Silva, C. et al. (2010). Health-related
quality of life of medical students. Med Ed, 44:227-235.
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