Journal Article Annotations
2024, 1st Quarter
Annotations by Christian Bjerre Real, MD, MMCI, Deepti Chopra, MBBS, MPH, Daniel McFarland, MD, Marie Tobin, MD
April, 2024
The finding:
This systematic review delineates systemic and individual factors associated with the moral and occupational distress of healthcare workers (HCW) with an emphasis in neurobiological correlates such as HPA axis, autonomic nervous system, immunity, genetic and epigenetic changes during circumstances of struggle. It summarizes potential intervention points to mitigate the risk of mood disorders and burn-out syndromes. They modified the “job demands-resources” (JDR) health model to fit healthcare workers circumstances. This model helps with finding points of interventions at different levels of specific occupational circumstances.
Strength and weaknesses:
The study does a great job at pointing out potential neurobiological mechanisms pertaining to the pathophysiology of moral distress. The JDR model can be a helpful way to evaluate system wide resources compared to job specific demands. Although the study clarifies some of their methodology in the Prospero registration website, it would have been helpful to expand on it within the written article as well.
Relevance:
Moral distress is particularly pronounced in clinicians who care for seriously/terminally ill patients. Having knowledge of potential interventions at the individual and system levels place CL psychiatrists in a position to generate impacting change in the lives of themselves and their co-workers. Narrative medicine competence (emotion focused process groups based on clinical cases) could be of particular interest to the CL psychiatrist working in healthcare systems.
The finding:
The authors performed an open-label, single arm, feasibility, and efficacy study of accelerated transcranial stimulation on six admitted participants with advanced cancer and co-morbid psychological distress. rTMS was administered eight times per day over a five-day period. On validated measures, five of the six participants had a >50% reduction in depression or anxiety or both at two weeks from baseline. Mean changes in depression were significant. Reductions in mean anxiety and demoralization scores were non-significant. No differences in quality-of-life measures were found. The treatment was well tolerated with minimal side effects.
Strength and weaknesses:
This study used a prospective design to examine a group of patients who suffer significant psychological and existential suffering for which few effective treatment options exist. Treatment options that currently exist are frequently poorly tolerated. The findings of tolerability and efficacy of rTMS in this patient population identify new avenues for treatment. Clear inclusion and exclusion criteria and the use of validated scales are also strengths of this study.
Weaknesses included that the study enrolment was poor, partially impacted by the COVID-19 pandemic but perhaps also highlighting the reluctance of patients with advanced illness to undergo additional treatment. It is difficult to quantify the placebo effect given the absence of a sham rTMS control arm.
Relevance:
This first study of rTMS in the palliative care setting found it to be feasible, tolerable, and effective over a short period of time (baseline to two weeks post-treatment). Given the paucity of effective treatment in this specific patient population this is an important contribution. The study highlights the need for a larger sham-controlled study to confirm findings here and also to characterize more fully the optimal anatomical targets and dose regimens.