NUDGE: IMPROVING DECISIONS ABOUT HEALTH, WEALTH, AND HAPPINESS by Richard H. Thaler and Cass R. Sunstein Penguin Books, 2009, 312 pp, ISBN 978-0-14-311526-7This book is best described formally as a general explanation of and advocacy for libertarian paternalism, a term coined by the authors in earlier publications. Informally, it is about how leaders, systems, organizations, and governments can nudge people to do the things the nudgers want and need done for the betterment of the nudgees, or of society. It is paternalism in the sense that "it is legitimate for choice architects to try to influence people's behavior in order to make their lives longer, healthier, and better", (p. 5) It is libertarian in that "people should be free to do what they like - and to opt out of undesirable arrangements if they want to do so", (p. 5) The built-in possibility of opting out or making a different choice preserves freedom of choice even though people's behavior has been influenced by the nature of the presentation of the information or by the structure of the decisionmaking system. I had never heard of libertarian paternalism before reading this book, and I now find it fascinating.Written for a general audience, this book contains mostly social and behavioral science theory and models, but there is considerable discussion of structure and process that has roots in mathematical and quantitative modeling. One of the main applications of this social system is economic choice in investing, selecting and purchasing products and services, systems of taxes, banking (mortgages, borrowing, savings), and retirement systems. Other quantitative social choice systems discussed include environmental effects, health care plans, gambling, and organ donations. Softer issues that are also subject to a nudge-based approach are marriage, education, eating, drinking, smoking, influence, spread of information, and politics. There is something in this book for everyone.The basis for this libertarian paternalism concept is in the social theory called "science of choice", the study of the design and implementation of influence systems on various kinds of people. The terms Econs and Humans, are used to refer to people with either considerable or little rational decision-making talent, respectively. The various libertarian paternalism concepts and systems presented are tested and compared in light of these two types of people. Two foundational issues that this book has in common with another book, Network of Echoes: Imitation, Innovation and Invisible Leaders, that was also reviewed for this issue of the Journal are that 1 ) there are two modes of thinking (or components of the brain) - an automatic (intuitive) process and a reflective (rational) process and 2) the need for conformity and the desire for imitation are powerful forces in human behavior. …

Nudge: Improving Decisions about Health, Wealth, and Happiness

ContextFew depressed older adults receive effective treatment in primary care
settings.ObjectiveTo determine the effectiveness of the Improving Mood–Promoting
Access to Collaborative Treatment (IMPACT) collaborative care management program
for late-life depression.DesignRandomized controlled trial with recruitment from July 1999 to August
2001.SettingEighteen primary care clinics from 8 health care organizations in 5
states.ParticipantsA total of 1801 patients aged 60 years or older with major depression
(17%), dysthymic disorder (30%), or both (53%).InterventionPatients were randomly assigned to the IMPACT intervention (n = 906)
or to usual care (n = 895). Intervention patients had access for up to 12
months to a depression care manager who was supervised by a psychiatrist and
a primary care expert and who offered education, care management, and support
of antidepressant management by the patient's primary care physician or a
brief psychotherapy for depresssion, Problem Solving Treatment in Primary
Care.Main Outcome MeasuresAssessments at baseline and at 3, 6, and 12 months for depression, depression
treatments, satisfaction with care, functional impairment, and quality of
life.ResultsAt 12 months, 45% of intervention patients had a 50% or greater reduction
in depressive symptoms from baseline compared with 19% of usual care participants
(odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of
depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001),
more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group
difference, −0.4; 95% CI, −0.46 to −0.33; P<.001), less functional impairment (range, 0-10; between-group
difference, −0.91; 95% CI, −1.19 to −0.64; P<.001), and greater quality of life (range, 0-10; between-group
difference, 0.56; 95% CI, 0.32-0.79; P<.001) than
participants assigned to the usual care group.ConclusionThe IMPACT collaborative care model appears to be feasible and significantly
more effective than usual care for depression in a wide range of primary care
practices.

https://jamanetwork.com/journals/jama/articlepdf/195599/JOC21093.pdf

Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial

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Applied Missing Data Analysis

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.
 
The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

/pdf/physician-advice-for-smoking-cessation-3keveyx1e5.pdf

Physician advice for smoking cessation

These guidelines have been replaced by British Guideline on the Management of Asthma. A national clinical guideline. Superseded By 2012 Revision Of 2008 Guideline: British Guideline on the Management of Asthma. Thorax 2008 May; 63(Suppl 4): 1–121.

/pdf/british-guideline-on-the-management-of-asthma-a-national-3q1wreyszl.pdf

British guideline on the management of asthma: A national clinical guideline

The Prevalence of DSM-IV Anxiety and Depressive Disorders in Youth with Asthma Compared with Controls

OBJECTIVE Difficulties collaborating with providers and important others may adversely influence self-management in patients with diabetes. We predicted that dismissing attachment style, characterized by high interpersonal self-reliance and low trust of others, would be associated with poorer self-management in patients with diabetes. METHODS A population-based mail survey was sent to all patients with diabetes from nine primary care clinics of a health maintenance organization. We collected data on attachment style, self-care behaviors, the patient provider relationship and depression status and accessed automated diagnostic, pharmacy, and laboratory data to measure diabetes treatment intensity, medical comorbidity, glycosylated hemoglobin levels, and diabetes complications. We used logistic regression to determine whether dismissing attachment style was associated with poorer diabetes self-care behaviors, adherence to medication, smoking status, and higher glycosylated hemoglobin. RESULTS In 4095 primary care patients with diabetes, prevalence rates for secure, dismissing, preoccupied, and fearful attachment styles were 44.2%, 35.8%, 7.9%, and 12.1%, respectively. When compared with secure attachment style, dismissing attachment style was associated with significantly lower levels of exercise (p =.005), foot care (p 8%, compared with secure attachment style. CONCLUSION Attachment style is significantly associated with diabetes self-management and outcomes.

/pdf/influence-of-patient-attachment-style-on-self-care-and-4q8zpbv13i.pdf

Influence of patient attachment style on self-care and outcomes in diabetes.

OBJECTIVE. The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma. METHODS. We conducted a telephone survey of 767 youth with asthma (aged 11–17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity. RESULTS. After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with ≥1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire. CONCLUSIONS. The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms.

Objective To test a collaborative-care, cognitive-behavioral therapy (CBT) program adjunctive to selective serotonin reuptake inhibitor (SSRI) treatment in HMO pediatric primary care. Method A randomized effectiveness trial comparing a treatment-as-usual (TAU) control condition consisting primarily of SSRI medication delivered outside the experimental protocol ( n = 75) versus TAU SSRI plus brief CBT ( n = 77). Participants were identified by a recent dispense of SSRI medication followed by telephone screening. Adolescents with a diagnosis of major depressive disorder ( n = 152) were enrolled. The CBT program employed cognitive restructuring and/or behavioral activation training. Therapists consulted with prescribing pediatricians to improve medication adherence. Results Through 1-year follow-up, the authors found CBT advantages on the Short Form-12 Mental Component Scale ( p = .04), reductions in TAU outpatient visits ( p = .02), and days' supply of all medications ( p = .01). No effects were detected for major depressive disorder episodes; a nonsignificant trend favoring CBT was detected on the Center for Epidemiology Depression Scale ( p = .07). Conclusions The authors detected a weak CBT effect, possibly rendered less significant by the small sample and likely attenuated by the unexpected reduction in SSRI pharmacotherapy in the CBT condition. Small, incremental improvements over monotherapy, such as observed in this study, most likely represent the new norm in adolescent depression treatment research.

A Randomized Effectiveness Trial of Brief Cognitive-Behavioral Therapy for Depressed Adolescents Receiving Antidepressant Medication.

OBJECTIVE: The prevalence of major depression is approximately 2-fold higher in patients with diabetes mellitus compared to medical controls. We explored the association of major depression with 8 cardiac risk factors in diabetic patients with and without evidence of cardiovascular disease (CVD).

/pdf/cardiac-risk-factors-in-patients-with-diabetes-mellitus-and-3f5sx9kyfj.pdf

Terry Bush

Papers

The Prevalence of DSM-IV Anxiety and Depressive Disorders in Youth with Asthma Compared with Controls

Influence of patient attachment style on self-care and outcomes in diabetes.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms.

A Randomized Effectiveness Trial of Brief Cognitive-Behavioral Therapy for Depressed Adolescents Receiving Antidepressant Medication.

Cardiac risk factors in patients with diabetes mellitus and major depression.