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1.  Downtime after Critical Incidents in Emergency Medical Technicians/Paramedics 
BioMed Research International  2014;2014:483140.
Effective workplace-based interventions after critical incidents (CIs) are needed for emergency medical technicians (EMT)/paramedics. The evidence for a period out of service post-CI (downtime) is sparse; however it may prevent posttraumatic stress disorder (PTSD) and burnout symptoms. We examined the hypothesis that downtime post-CI is associated with fewer symptoms of four long-term emotional sequelae in EMT/paramedics: depression, PTSD, burnout, and stress-related emotional symptoms (accepted cut-offs defined high scores). Two hundred and one paramedics completed questionnaires concerning an index CI including downtime experience, acute distress, and current emotional symptoms. Nearly 75% received downtime; 59% found it helpful; 84% spent it with peers. Downtime was associated only with lower depression symptoms, not with other outcomes. The optimal period for downtime was between <30 minutes and end of shift, with >1 day being less effective. Planned testing of mediation of the association between downtime and depression by either calming acute post-CI distress or feeling helped by others was not performed because post-CI distress was not associated with downtime and perceived helpfulness was not associated with depression. These results suggest that outcomes of CIs follow different pathways and may require different interventions. A brief downtime is a relatively simple and effective strategy in preventing later depression symptoms.
PMCID: PMC4024400  PMID: 24877101
2.  The critical incident inventory: characteristics of incidents which affect emergency medical technicians and paramedics 
Emergency medical technicians (EMTs) and paramedics experience critical incidents which evoke distress and impaired functioning but it is unknown which aspects of incidents contribute to their impact. We sought to determine these specific characteristics by developing an inventory of critical incident characteristics and testing their relationship to protracted recovery from acute stress, and subsequent emotional symptoms.
EMT/paramedics (n = 223) completed a retrospective survey of reactions to an index critical incident, and current depressive, posttraumatic and burnout symptoms. Thirty-six potential event characteristics were evaluated; 22 were associated with peritraumatic distress and were retained. We assigned inventory items to one of three domains: situational, systemic or personal characteristics. We tested the relationships between (a) endorsing any domain item and (b) outcomes of the critical incident (peritraumatic dissociation, recovery from components of the Acute Stress Reaction and depressive, posttraumatic, and burnout symptoms). Analyses were repeated for the number of items endorsed.
Personal and situational characteristics were most frequently endorsed. The personal domain had the strongest associations, particularly with peritraumatic dissociation, prolonged distressing feelings, and current posttraumatic symptoms. The situational domain was associated with peritraumatic dissociation, prolonged social withdrawal, and current posttraumatic symptoms. The systemic domain was associated with peritraumatic dissociation and prolonged irritability. Endorsing multiple characteristics was related to peritraumatic, acute stress, and current posttraumatic symptoms. Relationships with outcome variables were as strong for a 14-item inventory (situational and personal characteristics only) as the 22-item inventory.
Emotional sequelae are associated most strongly with EMT/paramedics’ personal experience, and least with systemic characteristics. A14-item inventory identifies critical incident characteristics associated with emotional sequelae. This may be helpful in tailoring recovery support to individual provider needs.
PMCID: PMC3549754  PMID: 22862821
3.  Prevalence of Psychiatric Disorders Among Toronto Hospital Workers One to Two Years After the SARS Outbreak 
This study aimed to determine the incidence of psychiatric disorders among health care workers in Toronto in the one- to two-year period after the 2003 outbreak of severe acute respiratory syndrome (SARS) and to test predicted risk factors.
New-onset episodes of psychiatric disorders were assessed among 139 health care workers by using the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale. Past history of psychiatric illness, years of health care experience, and the perception of adequate training and support were tested as predictors of the incidence of new-onset episodes psychiatric disorders after the SARS outbreak.
The lifetime prevalence of any depressive, anxiety, or substance use diagnosis was 30%. Only one health care worker who identified the SARS experience as a traumatic event was diagnosed as having PTSD. New episodes of psychiatric disorders occurred among seven health care workers (5%). New episodes of psychiatric disorders were directly associated with a history of having a psychiatric disorder before the SARS outbreak (p=.02) and inversely associated with years of health care experience (p=.03) and the perceived adequacy of training and support (p=.03).
Incidence of new episodes of psychiatric disorders after the SARS outbreak were similar to or lower than community incidence rates, which may indicate the resilience of health care workers who continued to work in hospitals one to two years after the SARS outbreak. In preparation for future events, such as pandemic influenza, training and support may bolster the resilience of health care workers who are at higher risk by virtue of their psychiatric history and fewer years of health care experience.
PMCID: PMC2923654  PMID: 18182545 CAMSID: cams1445
4.  Psychobiological Subtypes of Ulcerative Colitis: pANCA Status Moderates the Relationship between Disease Activity and Psychological Distress 
Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions.
In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination and endoscopy using the St. Mark’s index, and depressive symptoms and health anxiety were measured with self report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated.
In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation= 0.48, p < 0.001) and for disease activity-health anxiety (partial correlation= 0.64, p < 0.001), whereas in 74 pANCA positive subjects, no relationships were found (disease activity-depression: partial correlation= 0.18, p = 0.14; disease activity-health anxiety: partial correlation= 0.20, p = 0.09). The differences in the strength of correlation between pANCA positive and pANCA negative subjects were statistically significant for both disease activity-depression (z = 2.0, p = 0.02) and for activity-health anxiety (z = 3.3, p < 0.001).
pANCA status demarcates psychobiologically distinct subtypes of UC, such that the absence of pANCA is associated with greater psychobiological interaction. These findings have implications for clinical care and understanding the pathophysiology of intestinal inflammation.
PMCID: PMC2923655  PMID: 17029612 CAMSID: cams1454
5.  Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training 
Working in a hospital during an extraordinary infectious disease outbreak can cause significant stress and contribute to healthcare workers choosing to reduce patient contact. Psychological training of healthcare workers prior to an influenza pandemic may reduce stress-related absenteeism, however, established training methods that change behavior and attitudes are too resource-intensive for widespread use. This study tests the feasibility and effectiveness of a less expensive alternative - an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic.
A "dose-finding" study compared pre-post changes in three different durations of training. We measured variables that are likely to mediate stress-responses in a pandemic before and after training: confidence in support and training, pandemic-related self-efficacy, coping style and interpersonal problems.
158 hospital workers took the course and were randomly assigned to the short (7 sessions, median cumulative duration 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat analysis, the course was associated with significant improvements in confidence in support and training, pandemic self-efficacy and interpersonal problems. Participants who under-utilized coping via problem-solving or seeking support or over-utilized escape-avoidance experienced improved coping. Comparison of doses showed improved interpersonal problems in the medium and long course but not in the short course. There was a trend towards higher drop-out rates with longer duration of training.
Computer-assisted resilience training in healthcare workers appears to be of significant benefit and merits further study under pandemic conditions. Comparing three "doses" of the course suggested that the medium course was optimal.
PMCID: PMC2851711  PMID: 20307302
6.  The impact of ulcerative colitis is greater in unmarried and young patients 
To determine whether the perceived impact of ulcerative colitis (UC) on activities of living (illness intrusiveness) is greater for people who are not living in a married or common-law relationship.
In general, social and occupational achievement is not greatly impaired by UC, yet patients, especially young adults, often have interpersonal concerns.
One hundred fifty-five outpatients with UC were assessed for disease activity, and completed self-reports of marital status, income, social support and illness intrusiveness.
Fifty-one patients (32.9%) were single, separated or divorced, and 104 patients (67.1%) were married or in common-law relationships. Compared with those who were married or in common-law relationships, single or separated patients were younger, had a lower household income, had lived with UC for fewer years and were less satisfied with social support. Among 135 patients in remission, marital status was significantly associated with illness intrusiveness, controlling for age, income and perceived social support (F=5.73; P=0.02). Low social support (F=4.94; P=0.03) and younger age (F=7.24; P=0.008) were independently associated with illness intrusiveness. Single patients in remission reported illness intrusiveness of similar severity to that reported by patients with active disease.
The perceived impact of UC on the lives of patients is greater in those who are not married or living in common-law relationships. Youth, single status and lower social support commonly coexist, and exert additive effects on the functional impact of UC. Resources to improve social support should be directed toward this group of patients.
PMCID: PMC2658585  PMID: 18026574
Marital status; Quality of life; Social support; Ulcerative colitis
7.  Insecure attachment is associated with the α-EEG anomaly during sleep 
The α-EEG anomaly during sleep, originally associated with chronic pain, is noted in several psychiatric and medical conditions and is also present in some normal subjects. The exact significance of the α-EEG anomaly is uncertain, but it has been suggested to be a nonspecific response to a variety of noxious stimuli. We propose that attachment insecurity, which is often associated with a state of hypervigilance during wakefulness, may be associated with the α-EEG anomaly during sleep.
Thirty one consecutive patients referred to a Sleep Disorders Clinic for clinical assessment of sleep complaints underwent standard polysomnographic recording. The degree of alpha activity in polysomnographs was scored visually according to standard criteria. Attachment insecurity was measured with the Experience in Close Relationships – Revised questionnaire.
Attachment anxiety was significantly associated with the proportion of sleep in which α waves were present (df = 1, F = 5.01, p = 0.03). The relationship between the α-EEG anomaly and attachment anxiety was not explained by the distribution of sleep and mood diagnoses, medications, anxiety symptoms or depression symptoms.
Interpersonal style in close relationships may be related to sleep physiology. Further research to determine the nature of the relationship between attachment, sleep and other factors that are related to each of these, such as a history of personal adversity, is warranted.
PMCID: PMC2186352  PMID: 17976231
8.  Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak 
Emerging Infectious Diseases  2006;12(12):1924-1932.
TOC Summary Line: Healthcare workers in hospitals affected by SARS experience increased psychological stress 1–2 years after the outbreak.
Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.
PMCID: PMC3291360  PMID: 17326946
Severe Acute Respiratory Syndrome; Stress, Psychological; Health Personnel; Stress, Traumatic; Burnout, Professional, research

Results 1-8 (8)