OBJECTIVES The “neurotrophin hypothesis” of depression posits a role of brain-derived neurotrophic factor (BDNF) in depression, although it is unknown whether BDNF is more involved in the etiology of depression or in the mechanism of action of antidepressants. . It is also unknown whether pre-treatment serum BDNF levels predict antidepressant response. METHODS Thirty un-medicated depressed subjects were treated with escitalopram (N=16) or sertraline (N=14) for eight weeks. Twenty-five of the depressed subjects completed 8 weeks of antidepressant treatment and had analyzable data. Twenty-eight healthy controls were also studied. Serum for BDNF assay was obtained at baseline in all subjects and after 8 weeks of treatment in the depressed subjects. Depression ratings were obtained at baseline and after 8 weeks of treatment in the depressed subjects. RESULTS Pre-treatment BDNF levels were lower in the depressed subjects than the controls (p= 0.001) but were not significantly correlated with pre-treatment depression severity. Depression ratings improved with SSRI treatment (p< 0.001), and BDNF levels increased with treatment (p= 0.005). Changes in BDNF levels were not significantly correlated with changes in depression ratings. However, pre-treatment BDNF levels were directly correlated with antidepressant responses (p<0.01), and “Responders” to treatment (≥ 50% improvement in depression ratings) had higher pre-treatment BDNF levels than did “Non-responders” (p< 0.05). CONCLUSIONS These results confirm low serum BDNF levels in unmedicated depressed subjects and confirm antidepressant-induced increases in BDNF levels, but they suggest that antidepressants do not work simply by correcting BDNF insufficiency. Rather, these findings are consistent with a permissive or facilitatory role of BDNF in the mechanism of action of antidepressants.

PURPOSE Although health coaches are a growing resource for supporting patients in making health decisions, we know very little about the experience of health. We undertook a qualitative study of how health coaches support patients in making decisions and implementing changes to improve their health. METHODSWe conducted 6 focus groups (3 in Spanish and 3 in English) with 25 patients and 5 friends or family members, followed by individual interviews with 42 patients, 17 family members, 17 health coaches, and 20 clinicians. Audio recordings were transcribed and analyzed by at least 2 members of the study team in ATLAS.ti using principles of grounded theory to identify themes and the relationship between them. RESULTSWe identified 7 major themes that were related to each other in the final conceptual model. Similarities between health coaches and patients and the time health coaches spent with patients helped establish the health coachpatient relationship. The coach-patient relationship allowed for, and was further strengthened by, 4 themes of key coaching activities: education, personal support, practical support, and acting as a bridge between patients and clinicians. CONCLUSIONSWe identified a conceptual model that supports the development of a strong relationship, which in turn provides the basis for effective coaching. These results can be used to design health coach training curricula and to support health coaches in practice. Ann Fam Med 2016;14:509-516. doi: 10.1370/afm.1988. INTRODUCTIONR ecent efforts to provide more integrated, patient-centered primary care have included patient activation, patient education and engagement, shared decision making, and self-management support. Health coaches work in all of these areas, providing patients with health-related information, navigational support, connections to community resources, and personal support.1,2 Coaches focus on helping patients to identify goals, create plans to make changes, and implement changes. Although health coaching can be performed by licensed professionals including nurses, physical therapists and respiratory therapists, 3,4 or by other patients (peer support), 5-8 medical assistants 1,9,10 and other unlicensed health workers (eg, community health workers, lay health advisers, and promotoras) [11][12][13][14][15][16] are emerging as a common and relatively economical workforce that may meet the demand for self-management support. Health coaching has been proposed as an inexpensive and effective means to improve control of chronic conditions 1 and has been effective in improving management of diabetes and other risk factors for cardiovascular disease, asthma, and chronic obstructive pulmonary disease. 4,5,9,10,[17][18][19] Coaches may be particularly valuable in resource-poor settings, where minority and low-income communities bear a disproportionate burden of chronic disease and its complications, and are less likely to engage in effective self-management of their conditions. 20 In these settings, clinics can often employ coaches wh...

These results help inform expectations regarding the limitations and benefits of health coaching for patients with COPD. They may be useful to health policy experts in assessing the potential value of reimbursement and incentives for health coaching-type activities for patients with chronic disease. Clinical trial registered with www.clinicaltrials.gov (NCT02234284).

Background Recruitment and retention are two significant barriers in research, particularly for historically underrepresented groups, including racial and ethnic minorities, patients who are low-income, or people with substance use or mental health issues. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and disproportionately affects many underrepresented groups. The lack of representation of these groups in research limits the generalizability and applicability of clinical research and results. In this paper we describe our experience and rates of recruitment and retention of underrepresented groups for the Aides in Respiration (AIR) COPD Health Coaching Study. Methods A priori design strategies included minimizing exclusion criteria, including patients in the study process, establishing partnerships with the community clinics, and ensuring that the health coaching intervention was flexible enough to accommodate patient needs. Results Challenges to recruitment included lack of spirometric data in patient records, space constraints at the clinic sites, barriers to patient access to clinic sites, lack of current patient contact information and poor patient health. Of 282 patients identified as eligible, 192 (68%) were enrolled in the study and 158 (82%) completed the study. Race, gender, educational attainment, severity of disease, health literacy, and clinic site were not associated with recruitment or retention. However, older patients were less likely to enroll in the study and patients who used home oxygen or had more than one hospitalization during the study period were less likely to complete the study. Three key strategies to maximize recruitment and retention were identified during the study: incorporating the patient perspective, partnering with the community clinics, and building patient rapport. Conclusions While the AIR study included design features to maximize the recruitment and retention of patients from underrepresented groups, additional challenges were encountered and responded to during the study. We also identified three key strategies recommended for future studies of COPD and similar conditions. Incorporating the approaches described into future studies may increase participation rates from underrepresented groups, providing results that can be more accurately applied to patients who carry a disparate burden of disease. Trial registration This trial was registered at ClinicalTrial.gov at identifier NCT02234284 on August 12, 2014. Descriptor number: 2.9 Racial, ethnic, or social disparities in lung disease and treatment.

BackgroundChronic obstructive pulmonary disease (COPD) severely hinders quality of life for those affected and is costly to the health care system. Care gaps in areas such as pharmacotherapy, inhaler technique, and knowledge of disease are prevalent, particularly for vulnerable populations served by community clinics. Non-professionally licensed health coaches have been shown to be an effective and cost-efficient solution in bridging care gaps and facilitating self-management for patients with other chronic diseases, but no research to date has explored their efficacy in improving care for people living with COPD.MethodThis is multi-site, single blinded, randomized controlled trial evaluates the efficacy of health coaches to facilitate patient self-management of disease and improve quality of life for patients with moderate to severe COPD. Spirometry, survey, and an exercise capacity test are conducted at baseline and at 9 months. A short survey is administered by phone at 3 and 6 months post-enrollment. The nine month health coaching intervention focuses on enhancing disease understanding and symptom awareness, improving use of inhalers; making personalized plans to increase physical activity, smoking cessation, or otherwise improve disease management; and facilitating care coordination.DiscussionThe results of this study will provide evidence regarding the efficacy and feasibility of health coaching to improve self-management and quality of life for urban underserved patients with moderate to severe COPD.Trial registrationClinicalTrials.gov identifier NCT02234284. Registered 12 August 2014.

PURPOSE Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique.METHODS Within a randomized controlled trial, we recruited English-and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site. RESULTSBaseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted P = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted P = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted P = .01) and mastery of essential steps (40% vs 11%; adjusted P <.001).CONCLUSIONS Health coaching may provide a scalable model that can improve care for people living with COPD.

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This study will allow the development of a tool for clinicians to use to predict severe pain during WCPs and identify biological factors significantly associated with severe pain during WCPs.