Trajectory Pathways for Depressive Symptoms and Their Associated Factors in a Chinese Primary Care Cohort by Growth Mixture Modelling

Background

The naturalistic course for patients suffering from depressive disorders can be quite varied. Whilst some remit with little or no intervention, others may suffer a more prolonged course of symptoms. The aim of this study was to identify trajectory patterns for depressive symptoms in a Chinese primary care cohort and their associated factors.

Methods and Results

A 12-month cohort study was conducted. Patients recruited from 59 primary care clinics across Hong Kong were screened for depressive symptoms using the Centre for Epidemiologic Studies Depression Scale (CES-D) and monitored over 12 months using the Patient Health Questionnaire-9 items (PHQ-9) administered at 12, 26 and 52 weeks. 721 subjects were included for growth mixture modelling analysis. Using Akaike Information Criterion, Bayesian Information Criterion, Entropy and Lo-Mendell-Rubin adjusted likelihood ratio test, a seven-class trajectory path model was identified. Over 12 months, three trajectory groups showed improvement in depressive symptoms, three remained static, whilst one deteriorated. A mild severity of depressive symptoms with gradual improvement was the most prevalent trajectory identified. Multivariate, multinomial regression analysis was used to identify factors associated with each trajectory. Risk factors associated with chronicity included: female gender; not married; not in active employment; presence of multiple chronic disease co-morbidities; poor self-rated general health; and infrequent health service use.

Conclusions

Whilst many primary care patients may initially present with a similar severity of depressive symptoms, their course over 12 months can be quite heterogeneous. Although most primary care patients improve naturalistically over 12 months, many do not remit and it is important for doctors to be able to identify those who are at risk of chronicity. Regular follow-up and greater treatment attention is recommended for patients at risk of chronicity.     

Patient's weight 6 months after depression treatment is not affected by either clinical remission or enrolment in collaborative care management

Objective The primary aim of this study was to determine whether enrolment in collaborative care management (CCM) for treatment of major depression would have a significant impact on 6-month changes in weight compared with patients treated by their primary care provider with usual care. The secondary aim was to determine whether clinical remission would also affect 6-month weight changes.Design A retrospective chart review study included 1550 patients who had been diagnosed with major depression or dysthymia and who had a Patient Health Questionnaire (PHQ-9) score of ≥ 10 with follow-up data (PHQ-9 score and weight) at 6 months.Subjects The study sample consisted of adult patients (aged ≥ 18 years) from primary care practices, representing all body mass index (BMI) categories. The exclusion criteria were a diagnosis of bipolar disorder, recent obstetric delivery or recent gastric bypass procedure.Measurements Weight was measured at index and 6 months, with BMI calculated from electronic medical record data. Patient assessment data (including PHQ-9 score and clinical diagnosis) and demographic variables (age, gender, marital status and clinical location) were also collected.Results With regression modelling, neither enrolment in CCM (P = 0.306) nor clinical remission (P = 0.828) was associated with a significant weight gain.Conclusion After 6 months, enrolment in CCM had no significant impact on weight gain or weight loss among patients treated for depression, nor was improvement to clinical remission a factor in the patient''s weight after 6 months. Incorporating a weight loss management intervention within the model may be warranted if concomitant weight reduction is desired.     

Prevalence and Psychosocial Correlates of Depressive Symptoms in Urban Chinese Women during Midlife

Objective

Depression is common in women with much research focusing on hormonal changes and menopausal symptoms but with little exploration of psychosocial problems in midlife. This study investigates the prevalence of clinically relevant depressive symptoms in midlife Chinese women and its association with psychosocial factors.

Methods

A cross-sectional, community-based household survey of women aged 45 to 64 years of age was conducted in Hong Kong from September 2010 to March 2011. The structured questionnaire included demographic data, educational status, marital status and household income, as well as perceived current stressful events and significant life events in the past 12 months. Information on clinically relevant depressive symptoms was measured by the validated chinese Patient Health Questionnaire (PHQ-9).

Results

A total of 402 participants were recruited in the study period. Of the 393 women who completed the questionnaire, the prevalence of clinically relevant depressive symptoms (PHQ-9 score≧10) was 11.0%. In multiple regression analysis, being single/divorced/separated/widowed, having an educational level of primary school level or below, having multiple chronic diseases, loss of hobby or loss of close social support in the past 12 months in midlife were associated with clinically relevant depressive symptoms.

Conclusions

Correlates of clinically relevant depressive symptoms in midlife Chinese women can be used to identify those at increased risk and potentiate further studies to explore early psychosocial and community interventions.     

Symptoms of Eating Disorders and Depression in Emerging Adults with Early-Onset,Long-Duration Type 1 Diabetes and Their Association with Metabolic Control

Background

This study analyzed the prevalence of and association between symptoms of eating disorders and depression in female and male emerging adults with early-onset, long-duration type 1 diabetes and investigated how these symptoms are associated with metabolic control.

Methods

In a nationwide population-based survey, 211 type 1 diabetes patients aged 18-21 years completed standardized questionnaires, including the SCOFF questionnaire for eating disorder symptoms and the Patient Health Questionnaire (PHQ-9) for symptoms of depression and severity of depressive symptoms (PHQ-9 score). Multiple linear and logistic regression models were used to analyze the association between eating disorder and depressive symptoms and their associations with HbA1c.

Results

A total of 30.2% of the women and 9.5% of the men were screening positive for eating disorders. The mean PHQ-9 score (standard deviation) was 5.3 (4.4) among women and 3.9 (3.6) among men. Screening positive for an eating disorder was associated with more severe depressive symptoms among women (β_women 3.8, p<0.001). However, neither eating disorder symptoms nor severity of depressive symptoms were associated with HbA1c among women, while HbA1c increased with the severity of depressive symptoms among men (β_men 0.14, p=0.006).

Conclusions

Because of the high prevalence of eating disorder and depressive symptoms, their interrelationship, and their associations with metabolic control, particularly among men, regular mental health screening is recommended for young adults with type 1 diabetes.     

Screening for Major Depressive Disorder with the Patient Health Questionnaire (PHQ-9 and PHQ-2) in an Outpatient Clinic Staffed by Primary Care Physicians in Japan: A Case Control Study

Objective

The Patient Health Questionnaire (PHQ-9) is a self-report questionnaire commonly used to screen for depression, with ≥8–11 generally recommended as the cut-off. In Japan, studies of the validity of the PHQ-9 and PHQ-2 have been limited. In this study, we examined the utility of the PHQ-9 and PHQ-2 at an outpatient clinic in a Medical University Hospital in Japan.

Methods

New consecutive outpatients were included in the study. We administered the PHQ-9 to 574 patients, and acquired complete PHQ-9 and PHQ-2 data for 521 patients. Major depressive disorders were diagnosed according to the DSM-IV-TR.

Results

Forty-two patients were diagnosed with major depressive disorders. The mean PHQ-9 (15.7) and PHQ-2 (3.8) scores of the patients with major depressive disorders were significantly higher than the scores of the patients without depression (6.0 (PHQ-9) and 1.8 (PHQ-2)). The best cut-off points for the PHQ-9 and PHQ-2 summary scores were ≥11 (sensitivity 0.76, specificity 0.81) and ≥3 (sensitivity 0.76, specificity 0.82), respectively. No relationship was observed between the age and PHQ-9 scores.

Conclusion

The PHQ-9 and PHQ-2 were useful instruments for screening for major depressive disorders. The best cut-off point for the PHQ-9 summary score should be ≥11 to detect depression in the primary care setting in Japan.     

Depression in Atrial Fibrillation in the General Population

Background

Initial evidence suggests that depressive symptoms are more frequent in patients with atrial fibrillation. Data from the general population are limited.

Methods and Results

In 10,000 individuals (mean age 56±11 years, 49.4% women) of the population-based Gutenberg Health Study we assessed depression by the Patient Health Questionnaire (PHQ-9) and a history of depression in relation to manifest atrial fibrillation (n = 309 cases). The median (25th/75th percentile) PHQ-9 score of depressive symptoms was 4 (2/6) in atrial fibrillation individuals versus 3 (2/6) individuals without atrial fibrillation, . Multivariable regression analyses of the severity of depressive symptoms in relation to atrial fibrillation in cardiovascular risk factor adjusted models revealed a relation of PHQ-9 values and atrial fibrillation (odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01–1.08; P = 0.023). The association was stronger for the somatic symptom dimension of depression (OR 1.08, 95% CI 1.02–1.15; P = 0.0085) than for cognitive symptoms (OR 1.05, 95% CI 0.98–1.11; P = 0.15). Results did not change markedly after additional adjustment for heart failure, partnership status or the inflammatory biomarker C-reactive protein. Both, self-reported physical health status, very good/good versus fair/bad, (OR 0.54, 95% CI 0.41–0.70; P<0.001) and mental health status (OR 0.61 (0.46–0.82); P = 0.0012) were associated with atrial fibrillation in multivariable-adjusted models.

Conclusions

In a population-based sample we observed a higher burden of depressive symptoms driven by somatic symptom dimensions in individuals with atrial fibrillation. Depression was associated with a worse perception of physical or mental health status. Whether screening and treatment of depressive symptoms modulates disease progression and outcome needs to be shown.     

A Randomized Controlled Trial Evaluating a Manualized TeleCoaching Protocol for Improving Adherence to a Web-Based Intervention for the Treatment of Depression

Background

Web-based interventions for depression that are supported by coaching have generally produced larger effect-sizes, relative to standalone web-based interventions. This is likely due to the effect of coaching on adherence. We evaluated the efficacy of a manualized telephone coaching intervention (TeleCoach) aimed at improving adherence to a web-based intervention (moodManager), as well as the relationship between adherence and depressive symptom outcomes.

Methods

101 patients with MDD, recruited from primary care, were randomized to 12 weeks moodManager+TeleCoach, 12 weeks of self-directed moodManager, or 6 weeks of a waitlist control (WLC). Depressive symptom severity was measured using the PHQ-9.

Results

TeleCoach+moodManager, compared to self-directed moodManager, resulted in significantly greater numbers of login days (p = 0.01), greater time until last use (p = 0.007), greater use of lessons (p = 0.03), greater variety of interactive tools used (p = 0.02), but total instances of tool use did not reach statistical significance. (p = 0.07). TeleCoach+moodManager produced significantly lower PHQ-9 scores relative to WLC at week 6 (p = 0.04), but there were no other significant differences in PHQ-9 scores at weeks 6 or 12 (ps>0.20) across treatment arms. Baseline PHQ-9 scores were no significantly related to adherence to moodManager.

Conclusions

TeleCoach produced significantly greater adherence to moodManager, relative to self-directed moodManager. TeleCoached moodManager produced greater reductions in depressive symptoms relative to WLC, however, there were no statistically significant differences relative to self-directed moodManager. While greater use was associated with better outcomes, most users in both TeleCoach and self-directed moodManager had dropped out of treatment by week 12. Even with telephone coaching, adherence to web-based interventions for depression remains a challenge. Methods of improving coaching models are discussed.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00719979","term_id":"NCT00719979"}}NCT00719979     

Behavioural activation to prevent depression and loneliness among socially isolated older people with long-term conditions: The BASIL COVID-19 pilot randomised controlled trial

BackgroundOlder adults, including those with long-term conditions (LTCs), are vulnerable to social isolation. They are likely to have become more socially isolated during the Coronavirus Disease 2019 (COVID-19) pandemic, often due to advice to “shield” to protect them from infection. This places them at particular risk of depression and loneliness. There is a need for brief scalable psychosocial interventions to mitigate the psychological impacts of social isolation. Behavioural activation (BA) is a credible candidate intervention, but a trial is needed.Methods and findingsWe undertook an external pilot parallel randomised trial (ISRCTN94091479) designed to test recruitment, retention and engagement with, and the acceptability and preliminary effects of the intervention. Participants aged ≥65 years with 2 or more LTCs were recruited in primary care and randomised by computer and with concealed allocation between June and October 2020. BA was offered to intervention participants (n = 47), and control participants received usual primary care (n = 49). Assessment of outcome was made blind to treatment allocation. The primary outcome was depression severity (measured using the Patient Health Questionnaire 9 (PHQ-9)). We also measured health-related quality of life (measured by the Short Form (SF)-12v2 mental component scale (MCS) and physical component scale (PCS)), anxiety (measured by the Generalised Anxiety Disorder 7 (GAD-7)), perceived social and emotional loneliness (measured by the De Jong Gierveld Scale: 11-item loneliness scale). Outcome was measured at 1 and 3 months. The mean age of participants was aged 74 years (standard deviation (SD) 5.5) and they were mostly White (n = 92, 95.8%), and approximately two-thirds of the sample were female (n = 59, 61.5%). Remote recruitment was possible, and 45/47 (95.7%) randomised to the intervention completed 1 or more sessions (median 6 sessions) out of 8. A total of 90 (93.8%) completed the 1-month follow-up, and 86 (89.6%) completed the 3-month follow-up, with similar rates for control (1 month: 45/49 and 3 months 44/49) and intervention (1 month: 45/47and 3 months: 42/47) follow-up. Between-group comparisons were made using a confidence interval (CI) approach, and by adjusting for the covariate of interest at baseline. At 1 month (the primary clinical outcome point), the median number of completed sessions for people receiving the BA intervention was 3, and almost all participants were still receiving the BA intervention. The between-group comparison for the primary clinical outcome at 1 month was an adjusted between-group mean difference of −0.50 PHQ-9 points (95% CI −2.01 to 1.01), but only a small number of participants had completed the intervention at this point. At 3 months, the PHQ-9 adjusted mean difference (AMD) was 0.19 (95% CI −1.36 to 1.75). When we examined loneliness, the adjusted between-group difference in the De Jong Gierveld Loneliness Scale at 1 month was 0.28 (95% CI −0.51 to 1.06) and at 3 months −0.87 (95% CI −1.56 to −0.18), suggesting evidence of benefit of the intervention at this time point. For anxiety, the GAD adjusted between-group difference at 1 month was 0.20 (−1.33, 1.73) and at 3 months 0.31 (−1.08, 1.70). For the SF-12 (physical component score), the adjusted between-group difference at 1 month was 0.34 (−4.17, 4.85) and at 3 months 0.11 (−4.46, 4.67). For the SF-12 (mental component score), the adjusted between-group difference at 1 month was 1.91 (−2.64, 5.15) and at 3 months 1.26 (−2.64, 5.15). Participants who withdrew had minimal depressive symptoms at entry. There were no adverse events. The Behavioural Activation in Social Isolation (BASIL) study had 2 main limitations. First, we found that the intervention was still being delivered at the prespecified primary outcome point, and this fed into the design of the main trial where a primary outcome of 3 months is now collected. Second, this was a pilot trial and was not designed to test between-group differences with high levels of statistical power. Type 2 errors are likely to have occurred, and a larger trial is now underway to test for robust effects and replicate signals of effectiveness in important secondary outcomes such as loneliness.ConclusionsIn this study, we observed that BA is a credible intervention to mitigate the psychological impacts of COVID-19 isolation for older adults. We demonstrated that it is feasible to undertake a trial of BA. The intervention can be delivered remotely and at scale, but should be reserved for older adults with evidence of depressive symptoms. The significant reduction in loneliness is unlikely to be a chance finding, and replication will be explored in a fully powered randomised controlled trial (RCT).Trial registrationISRCTN94091479.

In a pilot randomised controlled trial, Simon Gilbody and colleagues present preliminary findings from a telephone delivered intervention (behavioural activation) designed to prevent depression and loneliness among socially isolated older people with long term conditions.     

Collaborative Interventions for Circulation and Depression (COINCIDE): study protocol for a cluster randomized controlled trial of collaborative care for depression in people with diabetes and/or coronary heart disease

ABSTRACT: BACKGROUND: Depression is up to two to three times as common in people with long-term conditions. It negatively affects medical management of disease and self-care behaviors, and leads to poorer quality of life and high costs in primary care. Screening and treatment of depression is increasingly prioritized, but despite initiatives to improve access and quality of care, depression remains under-detected and under-treated, especially in people with long-term conditions. Collaborative care is known to positively affect the process and outcome of care for people with depression and long-term conditions, but its effectiveness outside the USA is still relatively unknown. Furthermore, collaborative care has yet to be tested in settings that resemble more naturalistic settings that include patient choice and the usual care providers. The aim of this study was to test the effectiveness of a collaborative-care intervention, for people with depression and diabetes/coronary heart disease in National Health Service (NHS) primary care, in which low-intensity psychological treatment services are delivered by the usual care provider - Increasing Access to Psychological Therapies (IAPT) services.s. The study also aimed to evaluate the cost-effectiveness of the intervention over 6 months of collaborative care, and to assess qualitatively the extent to which collaborative care was implemented in the intervention general practices. METHODS: This is a cluster randomized controlled trial of 30 general practices allocated to either collaborative care or usual care. Fifteen patients per practice will be recruited after a screening exercise to detect patients with recognized depression (greater than or equal to 10 on the nine-symptom Patient Health Questionnaire; PHQ-9). Patients in the collaborative-care arm with recognized depression will be offered a choice of evidence-based low-intensity psychological treatments based on cognitive and behavioral approaches. Patients will be case managed by psychological well-being practitioners employed by IAPT in partnership with a practice nurse and/or general practitioner. The primary outcome will be change in depressive symptoms at 6 months on the 90-item Symptoms Checklist (SCL-90). Secondary outcomes include change in health status, self-care behaviors, and self-efficacy. A qualitative process evaluation will be undertaken with patients and health practitioners to gauge the extent to which the collaborative-care model is implemented, and to explore sustainability beyond the clinical trial. DISCUSSION: COINCIDE will assess whether collaborative care can improve patient-centered outcomes, and evaluate access to and quality of care of co-morbid depression of varying intensity in people with diabetes/coronary heart disease. Additionally, by working with usual care providers such as IAPT, and by identifying and evaluating interventions that are effective and appropriate for routine use in the NHS, the COINCIDE trial offers opportunities to address translational gaps between research and implementation.Trial Registration NumberISRCTN80309252Trial StatusOpen.     

Effects of gender and depression on oral medication adherence in persons with type 2 diabetes mellitus

Background: In a range of chronic conditions including diabetes, it has been observed that depressive symptoms may be associated with nonadherence to medications.Objective: The objective of the study was to determine the main effects, and interactive effect, of depression and gender on patients adherence to oral diabetes medications.Methods: A cross-sectional design was employed, in which persons with type 2 diabetes mellitus completed a questionnaire regarding medication use behaviors, depressive symptoms (measured by the 8-item Patient Health Questionnaire [PHQ-8]), health beliefs, and demographics. A 2 x 2 factorial analysis of variance was used to determine the effects of gender and depression on medication adherence after adjusting for age, education, self efficacy, social support, and number of doses of diabetes medications.Results: Of the 391 respondents who completed the questionnaire, 73 (18.7%) were categorized as having depression (ie, PHQ-8 score >10). Overall, women (n = 196) had a mean (SD) score of 6.10 (6.19) on the PHQ-8, and men (n = 195) had a lower score of 4.62 (5.28) (t = 2.75; P < 0.01). There was a significant main effect of depression, but not gender, on patients' adherence to diabetes medications in that those who were categorized as depressed had significantly worse adherence to diabetes medications (F = 4.82; P = 0.03).Additionally, there was a significant “gender x depression” interaction effect on adherence (F = 5.93; P = 0.01). Men with depression had mean adherence scores that indicated more nonadherence than did men without depression (9.44 [3.45] vs 7.47 [2.50], respectively), but adherence varied little between women with depression and women without depression (7.83 [2.69] vs 7.55 [2.58], respectively).Conclusions: The association between depression and medication adherence appears to be stronger in men than in women. Clinicians should be cognizant of the potential effect of depression on self-care for diabetes, particularly in men with depressive symptoms.     

Effects of Depressive Symptoms and Family Satisfaction on Health Related Quality of Life: The Hong Kong FAMILY Study

Objective

To examine the effect of depressive symptoms and satisfaction with family support (FS) on physical and mental Health Related Quality of Life (HRQoL).

Methods

Data were obtained from the Hong Kong FAMILY Project baseline survey in 2009–2011, which included 16,039 community residents (age ≥20). The FS was measured using the Family Adaptation, Partnership, Growth, Affection, Resolve (APGAR, range 0–10) Questionnaire. HRQoL were assessed using the SF-12 version 2. Depressive symptoms were recorded using the Patient Health Questionnaire-9 (PHQ-9). Demographic and lifestyle variables, stressful life events, perceived neighborhood cohesion were also assessed.

Results

In a multilevel regression model, socio-demographic and behavioral variables explained 21% and 19% of the variance in physical and mental HRQoL. The presence of depressive symptoms (PHQ-9 score ≥10, standardized coefficients, β of −1.73) and high FS (APGAR score 7–10, 1.15) were associated with mental HRQoL, after adjustment for age, education, household monthly income, drinking status, physical activity, chronic conditions, life stress and neighborhood cohesion. Not FS but the presence of depressive symptoms (β of −0.88) was associated with physical HRQoL. The presence of depressive symptoms in women than men were more associated with a poorer physical HRQoL (p<0.01) while depressive symptoms in men were associated with a decrease in mental HRQoL (p<0.001). The interaction between FS and depressive symptoms was nonsignificant in relation to HRQoL. Among those with depressive symptoms, high FS was associated with a better mental HRQoL (41.1 vs. 37.9, p<0.001) in women but not contribute to variance in men.

Conclusions

Higher FS and presence of depressive symptoms were significantly associated with HRQoL in general population in Hong Kong. Among those with depressive symptoms, high FS was associated with a favorable mental HRQoL in women but not men.     

Resiliencia en las personas mayores durante la primera ola pandémica de la COVID-19 en Chile: una perspectiva desde los determinantes sociales de la salud

ObjectiveTo assess the association between social determinants of health (SDH) and resilience in older people during the first period of confinement in the COVID-19 pandemic in Chile.Materials and methodsAn observational study with a cross-sectional design was conducted using a nationally representative survey data-set. In this survey, using a systematic randomization process, a subsample of people aged ≥60 years from the community were interviewed by telephone during the first wave of the COVID-19 pandemic in Chile. Resilience was assessed using the Brief Resilient Coping Scale (BRCS) and depressive symptoms using the Patient Health Questionnaire (PHQ-9) scale. The SDH considered were: age, sex, educational level, employment status, social isolation, loneliness, discontent with housing and health care needs.ResultsA total sample of 582 persons was obtained. The mean age was 71 years (SD: 7.64; 69% women). A significant association was obtained between low resilience and the following conditions: loneliness (OR: 1.776 [95% CI: 1.146–2.751]), high risk of social isolation (OR: 1.667 [95% CI: 1.149-2.419]), and depressive symptoms (OR: 2.602 [95% CI: 1.795-3.774]). Female gender was a protective factor (OR: 0.589 [95% CI: 0.406-0.855]).ConclusionThe SDH, such as loneliness and social isolation, are factors associated with low resilience in older people during the COVID-19 pandemic and may be taken into account in planning public health intervention strategies.     

Detecting Depression in Patients with Coronary Heart Disease: a Diagnostic Evaluation of the PHQ-9 and HADS-D in Primary Care,Findings From the UPBEAT-UK Study

Objective

People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R).

Methods

The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London.

Results

Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%.Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression.

Conclusion

This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.     

Efficacies of the new Paclitaxel-eluting Coroflex Please™ Stent in percutaneous coronary intervention; comparison of efficacy between Coroflex Please™ and Taxus™ (ECO-PLEASANT) trial: study rationale and design

Background

Almost 50% of Americans have elevated low-density lipoprotein cholesterol (LDL-C). The behaviors required to lower LDL-C levels may be difficult to adhere to if they are inconsistent with spouses' health practices, and, alternatively, may be enhanced by enlisting support from the spouse. This trial extends previous trials by requiring spouse enrollment, teaching spouses how to provide emotional and instrumental support, allowing patients to decide which component of the intervention they would like to receive, and having patients determine their own goals and action plans.

Methods

Veteran outpatients with above-goal LDL-C (N = 250) and their spouses are randomized, as a couple, to receive printed education materials only or the materials plus an 11-month, nurse-delivered, telephone-based intervention. The intervention contains four modules: medication adherence, diet, exercise, and patient-physician communication. Patients decide which modules they complete and in which order; modules may be repeated or omitted. Telephone calls are to patients and spouses separately and occur monthly. During each patient telephone call, patients' progress is reviewed, and patients create goals and action plans for the upcoming month. During spouse telephone calls, which occur within one week of patient calls, spouses are informed of patients' goals and action plans and devise strategies to increase emotional and instrumental support. The primary outcome is patients' LDL-C, measured at baseline, 6 months, and 11 months. Linear mixed models will be used to test the primary hypothesis that an 11-month, telephone-based patient-spouse intervention will result in a greater reduction in LDL-C as compared to printed education materials. Various process measures, including social support, self-efficacy, medication adherence, dietary behavior, and exercise, are also assessed to explain any change, or lack thereof, in LDL-C.

Discussion

Given the social context in which self-management occurs, interventions that teach spouses to provide instrumental and emotional support may help patients initiate and adhere to behaviors that lower their LDL-C levels. Moreover, allowing patients to retain autonomy by deciding which behaviors they would like to change and how may improve adherence and clinical outcomes.

Trial Registration

The ClinicalTrials.gov registration number is NCT00321789.     

Correlation between mental health co-morbidity screening scores and clinical response in collaborative care treatment for depression

The hypothesis for this paper is that adult patients who have higher screening scores for mental health co-morbidities and depression have a greater likelihood of not responding to treatment with collaborative care management (CCM) for their depression within six months.For the 334 patients in this study, the primary endpoints were if the patient was in remission at six months (PHQ-9 score <5) or if they were non-responsive (NR) (PHQ-9 >50% of baseline score). Initial evaluation included screening for alcoholism (AUDIT), anxiety (GAD-7) and bipolar disorders (MDQ).The differences in marital status, percentage of minority patients, gender, initial PHQ-9 and AUDIT scores were not statistically significant. Mood Disorders Questionnaire (MDQ) screening was more likely to be negative for the group in remission (96.2% vs 90.0%, P=0.049) and positive for the NR group (8.0% vs 2.1%, P=0.026). GAD-7 screening was significantly lower in the remission group (9.85) than in the NR group (11.53, P=0.009).Results of multiple logistic regression analysis demonstrated that age, gender, race, marital status, PHQ-9 score and AUDIT score were not related to the odds of being NR. A one-point higher GAD-7 score was associated with approximately 6% higher adjusted odds of being NR. Patients with a positive MDQ were associated with elevated odds of non-response (adjusted OR=3.4714, P=0.044) when controlling for all other variables.A higher initial screening score for anxiety or bipolar disorder is associated with a statistically significant increase in the relative risk of patients in CCM not responding to current treatments for depression within six months.     

Effectiveness of focused structural massage and relaxation massage for chronic low back pain: protocol for a randomized controlled trial

Background

Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care.

Methods and design

This paper describes the protocol of a nested 2 × 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months.

Discussion

Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources.

Trial registration

ClinicalTrials.gov identifier NCT00201136     

Persistence of Psychological Distress in Surgical Patients with Interest in Psychotherapy: Results of a 6-Month Follow-Up

Objectives

This prospective observational study investigated whether self-reported psychological distress and alcohol use problems of surgical patients change between preoperative baseline assessment and postoperative 6-month follow-up examination. Patients with preoperative interest in psychotherapy were compared with patients without interest in psychotherapy.

Methods

A total of 1,157 consecutive patients from various surgical fields completed a set of psychiatric questionnaires preoperatively and at 6 months postoperatively, including Patient Health Questionnaire-4 (PHQ-4), Brief Symptom Inventory (BSI), Center for Epidemiologic Studies Depression Scale (CES-D), World Health Organization 5-item Well-Being Index (WHO-5), and Alcohol Use Disorder Identification Test (AUDIT). Additionally, patients were asked for their interest in psychotherapy. Repeated measure ANCOVA was used for primary data analysis.

Results

16.7% of the patients were interested in psychotherapy. Compared to uninterested patients, they showed consistently higher distress at both baseline and month 6 regarding all of the assessed psychological measures (p’s between <0.001 and 0.003). At 6-month follow-up, neither substantial changes over time nor large time x group interactions were found. Results of ANCOVA’s controlling for demographic variables were confirmed by analyses of frequencies of clinically significant distress.

Conclusion

In surgical patients with interest in psychotherapy, there is a remarkable persistence of elevated self-reported general psychological distress, depression, anxiety, and alcohol use disorder symptoms over 6 months. This suggests high and chronic psychiatric comorbidity and a clear need for psychotherapeutic and psychiatric treatment rather than transient worries posed by facing surgery.     

Systemic inflammation,depression and obstructive pulmonary function: a population-based study

Background

Levels of Interleukin-6 (IL-6) and C-creative protein (CRP) indicating systemic inflammation are known to be elevated in chronic diseases including chronic obstructive pulmonary disease (COPD) and depression. Comorbid depression is common in patients with COPD, but no studies have investigated whether proinflammatory cytokines mediate the association between pulmonary function and depressive symptoms in healthy individuals with no known history of obstructive pulmonary diseases.

Methods

In a population-based sample (n = 2077) of individuals aged 55 and above with no known history of obstructive pulmonary disease in the Singapore Longitudinal Ageing Study (SLAS), we analyzed the relationships between IL-6 and CRP, depressive symptoms (GDS-15 ≥5) and obstructive pulmonary function (FEV1% predicted and FEV1/FVC% predicted).

Results

High serum levels of IL-6 and CRP were associated with greater prevalence of depressive symptoms (p < 0.05). High IL-6, high CRP and depressive symptoms were independently associated with decreased FEV1% predicted and FEV1/FVC% predicted after adjusting for smoking status, BMI and number of chronic inflammatory diseases. Increasing grades of combination of inflammatory markers and/or depressive symptoms was associated with progressive increases in pulmonary obstruction. In hierarchical models, the significant association of depressive symptoms with pulmonary obstruction was reduced by the presence of IL-6 and CRP.

Conclusions

This study found for the first time an association of depressive symptoms and pulmonary function in older adults which appeared to be partly mediated by proinflammatory cytokines. Further studies should be conducted to investigate proinflammatory immune markers and depressive symptoms as potential phenotypic indicators for chronic obstructive airway disorders in older adults.     

Depression remission after six months of collaborative care management: role of initial severity of depression in outcome

Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management.Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis.Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345–0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659–0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803–0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables.Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.