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1.  Admixture analysis of age at onset in major depressive disorder 
General hospital psychiatry  2012;34(6):686-691.
Objectives
This study aimed to determine the distributions of the age at onset (AAO) in patients with major depressive disorder (MDD) using admixture analysis and to determine the clinical differences between subgroups with different AAO.
Methods
Participants were administered the Mini-International Neuropsychiatric Interview and the Montgomery–Asberg Depression Rating Scale to obtain clinical data. Admixture analysis was performed using the STATA module DENORMIX to identify subgroups characterized by differences in AAO.
Results
The best fit model was the three-component model with the following means, standard deviations and proportions: 14.60 (3.75) years (49.1%), 29.15 (6.75) years (34.1%) and 46.96 (6.06) years (16.8%) (χ2=3.64, 2 df, P=.162). The three subgroups were divided by AAO of 22 and 40. After controlling for duration of illness, there were no significant differences between the three subgroups in terms of gender and family history. However, the early-onset subgroup was significantly more likely to report being single compared to the intermediate- and late-onset groups. The proportion of individuals meeting criteria for lifetime comorbid panic disorders and obsessive–compulsive disorder did not differ significantly between the AAO groups. However, there was a trend for higher incidence of generalized anxiety disorder in the early- and intermediate-onset compared to the late-onset subgroup (43.4% and 41.9% vs. 30.0%, P=.095). Furthermore, the early-onset group reported a higher incidence of attention-deficit/hyperactivity disorder (5.1% vs. 1.7% and 1.2%, P=.085) diagnosis, although this was also not statistically significant. In addition, there was a trend for higher rate of lifetime substance use in the early-onset group compared to the intermediate- and late-onset groups (18.9% compared to 12.4% and 10.0%, respectively; P=.061).
Conclusions
Our study identified clinically different AAO subgroups in individuals suffering from MDD. The subgroups may reflect different underlying neurobiological mechanisms involved.
doi:10.1016/j.genhosppsych.2012.06.010
PMCID: PMC3941474  PMID: 22898442
2.  Skin Picking Disorder in University Students: Health Correlates and Gender Differences 
General hospital psychiatry  2012;35(2):168-173.
Objective
This study sought to examine the prevalence of skin picking disorder (SPD) in a university sample and assess associated physical and mental health correlates.
Methods
A 54-item anonymous, voluntary survey was distributed via random email generation to a sample of 6,000 university students. Current psychological and physical status was assessed, along with academic performance. Positive screens for SPD were determined based upon individuals meeting full proposed DSM-V criteria.
Results
A total of 1,916 participants (31.9%; mean age 22.7±5.1; 58.1% female) responded and were included in the analysis. The overall prevalence of SPD was 4.2% (females=5.8%; males=2.0%). SPD was associated with significantly higher lifetime rates of affective, anxiety, eating, substance use, and impulse control disorders. Men with SPD had significantly higher BMI ratings and perceived themselves as significantly less attractive to others while women had significantly higher depressive symptoms.
Conclusion
SPD is common in both genders and is associated with significant mental and physical health detriments, including as higher levels of stress, more psychiatric comorbidity, and poorer perceived health. Academic institutions, clinicians, and public health officials should be aware of the multimodal presentation of SPD and screen for it in primary care and dermatologic settings.
doi:10.1016/j.genhosppsych.2012.08.006
PMCID: PMC3566337  PMID: 23123103
body focused repetitive behaviors; comorbidity; gender; health
3.  Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for Alcohol at Trauma Centers Study Design 
General hospital psychiatry  2012;35(2):174-180.
Objective
In 2005 the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high quality alcohol screening and brief intervention (SBI) services at trauma centers.
Method
Twenty sites selected from all US Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma center-based alcohol SBI with blood alcohol positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed.
Results
The investigation has successfully recruited provider, patient, and trauma center staff samples into the study and outcomes are being followed longitudinally.
Conclusion
When completed, the DO-SBIS trial will inform future American College of Surgeons’ policy targeting the sustained integration of high quality alcohol SBI at trauma centers nationwide.
doi:10.1016/j.genhosppsych.2012.11.012
PMCID: PMC3594343  PMID: 23273831
Acute care medical trauma centers; Injury; Alcohol; Screening and brief intervention; American College of Surgeons
4.  IS TREATMENT ADHERENCE CONSISTENT ACROSS TIME, ACROSS DIFFERENT TREATMENTS, AND ACROSS DIAGNOSES? 
General hospital psychiatry  2012;35(2):195-201.
Objective
Examine consistency of adherence across depression treatments and consistency of adherence between depression treatments and treatments for chronic medical illness.
Methods
For 25,456 health plan members beginning psychotherapy for depression between 2003 and 2008, health plan records were used to examine adherence to all episodes of psychotherapy, antidepressant medication, antihypertensive medication, and lipid-lowering medication.
Results
Within treatments, adherence to psychotherapy in one episode predicted approximately 20% greater likelihood of subsequent psychotherapy adherence (OR 2.20, 95% CI 1.83 to 2.64). Similarly, adherence to antidepressant medication in one episode predicted approximately 20% greater likelihood of subsequent antidepressant adherence (OR 1.99, 95% CI 1.74 to 2.28). Across treatments, adherence to antidepressant medication predicted approximately 10% greater likelihood of concurrent or subsequent adherence to psychotherapy (OR 1.52, 95% CI 1.42 to 1.63), a 4% greater likelihood of adherence to antihypertensive medication (OR 1.24, 95% CI 1.14 to 1.37) and a 3% greater likelihood of adherence to lipid-lowering medication (OR 1.16, 95% CI 1.03 to 1.32). Adherence to psychotherapy predicted a 2% greater likelihood of concurrent or subsequent adherence to antihypertensive medication (OR 1.11, 95% CI 1.04 to 1.19) and was not a significant predictor of adherence to lipid-lowering medication (OR 0.99, 95% CI 0.90 to 1.18).
Conclusions
Adherence is moderately consistent across episodes of depression treatment. Depression treatment adherence is a statistically significant, but relatively weak, predictor of adherence to antihypertensive or lipid-lowering medication.
doi:10.1016/j.genhosppsych.2012.10.001
PMCID: PMC3594411  PMID: 23141589
depression; adherence; antidepressant; psychotherapy; hypertension; cholesterol
5.  Restoring professionalism: the physician fitness-for-duty evaluation☆ 
General hospital psychiatry  2013;35(6):659-663.
Objectives
We compare findings from 10 years of experience evaluating physicians referred for fitness-to-practice assessment to determine whether those referred for disruptive behavior are more or less likely to be declared fit for duty than those referred for mental health, substance abuse or sexual misconduct.
Method
Deidentified data from 381 physicians evaluated by the Vanderbilt Comprehensive Assessment Program (2001–2012) were analyzed and compared to general physician population data and also to previous reports of physician psychiatric diagnosis found by MEDLINE search.
Results
Compared to the physicians referred for disruptive behavior (37.5% of evaluations), each of the other groups was statistically significantly less likely to be assessed as fit for practice [substance use, %: odds ratio (OR)=0.22, 95% confidence interval (CI)=0.10–0.47, P<.001; mental health, %: OR=0.14, 95% CI=0.06–0.31, P<.001; sexual boundaries, %: OR=0.27, 95% CI=0.13–0.58, P=.001].
Conclusions
The number of referrals to evaluate physicians presenting with behavior alleged to be disruptive to clinical care increased following the 2008 Joint Commission guidelines that extended responsibility for professional conduct outside the profession itself to the institutions wherein physicians work. Better strategies to identify and manage disruptive physician behavior may allow those physicians to return to practice safely in the workplace.
doi:10.1016/j.genhosppsych.2013.06.009
PMCID: PMC3923266  PMID: 23910216
Professionalism; Medical ethics; Fitness for duty; Fitness to practice; Disruptive behavior; Physician health and wellness; Comprehensive psychiatric assessment; Psychiatric diagnosis
6.  Racial differences in the prevalence of antenatal depression 
General hospital psychiatry  2011;33(2):10.1016/j.genhosppsych.2010.11.012.
Objective
This study examined whether there were racial/ethnic differences in the prevalence of antenatal depression based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria in a community-based sample of pregnant women.
Method
Data were drawn from an ongoing registry of pregnant women receiving prenatal care at a university obstetric clinic from January 2004 through March 2010 (N =1997). Logistic regression models adjusting for sociodemographic, psychiatric, behavioral and clinical characteristics were used to examine racial/ethnic differences in antenatal depression as measured by the Patient Health Questionnaire.
Results
Overall, 5.1% of the sample reported antenatal depression. Blacks and Asian/Pacific Islanders were at increased risk for antenatal depression compared to non-Hispanic White women. This increased risk of antenatal depression among Blacks and Asian/Pacific Islanders remained after adjustment for a variety of risk factors.
Conclusion
Results suggest the importance of race/ethnicity as a risk factor for antenatal depression. Prevention and treatment strategies geared toward the mental health needs of Black and Asian/Pacific Islander women are needed to reduce the racial/ethnic disparities in antenatal depression.
doi:10.1016/j.genhosppsych.2010.11.012
PMCID: PMC3880676  PMID: 21596200
Racial disparity; Pregnancy; Depression; Black; Asian/Pacific islander
7.  Evaluating brief screeners to discriminate between drug use disorders in a sample of treatment-seeking adults 
General hospital psychiatry  2012;35(1):74-82.
Objective
To identify a potential core set of brief screeners for the detection of individuals with a substance use disorder (SUD) in medical settings.
Method
Data were from two multisite studies that evaluated stimulant use outcomes of an abstinence-based contingency management intervention as an addition to usual care (National Drug Abuse Treatment Clinical Trials Network [CTN] trials 006-007). The sample comprised 847 substance-using adults who were recruited from 12 outpatient substance abuse treatment settings across the United States. Alcohol and drug use disorders were assessed by the DSM-IV Checklist. Data were analyzed by factor analysis, item response theory (IRT), sensitivity, and specificity procedures.
Results
Comparatively prevalent symptoms of dependence, especially inability to cut down for all substances, showed high sensitivity for detecting a SUD (low rate of false negative). IRT-defined severe (infrequent) and low discriminative items, especially withdrawal for alcohol, cannabis, and cocaine, had low sensitivity in identifying cases of a SUD. IRT-defined less severe (frequent) and high discriminative items, including inability to cut down or taking larger amounts than intended for all substances and withdrawal for amphetamines and opioids, showed good-to-high values of area under the receiver operating characteristic curve in classifying cases and non-cases of a SUD.
Conclusion
Findings suggest the feasibility of identifying psychometrically reliable substance dependence symptoms to develop a two-item screen for alcohol and drug disorders.
doi:10.1016/j.genhosppsych.2012.06.014
PMCID: PMC3504628  PMID: 22819723
Clinical trials network; Item response theory; Receiver operating characteristic curve; Brief screening; Substance use disorders
8.  Associations between health risk behaviors and symptoms of schizophrenia and bipolar disorder: a systematic review 
General hospital psychiatry  2012;35(1):16-22.
Objective
To systematically review the literature to determine if health risk behaviors in patients with schizophrenia or bipolar disorder are associated with subsequent symptom burden or level of functioning.
Method
Using the PRISMA systematic review method we searched PubMed, Cochrane, PsychInfo and EMBASE databases with key words: health risk behaviors, diet, obesity, overweight, BMI, smoking, tobacco use, cigarette use, sedentary lifestyle, sedentary behaviors, physical inactivity, activity level, fitness, sitting AND schizophrenia, bipolar disorder, bipolar illness, schizoaffective disorder, severe and persistent mental illness, and psychotic to identify prospective, controlled studies of greater than 6 months duration. Included studies examined associations between sedentary lifestyle, smoking, obesity, physical inactivity and subsequent symptom severity or functional impairment in patients with schizophrenia or bipolar disorder.
Results
Eight of the 2130 articles identified met inclusion criteria and included 508 patients with a health risk behavior and 825 controls. Six studies examined tobacco use and two studies examined weight gain/obesity. Seven studies found that patients with schizophrenia or bipolar illness and at least one health risk behavior had more severe subsequent psychiatric symptoms and/or decreased level of functioning.
Conclusion
Tobacco use and weight gain/obesity may be associated with increased severity of symptoms of schizophrenia and bipolar disorder or decreased level of functioning.
doi:10.1016/j.genhosppsych.2012.08.001
PMCID: PMC3543518  PMID: 23044246
Health risk behaviors; severe and persistent mental illness; obesity; sedentary behavior
9.  Details on suicide among U.S. physicians: Data from the National Violent Death Reporting System 
General hospital psychiatry  2012;35(1):45-49.
Objective
Physician suicide is an important public health problem as the rate of suicide is higher among physicians than the general population. Unfortunately, few studies have evaluated information about mental health comorbidities and psychosocial stressors which may contribute to physician suicide. We sought to evaluate these factors among physicians versus non-physician suicide victims.
Methods
We used data from the United States National Violent Death Reporting System to evaluate demographics, mental health variables, recent stressors, and suicide methods among physician versus non-physician suicide victims in 17 states.
Results
The dataset included 31,636 suicide victims of whom 203 were identified as physicians. Multivariable logistic regression found that having a known mental health disorder or a job problem which contributed to the suicide significantly predicted being a physician. Physicians were significantly more likely than non-physicians to have antipsychotics, benzodiazepines, and barbiturates present on toxicology testing but not antidepressants or antipsychotics.
Conclusions
Mental illness is an important comorbidity for physicians who complete a suicide but postmortem toxicology data shows low rates of medication treatment. Inadequate treatment and increased problems related to job stress may be potentially-modifiable risk factors to reduce suicidal death among physicians.
doi:10.1016/j.genhosppsych.2012.08.005
PMCID: PMC3549025  PMID: 23123101
suicide; physicians; health professionals; mental health; depression
10.  Effect of Diabetes Fatalism on Medication Adherence and Self-Care Behaviors in Adults with Diabetes 
General hospital psychiatry  2012;34(6):598-603.
Objective
Diabetes fatalism is defined as “a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness” and associated with poor glycemic control. This study examined the association between diabetes fatalism and medication adherence and self-care behaviors in adults with diabetes.
Methods
Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure diabetes fatalism, medication adherence, diabetes knowledge, and diabetes self-care behaviors (diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of diabetes fatalism on medication adherence and self-care behaviors controlling for relevant covariates.
Results
Fatalism correlated significantly with medication adherence (r = 0.24, p<0.001), diet (r = −0.26, p<0.001), exercise (r = −0.20, p<0.001) and blood sugar testing (r = −0.19, p<0.001). In the linear regression model, diabetes fatalism was significantly associated with medication adherence (β= 0.029, 95% CI 0.016, 0.043); diabetes knowledge (β= −0.042, 95% CI −0.001, −0.084); diet (β= −0.063, 95% CI −0.039, −0.087), exercise (β= −0.055, 95% CI −0.028, −0.083), and blood sugar testing (β= −0.055, 95% CI −0.023, −0.087). There was no significant association between diabetes fatalism and foot care (β= −0.018, 95% CI −0.047, 0.011). The association between diabetes fatalism and medication adherence, diabetes knowledge and diabetes self-care behaviors did not change significantly when depression was added to the models, suggesting that the associations are independent of depression.
Conclusion
Diabetes fatalism is associated with poor medication adherence and self-care and may be an important target for education and skills interventions in diabetes care. In addition, the effect of diabetes fatalism is independent of depression, suggesting that interventions that target depression may not be sufficient to deal with diabetes fatalism.
doi:10.1016/j.genhosppsych.2012.07.005
PMCID: PMC3479321  PMID: 22898447
fatalism; medication adherence; self-care; diabetes
11.  Association of Treatment Modality for Depression and Burden of Comorbid Chronic Illness in a Nationally Representative Sample in the United States 
General hospital psychiatry  2012;34(6):588-597.
Objective
We examined associations between treatment modality for depression and morbidity burden. We hypothesized that patients with higher numbers of co-occurring chronic illness would be more likely to receive recommended treatment for depression both with antidepressant medication and psychotherapy.
Methods
Using a retrospective cross-sectional design, we analyzed data on 165,826 people over 16 years from 2004–2008. Using a single multinomial logistic regression model, we examined the likelihood of treatment modality for depression: no treatment; psychotherapy alone; medication alone; and psychotherapy and medication. We examined the following predictors of therapy 1) morbidity burden, 2) five specific chronic conditions individually: diabetes mellitus II, coronary artery disease, congestive heart failure, hypertension, and chronic obstructive pulmonary disease or asthma, and 3) sociodemographic factors.
Results
The likelihood of any treatment for depression, specifically psychotherapy with medication, increased with the number of co-occurring illnesses. We did not find a clear pattern of association between the five specific conditions and treatment modality; though we identified treatment patterns associated with multiple sociodemographic factors.
Conclusion(s)
This study provides insight into the relationship between multimorbidity and treatment modalities which could prove helpful in developing implementation strategies for the dissemination of evidence-based approaches to depression care.
doi:10.1016/j.genhosppsych.2012.07.004
PMCID: PMC3479411  PMID: 23089065
Depression; Mental Health Services; Comorbidity; Psychotherapy; and Antidepressant Drugs
12.  Prescribed Opioid Difficulties, Depression, and Opioid Dose Among Chronic Opioid Therapy Patients 
General hospital psychiatry  2012;34(6):581-587.
Background
Chronic opioid therapy has increased dramatically, as have complications related to prescription opioids. Little is known about the problems and concerns attributed to opioids by patients receiving different opioid doses.
Methods
We surveyed 1883 patients who were receiving chronic opioid therapy for chronic non-cancer pain. Opioid regimen characteristics were ascertained from electronic pharmacy records. Patient-reported opioid-related problems and concerns were measured using the Prescription Opioid Difficulties Scale. Depression was assessed with the Patient Health Questionnaire.
Results
Patients prescribed higher opioid doses reported modestly higher pain intensity and pain impact. After adjustment, patients on higher doses attributed higher levels of psychosocial problems and control concerns to prescribed opioids (p<.0001). They also had higher levels of depression and were more likely to meet criteria for clinical depression. Over 60% of patients receiving 120+ mg daily (morphine equivalent) were clinically depressed, a 2.6-fold higher risk (95% CI of 1.5 to 4.4) than patients on low dose regimens (< 20 mg daily).
Conclusions
Higher opioid doses were associated with somewhat higher pain severity and higher levels of patient-reported opioid-related psychosocial problems, control concerns, and depression. These findings may result from patient selection for high dose therapy or problems caused by higher dose opioids.
doi:10.1016/j.genhosppsych.2012.06.018
PMCID: PMC3665511  PMID: 22959422
Opioid; Dosage; Chronic Pain; Depression; Addiction
13.  Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability 
General hospital psychiatry  2010;32(5):10.1016/j.genhosppsych.2010.04.001.
Objective
To describe the history and evolution of the collaborative depression care model and new research aimed at enhancing dissemination.
Method
Four keynote speakers from the 2009 NIMH Annual Mental Health Services Meeting collaborated in this article in order to describe the history and evolution of collaborative depression care, adaptation of collaborative care to new populations and medical settings, and optimal ways to enhance dissemination of this model.
Results
Extensive evidence across 37 randomized trials has shown the effectiveness of collaborative care vs. usual primary care in enhancing quality of depression care and in improving depressive outcomes for up to 2 to 5 years. Collaborative care is currently being disseminated in large health care organizations such as the Veterans Administration and Kaiser Permanente, as well as in fee-for-services systems and federally funded clinic systems of care in multiple states. New adaptations of collaborative care are being tested in pediatric and ob-gyn populations as well as in populations of patients with multiple comorbid medical illnesses. New NIMH-funded research is also testing community-based participatory research approaches to collaborative care to attempt to decrease disparities of care in underserved minority populations.
Conclusion
Collaborative depression care has extensive research supporting the effectiveness of this model. New research and demonstration projects have focused on adapting this model to new populations and medical settings and on studying ways to optimally disseminate this approach to care, including developing financial models to incentivize dissemination and partnerships with community populations to enhance sustainability and to decrease disparities in quality of mental health care.
doi:10.1016/j.genhosppsych.2010.04.001
PMCID: PMC3810032  PMID: 20851265
Collaborative depression care; Dissemination; Sustainability
14.  Trends in US Emergency Department Visits for Attempted Suicide and Self-inflicted Injury, 1993–2008 
General hospital psychiatry  2012;34(5):557-565.
Objective
To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
Method
Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950–E959) during 1993–2008.
Results
Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (CI) 1.33–1.67] visits per 1,000 US population) and the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008. During the same timeframe, ED visits for these injuries per 1,000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). Visits were most common among ages 15–19 and the number of visits coded as urgent/emergent decreased.
Conclusions
ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.
doi:10.1016/j.genhosppsych.2012.03.020
PMCID: PMC3428496  PMID: 22554432
Suicide; Emergency Departments; Public Health
15.  Post-myocardial infarction quality of care among disabled Medicaid beneficiaries with and without serious mental illness 
General hospital psychiatry  2012;34(5):493-499.
Objective
To examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries.
Methods
We conducted a retrospective cohort study disabled Maryland Medicaid beneficiaries with myocardial infarction from 1994 to 2004. Cardiac procedures and guideline-based medication use were compared for persons with and without serious mental illness.
Results
Of the 633 cohort members with myocardial infarction, 137 had serious mental illness. Serious mental illness was not associated with differences in receipt of cardiac procedures or guideline-based medications. Overall use of guideline-based medications was low; 30 days after the index hospitalization for myocardial infarction, 19%, 35%, and 11% of cohort members with serious mental illness and 22%, 37%, and 13% of cohort members without serious mental illness had any use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and statins, respectively. Study participants with and without serious mental illness had similar rates of mortality. Overall, use of beta-blockers (hazard ratio 0.93, 95% CI 0.90-0.97) and statins (hazard ratio 0.93, 95% CI 0.89-0.98) were associated with reduced risk of mortality.
Conclusions
Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.
doi:10.1016/j.genhosppsych.2012.05.004
PMCID: PMC3428513  PMID: 22763001
quality of care; myocardial infarction; mental illness
16.  Motivational Enhancement Therapy Coupled with Cognitive Behavioral Therapy versus Brief Advice; A Randomized Trial for Treatment of Hazardous Substance Use in Pregnancy and After Delivery 
General hospital psychiatry  2012;34(5):439-449.
Objective
To compare the efficacy of motivational enhancement therapy coupled with cognitive behavioral therapy (MET-CBT) to brief advice for treatment of substance use in pregnancy.
Method
This was a randomized, parallel, controlled trial that was yoked to prenatal care and delivered at hospital outpatient clinics. We enrolled 168 substance using women who had not yet completed an estimated 28 weeks of pregnancy. Obstetrical clinicians provided brief advice and study nurses administered manualized MET-CBT. The primary outcome was percentage of days in the prior 28 days, that alcohol and/or drugs were used immediately before and three months post delivery.
Results
There were no significant differences across groups in terms of self-reported percentage of days that drugs or alcohol were used prior to and three months post delivery. Biological measures showed similar results. There was a trend (p=0.08) for lower risk of preterm birth among those who received MET-CBT.
Conclusions
The tested interventions had similar therapeutic effects. Hence, both treatments may be suitable for pregnant substance users, depending on the population, setting, and provider availability. Interventions that are intensified after delivery may decrease postpartum ‘rebound’ effects in substance misuse.
doi:10.1016/j.genhosppsych.2012.06.002
PMCID: PMC3428516  PMID: 22795046
17.  Bottlenecks in the Emergency Department: the psychiatric clinicians’ perspective☆ 
General hospital psychiatry  2012;34(4):403-409.
Objective
To ask psychiatric clinicians for their perspectives on the rate-limiting steps (RLS) in patient care in the Emergency Department (ED) and to compare them to the patient’s actual length of stay.
Method
Prospective cohort study of clinicians’ perspectives on the RLS among 1092 adult ED patients. Medical records were abstracted for ED time and other data.
Results
Clinicians identified five RLS: limited availability of staff, limited availability of beds after discharge, need for clinical stability, need for additional history and patient’s financial issues. The last RLS was the only one not associated with increased wait times in the ED. There were significant differences in the patterns of RLS by trainee status and hospital. For example, significantly higher proportions of trainees reported that RLS in patient care were due to the need for clinical stability and additional history and lack of bed availability. In contrast, non-trainee clinicians were more likely to cite problems with the availability of ED staff as an RLS.
Conclusions
Most of the RLS in patient care identified by clinicians were associated with actual increases in ED wait time for their patients. Next steps include asking clinicians for possible solutions to the delays their patients experience.
doi:10.1016/j.genhosppsych.2012.03.005
PMCID: PMC3729212  PMID: 22516215
Emergency department; Mental health; Psychiatric patients
18.  Eight-Year Trends of Cardiometabolic Morbidity and Mortality in Patients with Schizophrenia 
General Hospital Psychiatry  2012;34(4):368-379.
Objective
We examined cardiometabolic disease and mortality over eight years among individuals with and without schizophrenia.
Method
We compared 65,362 patients in the Veteran Affairs (VA) health system with schizophrenia to 65,362 VA patients without serious mental illness (non-SMI) matched on age, service access year, and location. The annual prevalence of diagnosed cardiovascular disease, diabetes, dyslipidemia, hypertension, obesity, and all-cause and cause-specific mortality were compared for fiscal years 2000–2007. Mean years of potential life lost (YPLL) was calculated annually.
Results
The cohort was mostly male (88%) with a mean age of 54 years. Cardiometabolic disease prevalence increased in both groups with non-SMI patients having higher disease prevalence in most years. Annual between-group differences ranged from < 1% to 6%. Annual mortality was stable over time for schizophrenia (3.1%) and non-SMI patients (2.6%). Annual mean YPLL increased from 12.8 to 15.4 in schizophrenia and from 11.8 to 14.0 for non-SMI groups.
Conclusions
VA patients with and without schizophrenia show increasing but similar prevalence rates of cardiometabolic diseases. YPLLs were high in both groups and only slightly higher among patients with schizophrenia. Findings highlight the complex population served by the VA while suggesting a smaller mortality impact from schizophrenia than previously reported.
doi:10.1016/j.genhosppsych.2012.02.009
PMCID: PMC3383866  PMID: 22516216
schizophrenia; cardiovascular disease; morbidity; mortality; cardiometabolic
19.  Prevalence of physical symptoms and their association with race/ethnicity and acculturation in the United States 
General Hospital Psychiatry  2012;34(4):323-331.
Objective
Physical symptoms are common and a leading reason for primary care visits, however data are lacking on their prevalence among racial/ethnic minorities in the United States. This study aimed to compare the prevalence of physical symptoms among White, Latino, and Asian Americans, and examine the association of symptoms and acculturation.
Methods
We analyzed data from the National Latino and Asian American Study, a nationally-representative survey of 4864 White, Latino, and Asian Americans adults. We compared the age- and gender-adjusted prevalence of fourteen physical symptoms among the racial/ethnic groups and estimated the association between indicators of acculturation (English proficiency, nativity, generational status, and proportion of lifetime in the United States) and symptoms among Latino and Asian Americans.
Results
After adjusting for age and gender, the mean number of symptoms was similar for Whites (1.00) and Latinos (0.95) but significantly lower among Asian-Americans (0.60, p < 0.01 versus Whites). Similar percentages of Whites (15.4%) and Latinos (13.0%) reported 3 or more symptoms, whereas significantly fewer Asian-Americans (7.7%, p<0.05 versus Whites) did. In models adjusted for sociodemographic variables and clinical status (psychological distress, medical conditions, and disability), acculturation was significantly associated with physical symptoms among both Latino and Asian Americans, such that the most acculturated individuals had the most physical symptoms.
Conclusions
The prevalence of physical symptoms differs across racial/ethnic groups, with Asian Americans reporting fewer symptoms than Whites. Consistent with a ‘healthy immigrant’ effect, increased acculturation was strongly associated with greater symptom burden among both Latino and Asian Americans.
doi:10.1016/j.genhosppsych.2012.02.007
PMCID: PMC3383871  PMID: 22460006
Acculturation; Asian Americans; Epidemiology; Hispanic Americans; Signs and Symptoms
20.  Associations between Coping, Diabetes Knowledge, Medication Adherence, and Self-Care Behaviors in Adults with Type 2 Diabetes 
General Hospital Psychiatry  2012;34(4):385-389.
Background
Few studies have examined the emotional approach to coping on diabetes outcomes. This study examined the relationship between emotional coping and diabetes knowledge, medication adherence, and self-care behaviors in adults with type 2 diabetes.
Methods
Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure coping, medication adherence, diabetes knowledge, and diabetes self-care behaviors (including diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of coping through emotional approach on medication adherence and self-care behaviors while controlling for relevant covariates.
Results
Significant correlations were observed between emotional coping (as measured by emotional expression (EE) and emotional processing (EP)) and self-care behaviors. In the linear regression model, EP was significantly associated with medication adherence (β −0.17, 95% CI −0.32 to −0.015), diabetes knowledge (β 0.76, 95% CI 0.29 to 1.24), diet (β 0.52, 95% CI 0.24 to 0.81), exercise (β 0.51, 95% CI 0.19 to 0.82), blood sugar testing (β 0.54, 95% CI 0.16 to 0.91), and foot care (β 0.32, 95% CI −0.02 to 0.67). On the other hand, EE was associated with diet (β 0.38, 95% CI 0.13 to 0.64), exercise (β 0.54, 95% CI 0.27 to 0.82), blood sugar testing (β 0.42, 95% CI 0.09 to 0.76) and foot care (β 0.36, 95% CI 0.06 to 0.66), but it was not associated with diabetes knowledge.
Conclusion
These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.
doi:10.1016/j.genhosppsych.2012.03.018
PMCID: PMC3383912  PMID: 22554428
Coping; medication adherence; self-care; diabetes
21.  Abbreviated PTSD Checklist (PCL) as a Guide to Clinical Response 
General Hospital Psychiatry  2012;34(4):332-338.
Objective
The objective of this study was to evaluate two abbreviated versions of the PTSD Checklist (PCL), a self-report measure of posttraumatic stress disorder (PTSD) symptoms, as an index of change related to treatment.
Method
Data for this study were from 181 primary care patients diagnosed with PTSD who enrolled in a large randomized trial. These individuals received a collaborative care intervention (CBT and/or medication) or usual care and were followed 6 and 12 months later to assess their symptoms and functioning. The sensitivity of the PCL versions (i.e., full, 2-item, 6-item), correlations between the PCL versions and other measures, and use of each as indicators of reliable and clinically significant change were evaluated.
Results
All versions had high sensitivity (.92-.99). Correlations among the three versions were high, but the 6-item version corresponded more closely to the full version. Both shortened versions were adequate indicators of reliable and clinically significant change.
Conclusion
Whereas prior research has shown the 2-item or 6-item versions of the PCL to be good PTSD screening instruments for primary care settings, the 6-item version appears to be the better alternative for tracking treatment-related change.
doi:10.1016/j.genhosppsych.2012.02.003
PMCID: PMC3383936  PMID: 22460001
PTSD; assessment; primary care
22.  Depressive symptoms in adolescence: the association with multiple health risk behaviors 
General hospital psychiatry  2010;32(3):233-239.
Objective
Although multiple studies of adolescents have examined the association of depression with individual health risk behaviors such as obesity or smoking, this is one of the few studies that examined the association between depression and multiple risk behaviors.
Methods
A brief mail questionnaire, which screened for age, gender, weight, height, sedentary behaviors, physical activity, perception of general health, functional impairment and depressive symptoms, was completed by a sample of 2291 youth (60.7% response rate) aged 13–17 enrolled in a health care plan. A subset of youth who screened positive on the two-item depression screen and a random sample of those screening negative were approached to participate in a telephone interview with more in-depth information obtained on smoking and at-risk behaviors associated with drug and alcohol use.
Results
Youth screening positive for high levels of depressive symptoms compared to those with few or no depressive symptoms were significantly more likely to meet criteria for obesity, had a poorer perception of health, spent more time on the computer, got along less well with parents and friends, had more problems completing school work and were more likely to have experimented with smoking and a wide array of behaviors associated with drug and alcohol use.
Conclusions
Because many adverse health behaviors that develop in adolescence continue into adulthood, the association of depressive symptoms with multiple risk behaviors and poor functioning suggest that early interventions are needed at an individual, school, community and primary care level.
doi:10.1016/j.genhosppsych.2010.01.008
PMCID: PMC3671856  PMID: 20430225
Depression; Adolescence; Behavior
23.  The Relationship between Depressive Symptoms and Medication Non-Adherence in Type 2 Diabetes: The Role of Social Support 
General Hospital Psychiatry  2012;34(3):249-253.
Objective
Medication adherence promotion interventions are needed that target modifiable behavioral factors contributing to the link between depressive symptoms and poor adherence to diabetes self-care behaviors. In an effort to identify what factors contribute to this link, we examined the role of social support as a mediator of the relationship between depressive symptoms and medication non-adherence.
Method
We recruited 139 subjects with type 2 diabetes. Using an indirect effect test with bias corrected bootstrapping, we tested whether depressive symptoms had an indirect effect on medication non-adherence through a lack of social support.
Results
More depressive symptoms were associated with medication non-adherence (total effect =.06, p < .001), more depressive symptoms were associated with less social support (direct effect of the predictor on the mediator = −.96, p = .02), and less social support was associated with medication non-adherence (direct effect of the mediator on the outcome = −.01, p < .01). While the relationship between more depressive symptoms and medication non-adherence persisted with social support in the predicted pathway, the degree of this relationship was partially explained by a relationship between more depressive symptoms and less social support (indirect effect = .01, 95% BC bootstrapped CI of .0005 to .0325).
Conclusion
Providing social support to patients with diabetes who have symptoms of depression may ameliorate some of the deleterious effects of depressive symptoms on medication non-adherence, but social support alone is not enough.
doi:10.1016/j.genhosppsych.2012.01.015
PMCID: PMC3345067  PMID: 22401705
24.  Posttraumatic stress disorder in primary care one year after the 9/11 attacks☆ 
General hospital psychiatry  2006;28(3):213-222.
Objective
To screen for posttraumatic stress disorder (PTSD) in primary care patients 7–16 months after 9/11 attacks and to examine its comorbidity, clinical presentation and relationships with mental health treatment and service utilization.
Method
A systematic sample (n = 930) of adult primary care patients who were seeking primary care at an urban general medicine clinic were interviewed using the PTSD Checklist: the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire and the Medical Outcome Study 12-Item Short Form Health Survey (SF-12). Health care utilization data were obtained by a cross linkage to the administrative computerized database.
Results
Prevalence estimates of current 9/11-related probable PTSD ranged from 4.7% (based on a cutoff PCL-C score of 50 and over) to 10.2% (based on the DSM-IV criteria). A comorbid mental disorder was more common among patients with PTSD than patients without PTSD (80% vs. 30%). Patients with PTSD were more functionally impaired and reported increased use of mental health medication as compared to patients without PTSD (70% vs. 18%). Among patients with PTSD there was no increase in hospital and emergency room (ER) admissions or outpatient care during the first year after the attacks.
Conclusions
In an urban general medicine setting, 1 year after 9/11, the frequency of probable PTSD appears to be common and clinically significant. These results suggest an unmet need for mental health care in this clinical population and are especially important in view of available treatments for PTSD.
doi:10.1016/j.genhosppsych.2006.02.002
PMCID: PMC3622521  PMID: 16675364
Primary care; Posttraumatic stress disorder; 9/11 attacks
25.  Mental health, substance use, and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System 
General Hospital Psychiatry  2011;34(2):139-145.
Objectives
Suicide during pregnancy and the postpartum is a tragic event for the victim and profoundly impacts the baby, the family, and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors.
Methods
The analysis used data from 17 states reporting to the NVDRS from 2003–2007 to evaluate suicide patterns among pregnant, postpartum, and non-pregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems, and suicide methods were compared among groups.
Results
The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely die via asphyxia as cause of death compared to poisoning or firearms
Conclusions
These findings describe important mental health, substance use, and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population.
doi:10.1016/j.genhosppsych.2011.09.017
PMCID: PMC3275697  PMID: 22055329
Pregnancy; postpartum; suicide; mental health; intimate partner violence

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