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1.  Integrated medical care management and behavioral risk factor reduction for multicondition patients: behavioral outcomes of the TEAMcare trial 
General hospital psychiatry  2013;36(2):129-134.
Purpose
The purpose of the study was to compare behavioral outcomes (physical activity, sedentary behavior, smoking cessation, diet) between the intervention and usual care conditions from the TEAMcare trial.
Methods
TEAMcare was a randomized trial among 214 adults with depression and poorly controlled diabetes and/or coronary heart disease that promoted health behavior change and pharmacotherapy to improve health. Behavioral outcomes were measured with the International Physical Activity Questionnaire (physical activity, sitting time) and the Summary of Diabetes Self-Care Activities Measure (smoking, diet, exercise). Poisson regression models among completers (N=185) were conducted adjusting for age, education, smoking status and depression.
Results
Intervention participants had more days/week following a healthy eating plan [relative rate=1.2, 95% confidence interval (CI)=1.1–1.4] and more days of participation in 30 min of physical activity (relative rate=1.2, 95% CI=1.1–2.0) compared to usual care. Intervention participants were more likely to meet physical activity guidelines (7.5% increase) compared to usual care (12% decrease; P=.053).
Conclusion
Diet and activity generally improved for those receiving the intervention, while there were no differences in some aspects of diet (fruit and vegetable and high-fat food intake), smoking status and sitting time between conditions in the TEAMcare trial.
doi:10.1016/j.genhosppsych.2013.10.017
PMCID: PMC4301679  PMID: 24333157
Physical activity; Diet; Diabetes; Depression; Cardiovascular disease
2.  Holding Back Sharing Concerns, Dispositional Emotional Expressivity, Perceived Unsupportive Responses, and Distress Among Women Newly-Diagnosed with Gynecological Cancers 
General hospital psychiatry  2013;36(1):81-87.
Objective
Little attention has been paid to the role of holding back sharing concerns in the psychological adaptation of women newly diagnosed with gynecological cancers. The goal of the present study was to evaluate the role of holding back concerns in psychosocial adjustment and quality of life, as well as a possible moderating role for emotional expressivity and perceived unsupportive responses from family and friends.
Method
Two hundred forty four women diagnosed with gynecological cancer in the past eight months completed measures of holding back, dispositional emotional expressivity, perceived unsupportive responses from family and friends, cancer-specific distress, depressive symptoms, and quality of life.
Results
Emotional expressivity moderated the association between holding back and cancer- specific distress and quality of life, but not depressive symptoms. Greater holding back was more strongly associated with higher levels of cancer-related distress among women who were more emotionally expressive than among women who were less expressive. Perceived unsupportive responses did not moderate the associations between holding back and psychosocial outcomes.
Conclusion
Holding back sharing concerns was more common in this patient population than other cancer populations. Dispositional expressivity played a role in how harmful holding back concerns was for women, while unsupportive responses from family and friends did not.
doi:10.1016/j.genhosppsych.2013.10.001
PMCID: PMC3930348  PMID: 24211156
Gynecological cancer; depressive symptoms; trajectories of change; coping
3.  The prevalence of bipolar disorder in general primary care samples: a systematic review 
General hospital psychiatry  2013;36(1):10.1016/j.genhosppsych.2013.09.008.
Objective
To obtain an estimate of the prevalence of bipolar disorder in primary care.
Methods
We used the PRISMA method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed.
Results
We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients.
Conclusion
In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings.. Prevalence estimates from studies using screening measures which have been found to have low positive predictive value were generally higher than those found using structured interviews.
doi:10.1016/j.genhosppsych.2013.09.008
PMCID: PMC3877721  PMID: 24144521
bipolar disorder; primary care
4.  A meta-analysis of the relationship between antidepressant use in pregnancy and the risk of preterm birth and low birth weight 
General hospital psychiatry  2013;36(1):10.1016/j.genhosppsych.2013.08.002.
doi:10.1016/j.genhosppsych.2013.08.002
PMCID: PMC3877723  PMID: 24094568
antidepressants; pregnancy; prenatal; antenatal; adverse birth outcomes; low birth weight; preterm birth
5.  The work impact of dysthymia in a primary care population 
General hospital psychiatry  2004;26(4):269-276.
Physicians regard individuals with dysthymia as having relatively normal levels of functioning. This study examines in detail the work impact of dysthymia in a population of employed primary care patients. As part of an observational study conducted between 2001 and 2003 in clinics associated with three health plans in Massachusetts, we compared 69 patients diagnosed with DSM-IV dysthymia without concurrent major depressive disorder to 175 depression-free controls. Patients were employed at least 15 h per week, had no immediate plans to leave the labor market, and no major comorbid medical conditions. We assessed work absences and productivity loss due to on-the-job performance limitations (“presenteeism”). Patients with dysthymia, compared with controls, had less stable work histories and a greater frequency of significant problems at work. While absence rates were not significantly different (1.2 vs. 0.74 days, P < .09), individuals with dysthymia experienced significantly greater on-the-job productivity loss (6.3% vs. 2.8%, P < .0001). Dysthymia is an unrecognized cause of work impairment that has long-term negative consequences for individuals and their employers. The persistence of dysthymia with its serious impact on work functioning calls out for the development of new interventions.
doi:10.1016/j.genhosppsych.2004.04.004
PMCID: PMC4269288  PMID: 15234821
Dysthymia; Economic issues; Mood disorders; Outcome studies; Primary care; Work productivity
6.  PTSD and Obesity in the Detroit Neighborhood Health Study 
General hospital psychiatry  2013;35(6):10.1016/j.genhosppsych.2013.07.015.
Objective
Posttraumatic stress disorder (PTSD) has been associated with adverse health consequences, including overweight, obesity, and cardiovascular disease. African Americans, particularly women, have among the highest rates of overweight and obesity in the U.S. compared to other racial groups. High rates of violence exposure in urban African Americans may lead to the development of PTSD and increase risk for overweight and obesity. The current study investigated the comorbidity of lifetime PTSD and overweight/obesity in a population-based African American, urban sample.
Method
Data were from 463 African American male and female participants of the Detroit Neighborhood Health Study. Multivariable logistic regression models estimated the impact of lifetime PTSD on risk for overweight and obesity.
Results
The prevalence of obesity was significantly higher among women (60.9%) than men (33.1%; p<0.001). In sex-stratified models, after controlling for demographic variables, PTSD was associated obesity (OR=4.4, 95% CI: 1.3, 14.3) only among women.
Conclusions
PTSD was associated with obesity, after controlling for confounding variables, among African American women. Results underscore the contribution of PTSD to obesity among African American women and the importance of addressing the physical health correlates of women with PTSD.
doi:10.1016/j.genhosppsych.2013.07.015
PMCID: PMC3823753  PMID: 24035634
PTSD; obesity; urban; African American
7.  Sex Differences in Biopsychosocial Correlates of Binge Eating Disorder: A Study of Treatment-Seeking Obese Adults in Primary Care Setting 
General hospital psychiatry  2013;35(6):10.1016/j.genhosppsych.2013.07.010.
Objective
Although community-based studies suggest equivalent levels of physical and psychological impairment by BED in men and women, men with binge eating disorder (BED) are still underrepresented in clinical studies. This study aimed to provide a comprehensive analysis of sex differences in biopsychosocial correlates of treatment-seeking obese patients with BED in primary care.
Method
One-hundred-ninety obese adults (26% men) were recruited in primary care settings for a treatment study for obesity and BED.
Results
Very few significant sex differences were found in the developmental history and in current levels of eating-disorder features, as well as psychosocial factors. Women reported significantly earlier age at onset of overweight and dieting, and greater frequency of dieting. Men reported more frequent strenuous exercise. Men were more likely than women to meet criteria for metabolic syndrome (MetS); men were more likely to show clinically elevated levels of triglycerides, blood pressure, and fasting glucose levels.
Conclusion
Despite few sex differences in behavioral and psychosocial factors, metabolic problems associated with obesity were more common among treatment-seeking obese men with BED than women. The findings highlight the importance of including men in clinical studies of BED, and active screening of BED in obese men at primary care settings.
doi:10.1016/j.genhosppsych.2013.07.010
PMCID: PMC3845204  PMID: 23969142
binge eating; obesity; metabolic syndrome; gender; sex differences
8.  Depression and anxiety among high-risk obstetric inpatients 
General hospital psychiatry  2012;35(2):112-116.
Objective
To assess the following among women hospitalized antenatally due to high-risk pregnancies: (1) rates of depression symptoms and anxiety symptoms; (2) changes in depression symptoms and anxiety symptoms; and, (3) rates of mental health treatment.
Methods
Sixty-two participants hospitalized for high-risk obstetrical complications completed the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder 7-item scale (GAD-7), and Short-Form 12 (SF-12) weekly until delivery or discharge, and once postpartum.
Results
Average length of total hospital stay was 8.3±7.6 days for women who completed an initial admission survey (n=62) and 16.3±8.9 (n=34), 25.4±10.2 (n=17) and 35±10.9 days (n=9) for those who completed 2, 3 and 4 surveys, respectively. EPDS was ≥ 10 in 27% (n=17) and GAD-7 was ≥ 10 in 13% (n=8) of participants at initial survey. Mean anxiety (4.2±6.5 vs. 5.2±5.1, p=0.011) and depression (4.4±5.6 vs. 6.9±4.8, p=0.011) scores were lower postpartum compared to initial survey. Past mental health diagnosis predicted depression symptoms (OR=4.54; 95% CI 1.91–7.17) and anxiety symptoms (OR=5.95; 95% CI 3.04–8.86) at initial survey; however, 21% (n=10) with no diagnostic history had EPDS ≥ 10. Five percent (n=3) received mental health treatment during pregnancy.
Conclusion
Hospitalized high-risk obstetrical patients may commonly experience depression symptoms and/or anxiety symptoms and not receive treatment. A history of mental health treatment or diagnosis was associated with depression symptoms or anxiety symptoms in pregnancy. Of women with an EPDS ≥ 10, > 50% did not report a past mental health diagnosis.
doi:10.1016/j.genhosppsych.2012.11.006
PMCID: PMC4157064  PMID: 23265951
Pregnancy; Depression; Anxiety; Hospitalization; High-risk
9.  The Development of a Population-Based Automated Screening Procedure for PTSD in Acutely Injured Hospitalized Trauma Survivors 
General hospital psychiatry  2013;35(5):485-491.
Objective
This investigation aimed to advance posttraumatic stress disorder (PTSD) risk prediction among hospitalized injury survivors by developing a population-based automated screening tool derived from data elements available in the electronic medical record (EMR).
Method
Potential EMR derived PTSD risk factors with the greatest predictive utilities were identified for 878 randomly selected injured trauma survivors. Risk factors were assessed using logistic regression, sensitivity, specificity, predictive values, and receiver operator characteristic (ROC) curve analyses.
Results
Ten EMR data elements contributed to the optimal PTSD risk prediction model including: ICD-9-CM PTSD diagnosis, other ICD-9-CM psychiatric diagnosis, other ICD-9-CM substance use diagnosis or positive blood alcohol on admission, tobacco use, female gender, non-White ethnicity, uninsured, public or veteran insurance status, E-code identified intentional injury, intensive care unit admission, and EMR documentation of any prior trauma center visits. The 10-item automated screen demonstrated good area under the ROC curve (0.72), sensitivity (0.71), and specificity (0.66).
Conclusions
Automated EMR screening can be used to efficiently and accurately triage injury survivors at risk for the development of PTSD. Automated EMR procedures could be combined with stepped care protocols to optimize the sustainable implementation of PTSD screening and intervention at trauma centers nationwide.
doi:10.1016/j.genhosppsych.2013.04.016
PMCID: PMC3784242  PMID: 23806535
PTSD; screening; injury; EMR; information technology
10.  Correlates of depressive symptoms among at-risk youth presenting to the emergency department 
General hospital psychiatry  2013;35(5):537-544.
Objective
The study's objective was to identify correlates of depressive symptoms among at-risk youth in an urban emergency department (ED).
Method
A systematic sample of adolescents (ages 14–18) in the ED were recruited as part of a larger study. Participants reporting past-year alcohol use and peer aggression self-administered a survey assessing: demographics, depressive symptoms, and risk/protective factors. Logistic regression identified factors associated with depressive symptoms.
Results
Among 624 adolescents (88% response rate) meeting eligibility criteria, 22.8% (n=142) screened positive fordepressive symptoms. In logistic regression, depressive symptoms were positively associated with female gender (OR 2.84, 95% CI 1.78–4.51), poor academic performance (OR 1.57, 95% CI 1.01–2.44), binge drinking (OR 1.88, 95% CI 1.21–2.91), community violence exposure (OR 2.25, 95% CI 1.59–3.18), and dating violence (OR 2.14, 95% CI 1.36–3.38), and were negatively associated with same sex mentorship (OR 0.52, 95% CI 0.29–0.91) and older age (OR 0.55, 95% CI 0.34–0.89). Including gender interaction terms did not significantly change findings.
Conclusions
Screening and intervention approaches for youth in the urban ED should address the co-occurrence of depressive symptoms with peer and dating violence, alcohol, and non-marijuana illicit drug use.
doi:10.1016/j.genhosppsych.2013.05.007
PMCID: PMC3775848  PMID: 23810465
Violence; Depression; Dating Violence; Adolescent; Substance use
11.  Can familial factors account for the association of body mass index with poor mental health in men or women?✩ 
General hospital psychiatry  2013;35(5):502-507.
Objective
This study examined if associations between body mass index (BMI) and mental and physical health were independent of genetic and familial factors.
Method
Data from 2831 twins (66% female) were used in an epidemiological co-twin control design with measures of BMI and mental and physical health outcomes. Generalized estimating equation regressions assessed relationships between BMI and health outcomes controlling for interdependency among twins and demographics. Within-pair regression analyses examined the association of BMI with health outcomes controlling for genetic and familial influences.
Results
Adjusted analyses with individual twins found associations in women between BMI and perceived stress (P=.01) and depression (P=.002), and the link between BMI and depression (P=.03) was significant in men. All physical health outcomes were significantly related to BMI. Once genetic and familial factors were taken into account, mental health outcomes were no longer significantly associated with BMI. BMI in women remained related to ratings of physical health (P=.01) and body pain (P=.004), independent of genetic and familial influences.
Conclusion
These findings suggest that genetic and familial factors may account for the relationship between increased weight and poor mental health.
doi:10.1016/j.genhosppsych.2013.04.004
PMCID: PMC3775952  PMID: 23664570
Obesity; Mental health; Genetics; Familial; Body mass index
12.  Patient’s views on depression care in obstetric settings: how do they compare to the views of perinatal health care professionals?☆ 
General hospital psychiatry  2013;35(6):598-604.
Objectives
The objectives were to examine patients’ perspectives on patient-, provider- and systems-level barriers and facilitators to addressing perinatal depression in outpatient obstetric settings. We also compare the views of patients and perinatal health care professionals.
Method
Four 90-min focus groups were conducted with women 3–36 months after delivery (n=27) who experienced symptoms of perinatal depression, anxiety or emotional distress. Focus groups were transcribed, and resulting data were analyzed using a grounded theory approach.
Results
Barriers to addressing perinatal depression included fear of stigma and loss of parental rights, negative experiences with perinatal health care providers and lack of depression management knowledge/skills among professionals. Facilitators included psychoeducation, peer support and training for professionals.
Conclusions
Patients perceive many multilevel barriers to treatment that are similar to those found in our previous similar study of perinatal health care professionals’ perspectives. However, patients and professionals do differ in their perceptions of one another. Interventions would need to close these gaps and include an empathic screening and referral process that facilitates discussion of mental health concerns. Interventions should leverage strategies identified by both patients and professionals, including empowering both via education, resources and access to varied mental health care options.
doi:10.1016/j.genhosppsych.2013.07.011
PMCID: PMC4107904  PMID: 23969144
Depression; Barriers; Facilitators; Perinatal; Treatment
13.  What Clinical Differences Distinguish Depressed Teens with and without Comorbid Externalizing Problems? 
General hospital psychiatry  2013;35(4):444-447.
Objective
This study examined differences in co-occurring symptoms, psychosocial correlates, health care utilization, and functional impairment in youth who screened positive for depression, stratified by whether or not they also self-reported externalizing problems.
Methods
The AdoleSCent Health Study examined a random sample of youth ages 13-17 enrolled in a health care system. 2,291youth (60.7% of the eligible sample) completed a brief depression screen; the 2 item Patient Health Questionnaire (PHQ-2). The current analyses focus on a subset of youth (n=113) who had a follow-up interview and screened positive for possible depression on the Patient Health Questionnaire 9 using a cut off score of 11 or higher.1 Youth were categorized as having externalizing behavior if their score was ≥7 on the Pediatric Symptom Checklist (PSC) externalizing scale.2 Chi-squared tests and Wilcoxon rank sum tests were used to compare groups.
Results
Differences between groups included that youth with depression and externalizing symptoms had a higher rate of obesity and had higher self-reported functional impairment than youth with depression symptoms alone.
Conclusions
Adding screening for externalizing problems to existing recommendations for depression screening may help primary care providers to identify a high risk depressed group of youth for referral to mental health services.
doi:10.1016/j.genhosppsych.2013.04.002
PMCID: PMC3692614  PMID: 23648192
15.  Depression Care and Treatment in a Chronically Ill Medicare Population 
General hospital psychiatry  2013;35(4):382-386.
Objective
The purpose of this study is to examine depression care among chronically ill Medicare Advantage beneficiaries.
Methods
This study includes 5,898 Medicare Advantage members with a depression diagnosis enrolled between 2008 and 2010 in a care management program. Two depression care indicators were created: 1) Any depression care (≥ 1 antidepressant prescription or ≥ 1 specialty mental health visit) and 2) Among those receiving any depression care, those receiving an antidepressant prescription for ≥ 90 days or ≥ 2 specialty visits. Multivariable analysis using logistic regression was used to examine correlates of depression care.
Results
Among those < 65 years old, 72% received any depression care with 75% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. Among ≥ 65 years old, 65% received any depression care with 67% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. For both age groups, female gender, medical comorbidities, and dual eligibility were positively associated with an antidepressant prescription. In the older group, female gender was positively associated with at least a 90 day supply of an antidepressant prescription, while substance use disorders were negatively associated with receiving a minimum of 90 days of an antidepressant. Regional differences and certain psychiatric comorbidities were also associated with receiving depression care.
Conclusion
Two-thirds of the depressed patients in this Medicare Advantage population received depression care. Further studies are needed to examine the effects of quality improvement efforts in the context of care management programs for chronically ill older adults.
doi:10.1016/j.genhosppsych.2013.02.006
PMCID: PMC3692601  PMID: 23557895
Depression care; antidepressant; Medicare; chronic medical conditions
16.  Evaluating the promise of Health IT to enhance/expand the reach of mental health services 
General hospital psychiatry  2013;35(4):339-344.
doi:10.1016/j.genhosppsych.2013.03.013
PMCID: PMC3716575  PMID: 23701698
17.  Behavioral Intervention Technologies: Evidence review and recommendations for future research 
General hospital psychiatry  2013;35(4):332-338.
This paper reports on the findings of a technical expert panel convened by the Agency for Healthcare Research and Quality and the National Institute of Mental Health, charged with reviewing the state of research on behavioral intervention technologies (BITs) in mental health and identifying the top research priorities. BITs is the comprehensive term used to refer to behavioral and psychological interventions that use information and communication technology features to address behavioral and mental health outcomes. Mental health BITs using videoconferencing and standard telephone technologies to deliver psychotherapy have been wellvalidated. Web-based interventions have shown efficacy across a broad range of mental health outcomes, although outcomes vary widely. Social media such as online support groups have produced generally disappointing outcomes when used alone. Mobile technologies have received limited attention for mental health outcomes, although findings from behavioral health suggest they are promising. Virtual reality has shown good efficacy for anxiety and pediatric disorders. Serious gaming has received relatively little work in mental health. Recommendations for next step research in each of these are made. Research focused on understanding of reach, adherence, barriers and cost is recommended. As BITs can generate large amounts of data, improvements in the collection, storage, analysis, and visualization of big data will be required. Traditional psychological and behavioral theories have proven insufficient to understand how BITs produce behavioral change. Thus new theoretical models, as well as new evaluation strategies, will be required. Finally, for BITs to have a public health impact, research on implementation and application to prevention will be required.
doi:10.1016/j.genhosppsych.2013.03.008
PMCID: PMC3719158  PMID: 23664503
18.  National trends in antidepressant medication treatment among publicly-insured pregnant women 
General hospital psychiatry  2013;35(3):265-271.
Objective
Risk of depression in women is greatest at childbearing age. We sought to examine and explain national trends in antidepressant use in pregnant women.
Methods
Cohort study including pregnant women aged 12–55 who were enrolled in Medicaid during 2000–2007. We examined the proportion of women taking antidepressants during pregnancy by patient characteristics (descriptive), by region (mixed-effects model), and over time (interrupted time-series).
Results
We identified 1,106,757 pregnancies in 47 states; mean age was 23 years and 60% were non-white. Nearly 1 in 12 used an antidepressant during pregnancy. Use was higher for older (11.2% for age ≥30 vs. 7.6% for <30) and white (14.4% vs. 4.0% for non-white) women. There was a 4- to 5-fold difference in rate of antidepressant use among states. Of the 5.3% of women taking antidepressants at conception, 33% and 17% were still on treatment 90 and 180 days, respectively, into pregnancy; an additional 4% began use during pregnancy. Labeled pregnancy-related health advisories did not appear to affect antidepressant use.
Conclusions
Antidepressant use during pregnancy remains high in this population; treatment patterns vary substantially by patient characteristics and region. Comparative safety and effectiveness data to help inform treatment choices are needed in this setting.
doi:10.1016/j.genhosppsych.2012.12.010
PMCID: PMC4077674  PMID: 23374897
antidepressants; Medicaid; national cohort; patterns of medication use; pregnancy
19.  Depression treatment preferences of older white and Mexican origin men✩,✩✩,★,★★ 
General hospital psychiatry  2012;35(1):59-65.
Objective
Among older white and Mexican origin male primary care patients, we examined preferences for features of depression care programs that would encourage depressed older men to enter and remain in treatment.
Method
Sixty-three (45 white, 18 Mexican origin) older men were recruited in six primary care clinics. All had clinical depression in the past year and/or were receiving depression treatment. Participants completed a conjoint analysis preference survey regarding depression treatments, providers and treatment enhancements.
Results
The data suggest that white men preferred medication over counseling [odds ratio (OR): 1.64 95% confidence interval (CI): 1.12–2.41], while Mexican origin men preferred counseling (OR: medication over counseling: 0.28, 95% CI: 0.12–0.66). Both white and Mexican origin men preferred treatment that included family involvement (vs. none) (white: OR: 1.60, 95% CI 1.12–2.30; Mexican origin: OR: 3.31 95% CI 1.44–7.62) and treatment for insomnia (vs. treatment for alcohol use) (white: OR: 1.72, 95% CI 1.01–2.91; Mexican origin: OR: 3.93 95% CI 1.35–11.42). White men also preferred treatment by telephone (OR: 1.80, 95% CI 1.12–2.87).
Conclusions
Findings could inform development of patient-centered depression treatment programs for older men and suggest strategies, such as attention to sleep problems, which providers may employ to tailor treatment to preferences of older men.
doi:10.1016/j.genhosppsych.2012.08.003
PMCID: PMC4041603  PMID: 23141027
Older men; Depression; Treatment preferences; Conjoint analysis; Latino
20.  Excess heart-disease-related mortality in a national study of patients with mental disorders: identifying modifiable risk factors 
General hospital psychiatry  2009;31(6):555-563.
Objective
People with mental disorders are estimated to die 25 years younger than the general population, and heart disease (HD) is a major contributor to their mortality. We assessed whether Veterans Affairs (VA) health system patients with mental disorders were more likely to die from HD than patients without these disorders, and whether modifiable factors may explain differential mortality risks.
Methods
Subjects included VA patients who completed the 1999 Large Health Survey of Veteran Enrollees (LHSV) and were either diagnosed with schizophrenia, bipolar disorder, other psychotic disorders, major depressive disorder or other depression diagnosis or diagnosed with none of these disorders. LHSV data on patient sociodemographic, clinical and behavioral factors (e.g., physical activity, smoking) were linked to mortality data from the National Death Index of the Centers for Disease Control and Prevention. Hierarchical multivariable Cox proportional hazards models were used to assess 8-year HD-related mortality risk by diagnosis, adding patient sociodemographic, clinical and behavioral factors.
Results
Of 147,193 respondents, 11,809 (8%) died from HD. After controlling for sociodemographic and clinical factors, we found that those with schizophrenia [hazard ratio (HR)=1.25; 95% confidence interval (95% CI): 1.15–1.36; P<.001] or other psychotic disorders (HR=1.41; 95% CI: 1.27–1.55; P<.001) were more likely to die from HD than those without mental disorders. Controlling for behavioral factors diminished, but did not eliminate, the impact of psychosis on mortality. Smoking (HR=1.32; 95% CI: 1.26–1.39; P<.001) and inadequate physical activity (HR=1.66; 95% CI: 1.59–1.74; P<.001) were also associated with HD-related mortality.
Conclusions
Patients with psychosis were more likely to die from HD. For reduction of HD-related mortality, early interventions that promote smoking cessation and physical activity among veterans with psychotic disorders are warranted.
doi:10.1016/j.genhosppsych.2009.07.008
PMCID: PMC4033835  PMID: 19892214
Heart-disease-related mortality; Mental disorders; Modifiable risk factors; Mortality
21.  Pain in primary care patients with bipolar disorder☆,☆☆ 
General hospital psychiatry  2013;36(2):228.
doi:10.1016/j.genhosppsych.2013.11.004
PMCID: PMC4022279  PMID: 24360835
22.  Depression and Risk of Mortality in Individuals with Diabetes: A Meta-Analysis and Systematic Review 
General hospital psychiatry  2013;35(3):217-225.
OBJECTIVES
To estimate risk of comorbid depression on all-cause mortality over time among individuals with diabetes
METHODS
Medline, CINAHL, Cochrane Library, Embase, and Science Direct database were searched through September. 30, 2012. We limited our search to longitudinal or prospective studies reporting all-cause mortality among those having depression and diabetes, compared with those having diabetes alone that used hazard ratios as the main outcome. Two reviewers independently extracted primary data and evaluated quality of studies using predetermined criteria. The pooled random effects adjusted hazard ratios (HRs) were estimated using meta-analysis. The impact of moderator variables on study effect size was examined with meta-regression.
RESULTS
A total of 42,363 respondents from 10 studies were included in the analysis. Depression was significantly associated with risk of mortality (Pooled HRs: 1.50, 95% CI: 1.35, 1.66). Little evidence for heterogeneity was found across the studies (Cochran Q: 13.52, p-value: 0.20, I2: 26.03). No significant possibility of publication bias was detected (Egger’s regression intercept: 0.98, p-value: 0.23).
CONCLUSION
Depression significantly increases the risk of mortality among individuals with diabetes. Early detection and treatment of depression may improve health outcomes in this population.
doi:10.1016/j.genhosppsych.2013.01.006
PMCID: PMC3644308  PMID: 23415577
23.  A Longitudinal Investigation of Posttraumatic Stress and Depressive Symptoms over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission 
General hospital psychiatry  2013;35(3):226-232.
Objective
To identify risk factors for posttraumatic stress disorder (PTSD) and depressive symptoms after medical-surgical intensive care unit (ICU) admission.
Method
This longitudinal investigation included 150 medical-surgical ICU patients. We assessed acute stress and post-ICU PTSD symptoms with the PTSD Checklist-civilian version and post-ICU depressive symptoms with the Patient Health Questionnaire-9. Mixed-model linear regression ascertained associations between patient and clinical characteristics and repeated measures of post-ICU PTSD and depressive symptoms.
Results
The prevalences of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU, respectively. In-hospital substantial acute stress symptoms (beta: 16.9, 95%Confidence Interval [95%CI]: 11.4, 22.4) were independently associated with increased post-ICU PTSD symptoms. Lifetime history of major depression (beta: 2.2, 95%CI: 0.1, 4.2), greater prior trauma exposure (beta: 0.5, 95%CI: 0.2, 0.9) and in-hospital substantial acute stress symptoms (beta: 3.5, 95%CI: 0.8, 6.2) were independently associated with increased post-ICU depressive symptoms.
Conclusions
In-hospital acute stress symptoms may represent a modifiable risk factor for psychiatric morbidity in ICU survivors. Early interventions for at-risk ICU survivors may improve longer-term psychiatric outcomes.
doi:10.1016/j.genhosppsych.2012.12.005
PMCID: PMC3644338  PMID: 23369507
posttraumatic stress disorder; depression; critical care; intensive care; outcome assessment (health care)
24.  Anxiety treatment improves physical functioning with oblique scoring of the SF-12 Short Form Health Survey☆ 
General hospital psychiatry  2013;35(3):291-296.
Objective
No studies have found a positive effect of anxiety treatment on physical functioning, but recent investigations of the 12-item Short Form Health Questionnaire (SF-12), which is frequently used to assess physical functioning, have suggested that orthogonal scoring of the summary measure may distort representations of physical health. The current study reanalyzes whether anxiety treatment improves physical functioning using oblique scoring in the Coordinated Anxiety Learning and Management (CALM) randomized clinical trial for the treatment of anxiety disorders. Replication was tested in reanalysis of data from the earlier Collaborative Care for Anxiety and Panic (CCAP) randomized clinical trial for the treatment of panic disorder.
Method
The CALM study included 1004 primary care patients with panic, social anxiety, generalized anxiety or posttraumatic stress disorders. Patients received usual care (UC) or an evidence-based intervention (cognitive behavioral therapy, psychotropic medication or both; ITV). Physical functioning (SF-12v2) was assessed at baseline and at 6, 12 and 18 months. Oblique and orthogonal scoring methods for the physical functioning aggregate measure from SF-12 scale items were compared.
Results
In CALM, physical functioning improved to a greater degree in ITV than UC for oblique but not orthogonal scoring. Findings were replicated in the CCAP data.
Conclusions
Evidence-based treatment for anxiety disorders in primary care improves physical functioning when measured using oblique scoring of the SF-12. Due to this scoring issue, effects of mental health treatment on physical functioning may have been understated.
doi:10.1016/j.genhosppsych.2012.12.004
PMCID: PMC3747957  PMID: 23332608
Short Form Health Survey; Anxiety; Measurement; Physical functioning; Physical health; Health psychology
25.  Cognitive, Anxiety, and Mood Disorders in the Fragile X-associated Tremor/Ataxia Syndrome (FXTAS) 
General hospital psychiatry  2007;29(4):349-356.
Objective
The authors evaluated patients with Fragile X-associated Tremor/Ataxia Syndrome (FXTAS), a neurodegenerative disorder associated with a CGG repeat expansion in the premutation range in the fragile X mental retardation 1 gene (FMR1).
Method
Neurological, psychiatric, and neuropsychological evaluations were completed on 15 males with FXTAS.
Results
Seven cases were diagnosed with dementia; seven were diagnosed with mood and/or anxiety disorders. Twelve subjects demonstrated deficits on neuropsychological testing.
Conclusions
Physicians assessing dementia patients are urged to consider this newly-described syndrome, especially in patients with dementia associated with a movement disorder and in patients with family history of mental retardation. If FXTAS is a possible diagnosis, the physician may obtain FMR1 DNA testing; patients who are positive on DNA testing should have an MRI, be referred to neurology, and receive genetic counseling
doi:10.1016/j.genhosppsych.2007.03.003
PMCID: PMC3991490  PMID: 17591512
FXTAS; fragile X premutation; dementia; anxiety disorder; mood disorder

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