To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
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.
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.
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.
Suicide; Emergency Departments; Public Health
To examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries.
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.
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.
Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.
quality of care; myocardial infarction; mental illness
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.
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.
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.
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.
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.
Prospective cohort study of clinicians’ perspectives on the RLS among 1092 adult ED patients. Medical records were abstracted for ED time and other data.
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.
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.
Emergency department; Mental health; Psychiatric patients
We examined cardiometabolic disease and mortality over eight years among individuals with and without schizophrenia.
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.
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.
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.
schizophrenia; cardiovascular disease; morbidity; mortality; cardiometabolic
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.
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.
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.
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.
Acculturation; Asian Americans; Epidemiology; Hispanic Americans; Signs and Symptoms
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.
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.
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.
These findings indicate that coping through an emotional approach is significantly associated with behaviors that lead to positive diabetes outcomes.
Coping; medication adherence; self-care; diabetes
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.
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.
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.
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.
PTSD; assessment; primary care
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.
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.
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.
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.
Depression; Adolescence; Behavior
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.
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.
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).
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.
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.
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.
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.
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.
Primary care; Posttraumatic stress disorder; 9/11 attacks
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.
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.
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
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.
Pregnancy; postpartum; suicide; mental health; intimate partner violence
Anxiety disorders are prominent in chronic lung disease; lung transplant recipients may therefore also be at high risk for these disorders. We sought to provide the first prospective data on rates and risk factors for anxiety disorders as well as depressive disorders during the first two years after transplantation.
178 lung recipients, and a comparison group (126 heart recipients), received psychosocial and Structured Clinical Interview for DSM-IV assessments at 2-, 7-, 12-, 18-, and 24-months posttransplant. Survival analysis determined onset rates and risk factors.
The panic disorder rate was higher (p<.05) in lung than heart recipients (18% v. 8%). Lung and heart recipients did not differ on rates of transplant-related post-traumatic stress disorder (15% v. 14%), generalized anxiety disorder (4% v. 3%), or major depression (30% v. 26%). Risk factors for disorders included pretransplant psychiatric history, female gender, longer wait for transplant, and early posttransplant health problems and psychosocial characteristics (e.g., poorer caregiver support, use of avoidant coping).
Heightened vigilance for panic disorder in lung recipients and major depression in all cardiothoracic recipients is warranted. Strategies to prevent psychiatric disorder should target recipients based not only on pretransplant characteristics but early posttransplant characteristics as well.
lung transplantation; anxiety; depression; risk factors
The objective was to develop a brief posttraumatic stress disorder (PTSD) screening instrument that is useful in clinical practice, similar to the Framingham Risk Score used in cardiovascular medicine.
We used data collected in New York City after the World Trade Center disaster (WTCD) and other trauma data to develop a new PTSD prediction tool — the New York PTSD Risk Score. We used diagnostic test methods to examine different clinical domains, including PTSD symptoms, trauma exposures, sleep disturbances, suicidal thoughts, depression symptoms, demographic factors and other measures to assess different PTSD prediction models.
Using receiver operating curve (ROC) and bootstrap methods, five prediction domains, including core PTSD symptoms, sleep disturbance, access to care status, depression symptoms and trauma history, and five demographic variables, including gender, age, education, race and ethnicity, were identified. For the best prediction model, the area under the ROC curve (AUC) was 0.880 for the Primary Care PTSD Screen alone (specificity=82.2%, sensitivity=93.7%). Adding care status, sleep disturbance, depression and trauma exposure increased the AUC to 0.943 (specificity=85.7%, sensitivity=93.1%), a significant ROC improvement (P < .0001). Adding demographic variables increased the AUC to 0.945, which was not significant (P=.250). To externally validate these models, we applied the WTCD results to 705 pain patients treated at a multispecialty group practice and to 225 trauma patients treated at a Level I Trauma Center. These results validated those from the original WTCD development and validation samples.
The New York PTSD Risk Score is a multifactor prediction tool that includes the Primary Care PTSD Screen, depression symptoms, access to care, sleep disturbance, trauma history and demographic variables and appears to be effective in predicting PTSD among patients seen in healthcare settings. This prediction tool is simple to administer and appears to outperform other screening measures.
Posttraumatic stress disorder; Psychological Trauma; Diagnostic testing; Patient screening; Area under receiver operating characteristic (ROC) curve
To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model.
Collaborative depression care, based on principles from the IMPACT trial, was implemented in six community health organizations serving disadvantaged patients. Over three years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement.
Logistic regression analyses revealed that patients who were older, more depressed, or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, p<0.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (ps<0.001).
Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.
Depression; anxiety; disease management; primary health care; healthcare disparities
To examine whether depression is associated with pre-existing hypertension or pregnancy-induced hypertension in a large sample of women attending a university-based obstetrics clinic.
In this prospective study, participants were 2398 women receiving ongoing prenatal care at a university-based obstetrics clinic from January 2004 through January 2009. Prevalence of depression was measured using the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria based on the Patient Health Questionnaire-9 as well as the self-reported use of antidepressant medication. Evidence of pre-existing hypertension, pregnancy-induced hypertension and preeclampsia/eclampsia was determined by obstetrician ICD-9 codes. Logistic regression was used to quantify the association between hypertension in pregnancy and antenatal depression.
After adjusting for sociodemographic variables, chronic medical conditions, smoking and prior pregnancy complications, women with pre-existing hypertension had an increased risk of Any Depression (minor, major, use of antidepressants) (OR = 1.55, 95% CI 1.08, 2.23) and Major Depression and/or use of antidepressants) (OR = 1.65, 95% CI 1.10, 2.48) compared to women without hypertension. No differences were seen in risk of depression in women with pregnancy-induced hypertension or preeclampsia/eclampsia compared to those without hypertension.
Women with pre-existing hypertension, but not pregnancy induced hypertension are more likely to meet criteria for an antenatal depressive disorder and/or to be treated with antidepressants and could be targeted by obstetricians for screening for depression and enhanced treatment.
hypertension; pregnancy; antenatal depression
monamine oxidase inhibitor (MAOI); phenelzine; L-5-hydroxytryptophan (5-HTP); L-tryptophan; serotonin syndrome; major depressive disorder (MDD); mania; pharmacotherapy; treatment-resistant depression (TRD)
Depression is the most common psychiatric disorder in patients with chronic kidney disease (CKD). We sought to determine the association of major depression with mortality among diabetic patients with late stage CKD.
The Pathways Study is a longitudinal, prospective cohort study initiated to determine the impact of depression on outcomes among primary care diabetic patients. Subjects were followed from 2001 until 2007 for a mean duration of 4.4 years. Major depression, identified by the Patient Health Questionnaire-9 (PHQ-9), was the primary exposure of interest. Stage 5 CKD was determined by dialysis codes and estimated glomerular filtration rate (<15ml/min). An adjusted Cox proportional hazards multivariable model was used to determine the association of baseline major depression with mortality.
Of the 4128 enrolled subjects, 110 were identified with stage 5 CKD at baseline. Of those, 34 (22.1%) had major depression. Over a period of 5 years, major depression was associated with 2.95-fold greater risk of death (95% CI=1.24–7.02) compared to those with no or few depressive symptoms.
Major depression at baseline was associated with a 3-fold greater risk of mortality among stage 5 CKD diabetic patients. Given the high mortality risk, further testing of targeted depression interventions should be considered in this population.
Depression; diabetes; mortality; chronic kidney disease; ESRD
The study examined in HHC, demographic, functional and clinical factors by antidepressant type including SSRIs, SNRIs, TCAs and “Other” antidepressants such as buproprion and mirtazapine.
Cross-sectional sample (n= 909) analyzed the 2007 National Home Health and Hospice Care Survey, patients 65 years plus (mean 78.79 years, CI = 77.88-79.69 years) taking one antidepressant.
SSRIs were most commonly used (63.89%) then “Other” antidepressants (14.29%) , TCAs (11.31%) and SNRIs. In a multinomial regression referencing SSRIs, blacks had increased odds of tricyclic use compared to whites (OR = 5.96, CI = 1.85-19.19). . Hispanics had decreased odds of “Other” AD (OR= 0.13, CI= 0.02-0.73) and SNRI use (OR= 0.06, CI= 0.008-0.45) compared to non-Hispanics. HHC elderly taking psychotropic medications besides ADs were less likely to use SNRIs (OR= 0.31, CI= 0.11-0.88) and tricyclics (OR =0.27, CI= 0.08-0.87). Advancing age was marginally associated with tricyclic use (OR= 1.04, CI= 0.99-1.09).
Race/ethnicity and age differences by antidepressant type – including blacks’ increased TCA use, Hispanics decreased SNRI and “Other antidepressant” use, and older elderly increased tricyclic use -- suggests systematic differences in prescribing practice variations including differences by geography, patient preferences, or access to care in the HHC elderly.
home healthcare; elderly; antidepressant
Individuals with serious mental illness (SMI: e.g., schizophrenia, bipolar disorder) experience disparities in mortality relative tothe general population, mainly because of medical conditions (i.e., cardiometabolic disease).We assessed whether VA patients with SMI and receiving care from VA mental health facilities with colocated medical care were more likely to receive cardiometabolic risk assessments in accordance with clinical practice guidelines than patients from non-colocated facilities.
Patients with SMI identified prescribed second-generation antipsychotic medications in fiscal year (FY) 2007receiving care from VA mental health facilities completing the VA Mental Health Program Surveywere included. VA administrative data were ascertained to assess receipt of the following tests every 6 months in FY 2007: BMI, blood pressure, lipid profile, and fasting glucose.
Out of 40,600 patients with SMI prescribed second-generation antipsychotics, 29% received all cardiometabolic tests (lipid, glucose, BMI and blood pressure). While 79% and 76% received blood pressure and BMI assessments, respectively, only 37% received a lipid test. Patients from colocated sites were more likely to receive all cardiometabolic tests (OR=1.26, 95% CI: 1.18–1.35, p<0.001).
Colocated general medical providers in mental health clinicsare more likely to provide cardiometabolic assessments for patients with SMI prescribed second-generation antipsychotics.
Mental disorders; quality of care; cardiovascular disease; integrated care
This study examined whether depression is associated with a higher incidence of diabetic retinopathy among adults with type 2 diabetes, after controlling for sociodemographic factors, health risk behaviors, and clinical characteristics.
This study included 2,359 patients enrolled in Pathways Epidemiologic Follow-Up Study, a prospective cohort study investigating the impact of depression in primary care patients with type 2 diabetes. The predictor of interest was baseline severity of depressive symptoms assessed with the Patient Health Questionnaire-9 (PHQ-9). The outcome was incident diabetic retinopathy. Risk of diabetic retinopathy was assessed using logistic regression and time to incident diabetic retinopathy was examined using Cox proportional hazard models.
Over a 5-year follow-up period, severity of depression was associated with an increased risk of incident retinopathy (OR = 1.026; 95% CI (1.002,1.051)) as well as time to incident retinopathy (HR = 1.025; 95% CI (1.009,1.041)). The risk of incident diabetic retinopathy was estimated to increase by up to 15% for every significant increase in depressive symptoms severity (five point increase on the PHQ-9 score).
Diabetic patients with comorbid depression have a significantly higher risk of developing diabetic retinopathy. Improving depression treatment in patients with diabetes could contribute to diabetic retinopathy prevention.
depression; type 2 diabetes; diabetic retinopathy; microvascular complications; epidemiologic study
To determine sustained effectiveness in reducing depression symptoms and improving depression care one year following intervention completion.
Of 387 low-income, predominantly Hispanic diabetes patients with major depression symptoms randomized to 12-month socio-culturally adapted collaborative care (psychotherapy and/or antidepressants, telephone symptom monitoring/relapse prevention) or enhanced usual care, 264 patients completed two-year follow-up. Depression symptoms (SCL-20, PHQ-9), treatment receipt, diabetes symptoms, and quality of life were assessed 24 months post-enrollment using intent-to-treat analyses.
At 24 months, more intervention patients received ongoing antidepressant treatment (38% v 25%, chi-square=5.11, df=1, P=0.02); sustained depression symptom improvement (SCL-20<0.5 (adjusted OR=2.06, 95%CI=1.09–3.90, P=0.03), SCL-20 score (adjusted mean difference −0.22, P=0.001), and PHQ-9 ≥50% reduction (adjusted OR=1.87, 95%CI=1.05–3.32, P=0.03). Over 2 years, improved effects were found in significant study group by time interaction for SF-12 mental health, SDS functional impairment, diabetes symptoms, anxiety, and socioeconomic stressors (P=0.02 for SDS, P<0.0001 for all others); however, group differences narrowed over time and were no longer significant at 24 months.
Socio-culturally tailored collaborative care that included maintenance antidepressant medication, ongoing symptom monitoring and behavioral activation relapse prevention was associated with depression improvement over 24 months for predominantly Hispanic patients in primary safety net care.
Depression; Diabetes; Collaborative Care; Safety Net; Hispanic
Opioids are among the most commonly abused drugs among adolescents and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations.
We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially-insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions, and types of medications given, as well as clinical and demographic features of adolescents receiving opioids.
In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition.
Prescription of opioids among adolescents with NCP is common and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.
Pain; Adolescents; Opioids
To develop a predictive screener that when given soon after injury will accurately differentiate those who will later develop depression or PTSD from those who will not.
Prospective, longitudinal cohort design. Subjects were randomly selected from all injured patients in the emergency department; the majority was assessed within one week post-injury with a short predictive screener, followed with in-person interviews after 3 and 6 months to determine the emergence of depression or PTSD within 6 months after injury.
192 completed a risk factor survey at baseline; 165 were assessed over 6 months. Twenty-six subjects (15.8%, 95%CI 10.2–21.3) were diagnosed with depression, 4 (2.4%, 95% CI 0.7–5.9) with PTSD, and 1 with both. The final 8 item predictive screener was derived; optimal cut-off scores were ≥2 (of 4) depression risk items and ≥3 (of 5) PTSD risk items. The final screener demonstrated excellent sensitivity and moderate specificity for both clinically significant symptoms and for the diagnoses of depression and PTSD.
A simple screener that can help identify those patients at highest risk for future development of PTSD and depression post-injury allows the judicious allocation of costly mental health resources.
Injury; Depression; PTSD; Prediction; Screening