Showing papers in "Psychosomatic Medicine in 2004"
TL;DR: The notion of overfitting is presented in terms of asking too much from the available data, and three common practices—automated variable selection, pretesting of candidate predictors, and dichotomization of continuous variables—are shown to pose a considerable risk for spurious findings in models.
Abstract: OBJECTIVE Statistical models, such as linear or logistic regression or survival analysis, are frequently used as a means to answer scientific questions in psychosomatic research. Many who use these techniques, however, apparently fail to appreciate fully the problem of overfitting, ie, capitalizing on the idiosyncrasies of the sample at hand. Overfitted models will fail to replicate in future samples, thus creating considerable uncertainty about the scientific merit of the finding. The present article is a nontechnical discussion of the concept of overfitting and is intended to be accessible to readers with varying levels of statistical expertise. The notion of overfitting is presented in terms of asking too much from the available data. Given a certain number of observations in a data set, there is an upper limit to the complexity of the model that can be derived with any acceptable degree of uncertainty. Complexity arises as a function of the number of degrees of freedom expended (the number of predictors including complex terms such as interactions and nonlinear terms) against the same data set during any stage of the data analysis. Theoretical and empirical evidence--with a special focus on the results of computer simulation studies--is presented to demonstrate the practical consequences of overfitting with respect to scientific inference. Three common practices--automated variable selection, pretesting of candidate predictors, and dichotomization of continuous variables--are shown to pose a considerable risk for spurious findings in models. The dilemma between overfitting and exploring candidate confounders is also discussed. Alternative means of guarding against overfitting are discussed, including variable aggregation and the fixing of coefficients a priori. Techniques that account and correct for complexity, including shrinkage and penalization, also are introduced.
1,730 citations
TL;DR: Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients and depression has to be considered a relevant risk factor in patients with CHD.
Abstract: Background Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29-2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis. Objective To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality. Method English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]). Results Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37-3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12-2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27-2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82-5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53-4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models. Conclusions Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.
1,296 citations
TL;DR: Post-MI depression is associated with a 2- to 2.5-fold increased risk of impaired cardiovascular outcome and was more pronounced in the older studies than in the more recent studies.
Abstract: Objective To assess the association of depression following myocardial infarction (MI) and cardiovascular prognosis. Methods The authors performed a meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975-2003) combined with crossreferencing without language restrictions. The authors selected prospective studies that determined the association of depression with the cardiovascular outcome of MI patients, defined as mortality and cardiovascular events within 2 years from index MI. Depression had to be assessed within 3 months after MI using established psychiatric instruments. A quality assessment was performed. Results Twenty-two papers met the selection criteria. These studies described follow up (on average, 13.7 months) of 6367 MI patients (16 cohorts). Post-MI depression was significantly associated with all-cause mortality (odds ratio [OR], fixed 2.38; 95% confidence interval [CI], 1.76-3.22; p Conclusions Post-MI depression is associated with a 2- to 2.5-fold increased risk of impaired cardiovascular outcome. The association of depression with cardiac mortality or all-cause mortality was more pronounced in the older studies (OR, 3.22 before 1992) than in the more recent studies (OR, 2.01 after 1992).
1,018 citations
TL;DR: There is substantial evidence for a relationship between depression and adverse clinical outcomes, however, despite the availability of effective therapies for depression, there is a paucity of data to support the efficacy of these interventions to improve clinical outcomes for depressed CAD patients.
Abstract: Objective The present paper reviews the evidence that depression is a risk factor for the development and progression of coronary artery disease (CAD). Methods MEDLINE searches and reviews of bibliographies were used to identify relevant articles. Articles were clustered by theme: depression as a risk factor, biobehavioral mechanisms, and treatment outcome studies. Results Depression confers a relative risk between 1.5 and 2.0 for the onset of CAD in healthy individuals, whereas depression in patients with existing CAD confers a relative risk between 1.5 and 2.5 for cardiac morbidity and mortality. A number of plausible biobehavioral mechanisms linking depression and CAD have been identified, including treatment adherence, lifestyle factors, traditional risk factors, alterations in autonomic nervous system (ANS) and hypothalamic pituitary adrenal (HPA) axis functioning, platelet activation, and inflammation. Conclusion There is substantial evidence for a relationship between depression and adverse clinical outcomes. However, despite the availability of effective therapies for depression, there is a paucity of data to support the efficacy of these interventions to improve clinical outcomes for depressed CAD patients. Randomized clinical trials are needed to further evaluate the value of treating depression in CAD patients to improve survival and reduce morbidity.
826 citations
TL;DR: Psychological factors such as a depressive mood associated with anxiety and impaired HRQOL may exert a negative influence on the course of IBD and assessment and management of psychological distress should be included in clinical treatment of patients with IBD.
Abstract: OBJECTIVE There is evidence of an interaction between psychological factors and activity of inflammatory bowel disease (IBD). We examined the influence of depressive mood and associated anxiety on the course of IBD over a period of 18 months in a cohort of patients after an episode of active disease. METHODS In this prospective, longitudinal, observational study, 60 patients (37 women and 23 men) with clinically inactive IBD (Crohn disease, n = 47, 78%; ulcerative colitis, n = 13, 22%) were enrolled after a flare of disease. Psychological status, health-related quality of life (HRQOL), and disease activity were evaluated at baseline and then every 3 months for a period of 18 months by means of clinical and biological parameters, the Beck Depression Inventory (BDI), the Spielberger State-Trait Anxiety Inventory, the Inflammatory Bowel Disease Questionnaire, the Perceived Stress Questionnaire, and the Rating Form of Inflammatory Bowel Disease Patients Concerns. RESULTS At baseline, depression (BDI > or = 13 points) was found in 17 of 60 (28%) patients. Thirty-two patients (59%) experienced at least one relapse during the 18 months of follow-up. Regression analysis showed a significant correlation between BDI scores at baseline and the total number of relapses after 12 (p <.01) and 18 months (p <.01) of follow-up. Furthermore, depression scores at baseline correlated with the time until the first recurrence of the disease (p <.05). Anxiety and low HRQOL were also related with more frequent relapses during follow-up (p <.05 and p <.01, respectively). CONCLUSIONS Psychological factors such as a depressive mood associated with anxiety and impaired HRQOL may exert a negative influence on the course of IBD. Therefore, assessment and management of psychological distress should be included in clinical treatment of patients with IBD.
501 citations
TL;DR: Posttraumatic growth among breast cancer patients and their significant others over a 11/2-year time span after diagnosis is evaluated and cognitive and emotional processes in posttraumatic growth are examined.
Abstract: OBJECTIVE The purpose of this study was to evaluate posttraumatic growth among breast cancer patients and their significant others over a 1(1/2)-year time span after diagnosis and to examine cognitive and emotional processes in posttraumatic growth. METHODS One hundred sixty-two women with breast cancer and their partners completed surveys assessing posttraumatic growth, cognitive and emotional processing, and marital satisfaction at 3 time points spaced 9 months apart. RESULTS Posttraumatic growth increased for both partners during this period. Patient posttraumatic growth was predicted by younger age, contemplating reasons for cancer, and more emotional expression at time 1. Partner posttraumatic growth was predicted by younger age, more intrusive thoughts, and greater use of positive reappraisal and emotional processing at time 1. CONCLUSION Posttraumatic growth is reported by patients and by significant others. Cognitive and emotional processes predict growth. Patient growth is associated with the significant other's cognitive and emotional processing of breast cancer.
496 citations
TL;DR: FMS is not a homogeneous diagnosis, but shows varying proportions of comorbid anxiety and depression dependent on psychosocial characteristics of the patients, demonstrating the importance of not treating patients with FMS as a homogeneity group.
Abstract: Objective The prevalence as well as predictors of psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV] axis I and II) in patients with fibromyalgia syndrome (FMS) was evaluated. Method One-hundred fifteen patients with FMS participated in the Structured Clinical Interview for DSM-IV to assess current mental disorders. In addition, patients completed standardized questionnaires regarding pain, pain impact, anxiety, depression, posttraumatic stress disorder-like symptoms, and sexual and physical abuse. Results Patients were grouped into one of three psychosocial subgroups based on responses to the Multidimensional Pain Inventory (MPI)-Dysfunctional (DYS), Interpersonally Distressed (ID), and Adaptive Copers (AC). Axis I diagnoses were present in 74.8% of the participants overall with the DYS subgroup mainly reporting anxiety and the ID group mood disorders. The AC group showed little comorbidity. Axis II diagnoses were present in only 8.7% of the FMS sample. Conclusion These results suggest that FMS is not a homogeneous diagnosis, but shows varying proportions of comorbid anxiety and depression dependent on psychosocial characteristics of the patients. The results demonstrate the importance of not treating patients with FMS as a homogeneous group. Assessment should not only examine the presence of widespread pain and the number of tender points, but also the presence of affective distress. Treatment should focus both on physical and emotional dysfunction.
444 citations
TL;DR: Threat to the social self is an important elicitor of shame experience, decreases in social self-esteem and cortisol increases under demanding performance conditions.
Abstract: Objective Our Social Self Preservation Theory asserts that situations which threaten the "social self" (ie, one's social value or standing) elicit increased feelings of low social worth (eg, shame), decrements in social self-esteem, and increases in cortisol, a hormone released by the hypothalamic-pituitary-adrenal axis. To test our theoretical premise, cognitive, emotional, and physiological responses to the performance of laboratory stressor tasks were compared in participants who performed these tasks in the presence or absence of social-self threat. Methods Pre- and poststressor emotion, self-esteem, heart rate, blood pressure, and salivary cortisol were compared in 81 participants randomly assigned to complete speech and mental arithmetic stress tasks with social evaluation present (n = 41) or absent (n = 40). Results As hypothesized, participants in the social evaluation condition exhibited greater increases in shame and greater decrements in social self-esteem. Other psychological states (eg, anxiety, performance self-esteem) did not show differential changes as a function of the social context. Salivary cortisol increased in social evaluation condition participants but did not increase in participants who performed the same tasks in the absence of social evaluation. Cortisol increases were greater in participants who experienced greater increases in shame and greater decreases in social self-esteem under social-self threat. Conclusion Threat to the social self is an important elicitor of shame experience, decreases in social self-esteem and cortisol increases under demanding performance conditions. Cortisol changes may be specifically tied to the experience of emotions and cognitions reflecting low self-worth in this context.
440 citations
TL;DR: The weekend–weekday differences in the cortisol awakening response and their association with chronic stress clearly demonstrate that the day of cortisol assessment is crucial in psychoendocrinological stress studies.
Abstract: OBJECTIVE: The cortisol increase after awakening has been shown to be associated with work-related stress. Several studies demonstrated a moderate stability of cortisol awakening responses on subsequent days, suggesting situation-dependent variance. This study tests whether cortisol awakening responses are different on weekdays compared with weekend days and whether such differences may be explained by chronic work overload and worrying. METHODS: Two hundred nineteen participants took saliva samples immediately after awakening and 30, 45, and 60 minutes later on 6 consecutive days starting on Saturday. Perceived chronic work overload and worrying were assessed by a standardized questionnaire. RESULTS: There is a clear weekend–weekday difference in the cortisol response to awakening. This difference is associated with chronic work overload and worry. Independent of sex and weekend–weekday differences in time of awakening and sleep duration, participants who report higher levels of chronic work overload and worrying show a stronger increase and higher mean levels of cortisol after awakening on weekdays, but not on weekend days. CONCLUSIONS: The weekend–weekday differences in the cortisol awakening response and their association with chronic stress clearly demonstrate that the day of cortisol assessment is crucial in psychoendocrinological stress studies. Abbreviations: ANOVA = analysis of variance; CAR = cortisol awakening response; GLM = general linear model; HPA = hypothalamic–pituitary–adrenal axis.
419 citations
TL;DR: The prevalence of the metabolic syndrome is elevated among women with a history of depression, and it is important to better understand the role depression may play in the effort to reduce the prevalence ofThe metabolic syndrome and its health consequences.
Abstract: Objective: Previous reports have suggested that depression may lead to the development of cardiovascular disease through its association with the metabolic syndrome; however, little is known about the relationship between depression and the metabolic syndrome. The aim of this study was to establish an association between depression and the metabolic syndrome in a nationally representative sample. Methods: The Third National Health and Nutrition Examination Survey is a population-based health survey of noninstitutionalized US citizens completed between 1988 and 1994. Three thousand one hundred eighty-six men and 3003 women, age 17 to 39, free of coronary heart disease and diabetes, completed the depression module from the Diagnostic Interview Schedule and a medical examination that provided clinical data needed to establish the presence of the metabolic syndrome, as defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults. Results: Women with a history of a major depressive episode were twice as likely to have the metabolic syndrome compared with those with no history of depression. The relationship between depression and metabolic syndrome remained after controlling for age, race, education, smoking, physical inactivity, carbohydrate consumption, and alcohol use. Men with a history of depression were not significantly more likely to have the metabolic syndrome. Conclusions: The prevalence of the metabolic syndrome is elevated among women with a history of depression. It is important to better understand the role depression may play in the effort to reduce the prevalence of the metabolic syndrome and its health consequences. Key words: depression, the metabolic syndrome, the Third National Health and Nutrition Examination Survey.
363 citations
TL;DR: Autoregressive spectral analysis of the electrocardiogram (EKG) interbeat interval sequence was used to characterize stress-related changes in heart rate variability during sleep in 59 healthy men and women to represent one pathway to disturbed sleep.
Abstract: OBJECTIVE Although stress can elicit profound and lasting effects on sleep, the pathways whereby stress affects sleep are not well understood. In this study, we used autoregressive spectral analysis of the electrocardiogram (EKG) interbeat interval sequence to characterize stress-related changes in heart rate variability during sleep in 59 healthy men and women. METHODS Participants (N = 59) were randomly assigned to a control or stress condition, in which a standard speech task paradigm was used to elicit acute stress in the immediate presleep period. EKG was collected throughout the night. The high frequency component (0.15-0.4 Hz Eq) was used to index parasympathetic modulation, and the ratio of low to high frequency power (0.04-0.15 Hz Eq/0.15-0.4 Hz Eq) of heart rate variability was used to index sympathovagal balance. RESULTS Acute psychophysiological stress was associated with decreased levels of parasympathetic modulation during nonrapid eye movement (NREM) and rapid eye movement sleep and increased levels of sympathovagal balance during NREM sleep. Parasympathetic modulation increased across successive NREM cycles in the control group; these increases were blunted in the stress group and remained essentially unchanged across successive NREM periods. Higher levels of sympathovagal balance during NREM sleep were associated with poorer sleep maintenance and lower delta activity. CONCLUSIONS Changes in heart rate variability associated with acute stress may represent one pathway to disturbed sleep. Stress-related changes in heart rate variability during sleep may also be important in association with chronic stressors, which are associated with significant morbidity and increased risk for mortality.
TL;DR: Pain is present in two thirds of depressed primary care patients begun on antidepressant therapy, and the severity of pain is a strong predictor of poor depression and health-related quality of life outcomes at 3 months.
Abstract: Objective Pain commonly coexists with depression, but its impact on treatment outcomes has not been well studied. Therefore, we prospectively evaluated the impact of comorbid pain on depression treatment response and health-related quality of life. Methods We analyzed data from the ARTIST study, a randomized controlled trial with naturalistic follow-up conducted in 37 primary care clinics. Participants were 573 clinically depressed patients randomized to one of three selective serotonin reuptake inhibitor (SSRI) antidepressants: fluoxetine, paroxetine, or sertraline. Depression as assessed by the Symptom Checklist-20 (SCL-20) was the primary outcome. Secondary outcomes included pain and health-related quality of life. Results Pain was reported by more than two thirds of depressed patients at baseline, with the severity of pain mild in 25% of patients, moderate in 30%, and severe in 14%. After 3 months of antidepressant therapy, 24% of patients had a poor depression treatment response (ie, SCL-20 >1.3). Multivariate odds ratios for poor treatment response were 1.5 (95% confidence interval, 0.8-3.2) for mild pain, 2.0 (1.1-4.0) for moderate pain, and 4.1 (1.9-8.8) for severe pain compared with those without pain. Increasing pain severity also had an adverse impact on outcomes in multiple domains of health-related quality of life. Conclusions Pain is present in two thirds of depressed primary care patients begun on antidepressant therapy, and the severity of pain is a strong predictor of poor depression and health-related quality of life outcomes at 3 months. Better recognition, assessment, and treatment of comorbid pain may enhance outcomes of depression therapy.
TL;DR: There appears to be a high comorbidity of anxiety disorders in patients with asthma, which needs to be examined in a large population-based sample of children, adolescents, and adults with asthma.
Abstract: Objective: This article reviewed the child and adult medical literature on the prevalence of comorbid anxiety disorders in patients with asthma. Theoretical ideas regarding the relatively high comorbidity rates are presented along with a model describing putative interactions between anxiety disorders and asthma. Method: A search of the literature from the last 2 decades using MEDLINE by pairing the word, “asthma,” with the following words: “anxiety,” “depression,” “panic,” and “psychological disorders.” We located additional research by screening the bibliographies of articles retrieved in the MEDLINE search. Results: Both adult and child/adolescent populations with asthma appear to have a high prevalence of anxiety disorders. In child/adolescent populations with asthma, up to one third may meet criteria for comorbid anxiety disorders. In adult populations with asthma, the estimated rate of panic disorder ranges from 6.5% to 24%. However, most studies are limited by small samples, nonrepresentative populations, self-reported asthma status, and lack of controlling for important potential confounders such as smoking and asthma medications. There are also limited data on the impact of anxiety comorbidity in patients with asthma on symptom burden, self-care regimens (such as monitoring peak expiratory flow, taking medication, and quitting smoking), functional status, and medical costs. Conclusions: There appears to be a high comorbidity of anxiety disorders in patients with asthma. The prevalence and longitudinal impact of anxiety comorbidity needs to be examined in a large population-based sample of children, adolescents, and adults with asthma. If a high prevalence of comorbid anxiety disorder is documented and if this comorbidity adversely affects the self-efficacy and self-care, symptom burden, and functioning in persons with asthma, then it will be important to develop treatment trials.
TL;DR: There was a statistically significant relationship between anxiety, depression, and functional somatic symptoms, independent of age and gender.
Abstract: Objective Somatic symptoms are prevalent in the community, but at least one third of the symptoms lack organic explanation. Patients with such symptoms have a tendency to overuse the health care system with frequent consultations and have a high degree of disability and sickness compensation. Studies from clinical samples have shown that anxiety and depression are prevalent in such functional conditions. The aim of this study is to examine the connection between anxiety, depression, and functional somatic symptoms in a large community sample. Method The HUNT-II study invited all inhabitants aged 20 years and above in Nord-Trondelag County of Norway to have their health examined and sent a questionnaire asking about physical symptoms, demographic factors, lifestyle, and somatic diseases. Anxiety and depression were recorded by the Hospital Anxiety and Depression Scale. Of those invited, 62,651 participants (71.3%) filled in the questionnaire. A total of 10,492 people were excluded due to organic diseases, and 50,377 were taken into the analyses. Results Women reported more somatic symptoms than men (mean number of symptoms women/men: 3.8/2.9). There was a strong association between anxiety, depression, and functional somatic symptoms. The association was equally strong for anxiety and depression, and a somewhat stronger association was observed for comorbid anxiety and depression. The association of anxiety, depression, and functional somatic symptoms was equally strong in men and women (mean number of somatic symptoms men/women in anxiety: 4.5/5.9, in depression: 4.6/5.9, in comorbid anxiety and depression: 6.1/7.6, and in no anxiety or depression: 2.6/3.6) and in all age groups. The association between number of somatic symptoms and the total score on Hospital Anxiety and Depression Scale was linear. Conclusion There was a statistically significant relationship between anxiety, depression, and functional somatic symptoms, independent of age and gender.
TL;DR: The data suggest that the targets of intervention should include job stress, social isolation, and health fear, which are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome.
Abstract: OBJECTIVES A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses. METHODS A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression. RESULTS Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress. CONCLUSIONS Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.
TL;DR: These findings are the first to link both psychosocial and neuroendocrine factors to birth outcomes in a prospective design and support the mediation hypothesis at Time 2, indicating that women with high CRH levels and high maternal prenatal anxiety at 28 to 30 weeks gestation delivered earlier than women with lower CRH Levels and maternal prenatal Anxiety.
Abstract: OBJECTIVE: The high rate of preterm births is an imposing public health issue in the United States. Past research has suggested that prenatal stress, anxiety, and elevated levels of maternal plasma corticotropin-releasing hormone (CRH) are associated with preterm delivery in humans and animals. Studies to date have not examined all three variables together; that is the objective of this paper. METHODS: Data from 282 pregnant women were analyzed to investigate the effect of maternal prenatal anxiety and CRH on the length of gestation. It was hypothesized that at both 18 to 20 weeks (Time 1) and 28 to 30 weeks gestation (Time 2), CRH and maternal prenatal anxiety would be negatively associated with gestational age at delivery. CRH was also expected to mediate the relationship between maternal prenatal anxiety and gestational age at delivery. RESULTS: Findings supported the mediation hypothesis at Time 2, indicating that women with high CRH levels and high maternal prenatal anxiety at 28 to 30 weeks gestation delivered earlier than women with lower CRH levels and maternal prenatal anxiety. Women who delivered preterm had significantly higher rates of CRH at both 18 to 20 weeks gestation and 28 to 30 weeks gestation (p <.001) compared with women who delivered term. CONCLUSIONS: These findings are the first to link both psychosocial and neuroendocrine factors to birth outcomes in a prospective design.
TL;DR: Patients whose depression is refractory to cognitive behavior therapy and sertraline, two standard treatments for depression, are at high risk for late mortality after myocardial infarction.
Abstract: Objective The Enhancing Recovery in Coronary Heart Disease study was a multicenter clinical trial in which patients with depression and/or low perceived social support after an acute myocardial infarction were randomly assigned to an intervention consisting of cognitive behavior therapy and, in some cases, sertraline, or to usual care. There was no difference in survival between the groups. A possible reason why the intervention failed to affect survival is that too many patients with mild, transient depression were enrolled. Another is that some patients died too soon to complete the intervention. This analysis evaluates whether there was a difference in late (ie, > or =6 months after the myocardial infarction) mortality among initially depressed patients who had a Beck Depression Inventory score > or =10 and a past history of major depression, and who completed the 6-month post-treatment assessment. It also examines the relationship between change in depression and late mortality. Methods Out of the 1,165 (47%) of the Enhancing Recovery in Coronary Heart Disease study participants who met our criteria, 57 died in the first 6 months, and 858 (409 usual care, 449 intervention) completed the 6-month assessment. Cox regression was used to analyze survival. Results The intervention did not affect late mortality. However, intervention patients whose depression did not improve were at higher risk for late mortality than were patients who responded to treatment. Conclusions Patients whose depression is refractory to cognitive behavior therapy and sertraline, two standard treatments for depression, are at high risk for late mortality after myocardial infarction.
TL;DR: Naturally occurring changes in physical activity were negatively related with changes in depressive symptoms, and randomized controlled trials are encouraged to experimentally determine whether an increase inPhysical activity reduces depression risk among adolescent boys and girls.
Abstract: Objective We examined the relationship between naturally occurring changes in physical activity and depressive symptoms across a 2-year period among adolescent boys and girls. Methods Participants (N = 4594) reported their frequency of physical activity outside of school and completed the Center for Epidemiological Studies Depression scale in the Fall of 1998 (beginning of 7th grade; baseline data), Spring of 1999 (end of 7th grade; interim data), and Spring of 2000 (end of 8th grade; follow-up data). Results Latent growth modeling indicated that a 1 SD unit change in the frequency of leisure-time physical activity was inversely related to a.25 SD unit change in depressive symptoms. This relationship was attenuated but remained statistically significant when simultaneously controlling for the confounding variables of sex, socioeconomic status, smoking, alcohol consumption, and the value participants placed on their health, appearance, and achievement. Conclusions Naturally occurring changes in physical activity were negatively related with changes in depressive symptoms. The results encourage randomized controlled trials to experimentally determine whether an increase in physical activity reduces depression risk among adolescent boys and girls.
TL;DR: Hearing loss is associated with substantially reduced mental health ratings among some young and middle-aged persons, but usually does not affect mental health much among older persons.
Abstract: OBJECTIVE To estimate effects of hearing loss on symptoms of anxiety, depression, self-esteem, and subjective well-being. METHODS A normal population sample of 50,398 subjects, age 20 to 101 years, in Nord-Trondelag completed audiometric tests and questionnaires. The association between hearing loss and mental health was assessed with multiple linear regression analyses, controlling for social background variables. RESULTS Effects of hearing loss were mostly significant, but moderate in strength. Effects were stronger among young (20-44 years) and middle-aged (45-64 years) than among older (65+ years) people. Loss of high or middle frequency hearing had almost no impact on mental health measures if low frequency hearing was not also impaired. The strongest observed effect was a change of 0.1 SD in mental health per 10 dB hearing loss. CONCLUSIONS Hearing loss is associated with substantially reduced mental health ratings among some young and middle-aged persons, but usually does not affect mental health much among older persons.
TL;DR: This work examines several errors that often follow the use of statistical adjustment, including inferring a factor is causal because it predicts an outcome even after "statistical control" for other factors.
Abstract: When experimental designs are premature, impractical, or impossible, researchers must rely on statistical methods to adjust for potentially confounding effects. Such procedures, however, are quite fallible. We examine several errors that often follow the use of statistical adjustment. The first is inferring a factor is causal because it predicts an outcome even after "statistical control" for other factors. This inference is fallacious when (as usual) such control involves removing the linear contribution of imperfectly measured variables, or when some confounders remain unmeasured. The converse fallacy is inferring a factor is not causally important because its association with the outcome is attenuated or eliminated by the inclusion of covariates in the adjustment process. This attenuation may only reflect that the covariates treated as confounders are actually mediators (intermediates) and critical to the causal chain from the study factor to the study outcome. Other problems arise due to mismeasurement of the study factor or outcome, or because these study variables are only proxies for underlying constructs. Statistical adjustment serves a useful function, but it cannot transform observational studies into natural experiments, and involves far more subjective judgment than many users realize.
TL;DR: CD4+ lymphocyte counts increased after the intervention for participants in the emotional writing condition compared with control writing participants, suggesting that emotional writing may provide benefit for patients with HIV infection.
Abstract: Objectives: To determine whether writing about emotional topics compared with writing about neutral topics could affect CD4 lymphocyte count and human immunodeficiency virus (HIV) viral load among HIV-infected patients Methods: Thirty-seven HIV-infected patients were randomly allocated to 2 writing conditions focusing on emotional or control topics Participants wrote for 4 days, 30 minutes per day The CD4 lymphocyte count and HIV viral load were measured at baseline and at 2 weeks, 3 months, and 6 months after writing Results: The emotional writing participants rated their essays as more personal, valuable, and emotional than those in the control condition Relative to the drop in HIV viral load, CD4 lymphocyte counts increased after the intervention for participants in the emotional writing condition compared with control writing participants Conclusions: The results are consistent with those of previous studies using emotional writing in other patient groups Based on the self-reports of the value of writing and the preliminary laboratory findings, the results suggest that emotional writing may provide benefit for patients with HIV infection Key words: HIV infection, disclosure, emotional writing, HIV viral load, CD4 lymphocyte count HIV human immunodeficiency virus; AIDS acquired immune deficiency syndrome; ANOVA analysis of variance
TL;DR: Attachment style is significantly associated with diabetes self-management and outcomes and these associations were mediated through the patient-provider relationship.
Abstract: OBJECTIVE Difficulties collaborating with providers and important others may adversely influence self-management in patients with diabetes. We predicted that dismissing attachment style, characterized by high interpersonal self-reliance and low trust of others, would be associated with poorer self-management in patients with diabetes. METHODS A population-based mail survey was sent to all patients with diabetes from nine primary care clinics of a health maintenance organization. We collected data on attachment style, self-care behaviors, the patient provider relationship and depression status and accessed automated diagnostic, pharmacy, and laboratory data to measure diabetes treatment intensity, medical comorbidity, glycosylated hemoglobin levels, and diabetes complications. We used logistic regression to determine whether dismissing attachment style was associated with poorer diabetes self-care behaviors, adherence to medication, smoking status, and higher glycosylated hemoglobin. RESULTS In 4095 primary care patients with diabetes, prevalence rates for secure, dismissing, preoccupied, and fearful attachment styles were 44.2%, 35.8%, 7.9%, and 12.1%, respectively. When compared with secure attachment style, dismissing attachment style was associated with significantly lower levels of exercise (p =.005), foot care (p 8%, compared with secure attachment style. CONCLUSION Attachment style is significantly associated with diabetes self-management and outcomes.
TL;DR: The results highlight the importance of including a child psychiatric component in the treatment of obesity, which must engage the whole family.
Abstract: Objective To evaluate the type and frequency of psychiatric disorders in obese children and adolescents; to assess the correlation between psychopathology and severity of obesity; to explore the relationship between psychiatric disorders in obese children and obesity and psychopathology in their parents. Methods One hundred fifty-five children referred and followed for obesity were evaluated (98 girls and 57 boys; age, 5 to 17 years). Psychiatric disorders were assessed through a standardized diagnostic interview schedule (K-SADS R) and self-report questionnaires completed by the child (STAIC Trait-anxiety and CDI for depression) or his (her) parents (CBCL or GHQ). These obese children were compared with insulin-dependent diabetic (IDDM) outpatient children (N = 171) on questionnaire data. Results Eighty-eight obese children obtained a DSM-IV diagnosis, most often an anxiety disorder (N = 63). Psychological disorders were particularly pronounced in those obese children whose parents were disturbed. There was no correlation between severity of obesity in the child or his (her) parents and frequency of psychiatric disorders. Compared with diabetic children, they displayed significantly higher internalized and externalized questionnaire scores and poorer social skills. Conclusion These results highlight the importance of including a child psychiatric component in the treatment of obesity, which must engage the whole family.
TL;DR: Depression was significantly increased in the PCOS group and remained so after considering the variance related to physical symptomatology and other mood states, and a curvilinear relationship between FT and negative affect across groups was suggested.
Abstract: Objective Our understanding of the organizational and activational effects of human gonadal hormones on behavior has depended on the study of endocrine disorders. Polycystic ovarian syndrome (PCOS) is a hormonal disorder that begins in puberty and is characterized by chronically augmented free testosterone (FT) levels. The purposes of this study were 1) to compare negative mood states of women with PCOS to those of women with normal hormonal levels and 2) to examine the relationship between negative moods and androgens. Methods Twenty-seven women with PCOS were case-matched to 27 normal menstruating women on body mass index since being overweight is a common symptom of PCOS and could affect mood states. Serum levels of FT, total testosterone, sex hormone binding globulin, estradiol, and progesterone were determined. Self-reported depression, anger, anxiety, and aggression were analyzed between groups, and individual scores were compared across groups to hormone values. Results Depression was significantly increased in the PCOS group and remained so after considering the variance related to physical symptomatology and other mood states. Furthermore, a curvilinear relationship between FT and negative affect across groups was suggested: the most elevated negative mood-scale scores were associated with FT values just beyond the upper limits of normal, while lower negative mood levels corresponded to both normal and extremely high values of FT. Conclusions These results are consistent with a model of activational influences of testosterone on adult female behavior. Implications are discussed for future research and for treatment of PCOS and other menstrual-cycle mood disorders.
TL;DR: Sleep fragmentation was associated with elevated levels of metabolic and cardiovascular risk indicators of stress-related disorders, and number of arousals also seems to be related to workload/stress.
Abstract: Consistent with sleep restriction experiments, sleep fragmentation was associated with elevated levels of metabolic and cardiovascular risk indicators of stress-related disorders. Number of arousal ...
TL;DR: Higher importance should be attached to the diagnosis and treatment of these conditions in patients with pulmonary hypertension, given the fact that safe and efficacious treatments of mental disorders are available.
Abstract: Objective This is the first study that investigates the prevalence and actual treatment of anxiety, depression, and other mental disorders in patients with pulmonary hypertension (PH). The prevalence of mental disorders in patients with PH was compared with parallel groups of primary care patients and patients with inflammatory rheumatic diseases, and the relationship between functional status and prevalence of mental disorders was determined. Methods The patient group with PH (70.1% female; mean age, 47.8 +/- 12.7 years) and the two comparison groups, which were matched by age and sex, consisted of 164 patients each. Patients completed self-administered instruments, including the Patient Health Questionnaire for the diagnosis of mental disorders. New York Heart Association (NYHA) functional class was assessed in all patients with PH. Results Thirty-five percent of the patients with PH suffered from mental disorders, with the most common being major depressive disorder (15.9%) and panic disorder (10.4%). Both panic disorder and panic attacks were significantly more prevalent in patients with PH than in either patients with inflammatory rheumatic diseases or primary care patients. The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV). Only 24.1% of the patients with PH with mental disorders were receiving psychopharmacological or psychotherapeutic treatment. Conclusions Anxiety and depression are frequent in patients with PH and increase as the severity of disease progresses. Given the fact that safe and efficacious treatments of mental disorders are available, greater importance should be attached to the diagnosis and treatment of these conditions in patients with PH.
TL;DR: Current evidence supports the conclusion that the BP-elevating effects of dietary caffeine may be contributing appreciably to population levels of cardiovascular mortality and morbidity.
Abstract: Objective This review aims to determine whether, and to what extent, dietary caffeine may be a risk to cardiovascular health. Methods A critical review of the relevant experimental and epidemiologic literature was conducted, with particular reference to studies of caffeine and blood pressure (BP). Results There is extensive evidence that caffeine at dietary doses increases BP. However, concern that the drug may contribute to cardiovascular disease appears to have been dampened by (1) the belief that habitual use leads to the development of tolerance, and (2) confusion regarding relevant epidemiologic findings. When considered comprehensively, findings from experimental and epidemiologic studies converge to show that BP remains reactive to the pressor effects of caffeine in the diet. Overall, the impact of dietary caffeine on population BP levels is likely to be modest, probably in the region of 4/2 mm Hg. At these levels, however, population studies of BP indicate that caffeine use could account for premature deaths in the region of 14% for coronary heart disease and 20% for stroke. Conclusions Current evidence supports the conclusion that the BP-elevating effects of dietary caffeine may be contributing appreciably to population levels of cardiovascular mortality and morbidity. Accordingly, strategies for encouraging reduced dietary levels of caffeine deserve serious consideration.
TL;DR: It is suggested that inducing self-related emotions can cause changes in inflammatory products, and that shame may have specific immunological correlates.
Abstract: Objective To determine if inducing self-blame would lead to increases in shame and guilt as well as increases in proinflammatory cytokine activity and cortisol. Based on previous research and theory, it was hypothesized that induced shame would be specifically associated with elevations in proinflammatory cytokine activity. Materials and methods Healthy participants were randomly assigned to write about traumatic experiences in which they blamed themselves (N = 31) or neutral experiences (N = 18) during three 20-minute experimental laboratory sessions over 1 week. Tumor necrosis factor-alpha receptor levels (sTNFalphaRII), an indicator of proinflammatory cytokine activity, beta2-microglobulin, cortisol (all obtained from oral fluids), and emotion were assessed prewriting and postwriting. Results Participants in the self-blame condition showed an increase in shame and guilt as well as an increase in sTNFalphaRII activity when compared with those in the control condition. Cortisol and beta2-microglobulin levels were unaffected by the procedures. Those individuals in the self-blame condition reporting the greatest increases in shame in response to the task showed the greatest elevations in proinflammatory cytokine activity, while levels of guilt and general negative emotion were unrelated to cytokine changes. Conclusion These data suggest that inducing self-related emotions can cause changes in inflammatory products, and that shame may have specific immunological correlates.
TL;DR: PTSD symptoms predicted poor disease control in this cohort of MI survivors and the data suggest that screening MI survivors for symptoms of PTSD may be beneficial if this high-risk population is to be targeted for interventions.
Abstract: Objective Posttraumatic stress disorder (PTSD) symptoms have been reported in patients with coronary vascular disease, after the trauma of a myocardial infarction (MI). The effect of these symptoms on post-MI disease control has not been elucidated. We conducted a study that sought to determine whether PTSD symptoms post-MI are associated with increased likelihood of cardiovascular readmission and with nonadherence to treatment recommendations. Methods Patients were recruited during a visit in a cardiology clinic 6 months post-MI and were followed for 1 year. Adherence to aspirin was measured by platelet thromboxane production (an indication of aspirin's effect). Medical outcome was measured as rate of admission due to cardiovascular causes during the follow-up period. Self-report measures of PTSD (Impact of Event Scale), Depression, and Global Distress (SCL-90-R) were administered at enrollment. Results Seventy-three patients were studied. Above-threshold PTSD symptom scores at enrollment, but not depression or global distress scores, were significant predictors of nonadherence to aspirin and of an increased likelihood of cardiovascular readmission over the course of the following year. Conclusions PTSD symptoms predicted poor disease control in this cohort of MI survivors. The data suggest that screening MI survivors for symptoms of PTSD may be beneficial if this high-risk population is to be targeted for interventions.
TL;DR: Although women with MSA are more likely to have PTSD, results suggest that they are receiving fewer health care services, compared with those without a history of sexual assault.
Abstract: OBJECTIVE: This study examines the differential impact of military, civilian adult, and childhood sexual assault on the likelihood of developing posttraumatic stress disorder (PTSD). It also examines the relationship of military sexual assault (MSA) to service utilization and health care costs among women who access services through Veterans Affairs (VA). METHODS: A convenience sample of 270 veteran women receiving medical and/or mental health treatment at the VA North Texas Healthcare System participated in the study. Participants were interviewed using the Clinician Administered PTSD Scale (CAPS) and categorized into a sexual assault group using the Interview of Sexual Experiences (ISE). A chart review was also conducted to determine the frequency of diagnoses among the women. Data regarding health care utilization was obtained from self-report using the Utilization and Cost Patient Questionnaire (UAC-PQ) and VA administrative records. RESULTS: Compared with those without a history of sexual assault, women veterans were 9 times more likely to have PTSD if they had a history of MSA, 7 times more likely if they had childhood sexual assault (CSA) histories, and 5 times more likely if they had civilian sexual assault histories. An investigation of medical charts revealed that PTSD is diagnosed more often for women with a history of MSA than CSA. CSA was associated with a significant increase in health care utilization and cost for services, but there was no related increase in use or cost associated with MSA. CONCLUSION: Women veterans have differential rates of PTSD due to sexual assault, with higher rates found among those assaulted while on active duty. Although women with MSA are more likely to have PTSD, results suggest that they are receiving fewer health care services. (Abstract Adapted from Source: Psychosomatic Medicine, 2004. Copyright © 2004 by the American Psychosomatic Society; Lippincott Williams & Wilkins) Violence Against Women Adult Adjustment Adult Mental Health Adult Female Adult Victim Adult Survivor Female Victim Victim Health Sexual Assault Effects Sexual Assault Victim Rape Effects Rape Victim Psychological Victimization Effects Post-Traumatic Stress Disorder Texas Military Personnel Military Violence Against Women Child Abuse Effects Child Abuse Victim Child Sexual Abuse Effects Child Sexual Abuse Victim Child Victim Childhood Experience Childhood Victimization Emotional Adjustment Female Adjustment Victim Adjustment 11-04