Site Matters: Winning the Hearts and Minds of Patients in a Cardiology Clinic

Feasibility and impact of a guided symptom exposure augmented cognitive behavior therapy protocol to prevent symptoms of pharmacologically induced depression: A pilot study

Depression is the leading cause of disability and a major cause of morbidity worldwide, with societal costs now upwards of 1 trillion dollars across the globe. Hence, extending current efforts to augment prevention outcomes is consistent with global public health interests. Although many prevention programs have been developed and have demonstrated efficacy, studies have yet to demonstrate that CBT is effective in preventing symptoms in populations at risk for developing depression induced by pharmacological substances. Using a randomized, controlled design, this pilot study reports on the feasibility and preliminary effects of a novel, guided symptom exposure augmented cognitive behavioral prevention intervention (GSE-CBT) in a sample diagnosed with Hepatitis C at risk for developing medication induced depression. Results demonstrated that the guided symptom exposure augmented CBT (GSE-CBT) was feasible in this population and was delivered with high integrity. Although not statistically different, we observed a pattern of lower depression levels in the GSE-CBT group versus those in the control group throughout. This pilot study demonstrates that a psychosocial prevention intervention is feasible for use in patients at risk for developing pharmacologically induced depression and that a guided symptom exposure augmented CBT protocol has the potential to prevent symptoms of depression that develop as a side effect to taking these medications. Results are preliminary and future studies should use larger samples and test the intervention in other populations.

Estimating correlations among cardiovascular patients' psychiatric and physical symptom indicators: The biplot in correspondence analysis approach

OBJECTIVES

We employed the correspondence analysis (CA) biplot to estimate correlations between gender-age levels of cardiovascular disease patients and their psychiatric and physical symptoms. Utilization of this correlation estimation can inform clinical practice by elucidating associations between certain psychiatric or physical symptoms and specific gender-age levels.

METHOD

The CA biplot utilized here was designed to visually inspect row-column category associations in a 2-dimensional plane and then to numerically estimate the category associations with correlations. To do so, we (a) estimated dimensions from row and column categories with CA; (b) verified statistical significance of dimensions with a permutation test; (c) projected row and column categories in a plan constructed with the first 2 dimensions that were statistically significant; (d) visually inspected category associations in the plane; and (e) numerically estimated category associations with correlations.

RESULTS

Consistent with the previous results, female cardiovascular disease patients were more likely to experience psychiatric symptoms than the male patients. However, when examining the results by gender and age, both female and male patients in their 50s and 60s tended to experience elevated rates of the psychiatric symptoms.

CONCLUSIONS

The CA biplot can be useful for isolating key clinical concerns among any medical populations.

Validity of the European Society of Cardiology's Psychosocial Screening Interview in Patients With Coronary Artery Disease-The THORESCI Study

OBJECTIVE

The aim of the study was to examine the validity of the European Society of Cardiology (ESC) psychosocial screening instrument.

METHODS

A total of 508 acute (67%) or elective (33%) percutaneous coronary intervention patients (mean [standard deviation]age = 63 [10] years, 81% male) completed the ESC screening interview and established questionnaires for psychosocial risk markers, that is, depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder Questionnaire 7), type D personality (Type D Scale 14), hostility (Cook-Medley Hostility Scale 7), and marital/work stress (Maudsley Marital Quality Questionnaire 6, Effort-Reward Imbalance Scale) during or close after hospital admission. At 1-year follow-up, angina and cardiopulmonary symptoms were assessed.

RESULTS

Prevalence estimates of psychosocial factors based on the ESC screener were as follows: depression (18%), anxiety (33%), negative affectivity (11%), social inhibition (41%), work stress (17%), marital stress (2%), and hostility (38%). Analysis of correspondence with validated questionnaires revealed fair to moderate agreement (depression [κ = .39], anxiety [κ = .23], type D personality [κ = .21]), regardless of percutaneous coronary intervention indication. For work and marital stress, there was poor to fair performance (κ range = .04-.24); agreement for hostility was poor (κ = -.27). A positive ESC screen for depression, anxious tension, and type D personality was associated with more angina and cardiopulmonary symptoms at follow-up (odds ratios ranging between 1.85 (95% confidence interval = 0.84-4.08) and 8.01 (95% confidence interval = 2.35-27.35).

CONCLUSIONS

The ESC screener contributes to the search for a multidimensional and easy-to-use psychosocial screening instrument for cardiac patients. Although the screener, in its current form, may not be sufficiently valid to reliably detect all predefined psychosocial factors, screening scores for depression and anxiety might be useful in clinical practice. Our findings can be used for further refinement and validation of the screener.

Mental Health Screening Outcomes in a Pediatric Specialty Care Setting

OBJECTIVE

To evaluate whether a psychosocial screening program that included free and flexible access to mental health (MH) consultation resulted in increased rate of consultations.

STUDY DESIGN

This is a post hoc review of a clinical screening program in a pediatric food allergy clinic in New York City. Screening was limited to 2 days per week, providing an opportunity to compare screened and nonscreened cohorts. Previous results from more than 1000 other families were analyzed to create the 1-page screening questionnaire. Participants were children with allergies and their parents who sought care at the clinic between March and September 2013. Parents were screened for distress and quality of life burden related to their child's allergy, and children were screened for anxiety, bullying, and quality of life. The predefined primary outcome was the percentage of families who received the free MH consultation after screening vs no-screening days in the allergy clinic.

RESULTS

The 3143 encounters during the study period included 1171 on screening days and 1972 on no-screening days. Most (86%) eligible families completed the screen. Almost one-half (44%) met the initial screening thresholds. A total of 71 families (6.1% of screening days encounters) were referred to a MH consultation after a secondary review, but only 11 (1% of screening days encounters) scheduled a MH appointment. Eighteen families from the no-screening days came to a MH evaluation (1% of no-screening days encounters).

CONCLUSION

Screening did not lead to enhanced MH follow-up. Resources may be better used on ensuring the availability of MH care rather than on screening in pediatric specialty clinics.

Personality disorders in heart failure patients requiring psychiatric management: comorbidity detections from a routine depression and anxiety screening protocol

Several international guidelines recommend routine depression screening in cardiac disease populations. No previous study has determined the prevalence and comorbidities of personality disorders in patients presenting for psychiatric treatment after these screening initiatives. In the first stage 404 heart failure (HF) patients were routinely screened and 73 underwent structured interview when either of the following criteria were met: (a) Patient Health Questionnaire ≥10; (b) Generalized Anxiety Disorder Questionnaire ≥7); (c) Response to one item panic-screener. Or (d) Suicidality. Patients with personality disorders were compared to the positive-screen patients on psychiatric comorbidities. The most common personality disorders were avoidant (8.2%), borderline (6.8%) and obsessive compulsive (4.1%), other personality disorders were prevalent in less than <3% of patients. Personality disorder patients had significantly greater risk of major depression (risk ratio (RR) 1.2; 95% confidence interval (CI) 1.2-13.3), generalized anxiety disorder (RR 3.2; 95% CI 1.0-10.0), social phobia (RR 3.8; 95% CI 1.3-11.5) and alcohol abuse/dependence (RR 3.2; 95% 1.0-9.5). The findings that HF patients with personality disorders presented with complex psychiatric comorbidity suggest that pathways facilitating the integration of psychiatric services into cardiology settings are warranted when routine depression screening is in place.

The real world mental health needs of heart failure patients are not reflected by the depression randomized controlled trial evidence

INTRODUCTION

International depression screening guidelines in heart failure (HF) are partly based on depression treatment efficacy from randomized controlled trials (RCTs). Our aim was to test the external validity of depression RCT criteria in a sample of real-world HF patients.

METHODS

HF patients admitted to 3 hospitals in South Australia were referred to a HF psychologist if not already receiving current psychiatric management by psychologist or psychiatrist elsewhere. Screening and referral protocol consisted of the following; (a). Patient Health Questionnaire ≥ 10; (b). Generalized Anxiety Disorder Questionnaire ≥ 7); (c). positive response to 1 item panic attack screener; (d). evidence of suicidality. Patients were evaluated against the most common RCT exclusion criteria personality disorder, high suicide risk, cognitive impairment, psychosis, alcohol or substance abuse or dependency, bi-polar depression.

RESULTS

Total 81 HF patients were referred from 404 HF admissions, and 73 were assessed (age 60.6 ± 13.4, 47.9% female). Nearly half (47%) met at least 1 RCT exclusion criterion, most commonly personality disorder (28.5%), alcohol/substance abuse (17.8%) and high suicide risk (11.0%). RCT ineligibility criteria was more frequent among patients with major depression (76.5% vs. 46.2%, p<.01) and dysthymia (26.5% vs. 7.7%, p = .03) but not significantly associated with anxiety disorders. RCT ineligible patients reported greater severity of depression (M = 16.6 ± 5.0 vs. M = 12.9 ± 7.2, p = .02) and were higher consumers of HF psychotherapy services (M = 11.5 ± 4.7 vs. M = 8.5 ± 4.8, p = .01).

CONCLUSION

In this real-world sample comparable in size to recent RCT intervention arms, patients with depression disorders presented with complex psychiatric needs including comorbid personality disorders, alcohol/substance use and suicide risk. These findings suggest external validity of depression screening and RCTs could serve as a basis for level A guideline recommendations in cardiovascular diseases.

Utilizing correspondence analysis to characterize the mental health of cardiac patients with diabetes

The aim of this study was to examine the mental health of cardiac patients with diabetes and whether symptoms varied by gender and/or age. Screening for depression and posttraumatic stress symptoms was conducted on 1003 patients with cardiovascular disease. Correspondence analysis was utilized to identify clinical core profiles. Results suggested that cardiovascular disease patients with diabetes, particularly males, experience high rates of depression, suicide ideation, and posttraumatic stress symptoms. Clinical implications of these findings include targeted mental health screening options as well as offering a closer look at the specific concerns of cardiovascular disease patients with diabetes.

Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review

Objectives

To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes.

Background

A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes.

Conclusions

There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence.

An assessment of the mental health care needs and utilization by families of children with a food allergy

The present study aimed to examine whether caretakers of children with a food allergy experience distress and to determine their family’s mental health-care needs and utilization. An anonymous survey was given to a sample of 454 caretakers during conferences hosted by the Food Allergy & Anaphylaxis Network. Overall, 32 percent of caretakers reported above threshold levels of distress while 70 percent stated that mental health support would have been helpful, but only 23 percent sought it. Even when mental health support was desired and available, few received it. Routine discussion of mental health needs with families receiving medical care may help address barriers to utilization.

Engagement in Trauma-Specific CBT for Youth Post-9/11

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income ethnically diverse population were trained to deliver CBT and structured engagement strategies. Four hundred and forty-five youth ages 5-19 were eligible for CBT, and 417 (94%) received at least one treatment session. Pretreatment and treatment show rates and overall dose were examined. Treatment participation rates were higher than those typically reported in community studies of children's mental health services. Regression analyses indicated variability across sites in treatment show rates with the highest rates at where services were delivered in schools. However, sites, demographic factors and trauma symptoms accounted for a small amount of variance in treatment participation overall. The study suggests structured engagement strategies, linked to evidence-based treatments may improve treatment participation for youth.

Models of care for co-occurring mental and medical disorders

In this article we review practice models for treating common mental disorders in primary care. Novel treatment approaches by primary care providers and specialty providers, including collaborative care and telepsychiatric models, show considerable promise. An understanding of remaining barriers to improved care suggests several possible solutions and future directions for outpatient psychosomatic medicine.