Usefulness of the SF-36 Health Survey in measuring health outcomes in the depressed elderly

Patient satisfaction and outcomes of crisis resolution home treatment for the management of acute psychiatric crises: a study during the COVID-19 pandemic in Madrid

Background

Crisis Resolution Home Treatment (CRHT) seem to offer comparable results to the traditional hospitalization model, at a lower cost and offering greater flexibility and scope. However, in Madrid, its implementation in Mental Health did not occur until the midst of the COVID-19 pandemic. In this work we analysed the effectiveness of a mental health CRHT unit promoted during the COVID-19 pandemic, as well as the degree of satisfaction of patients and their families.

Methods

90 patients were treated by the CRHT unit in the period between October 2020 and June 2022. All patients met the inclusion criteria: (1) Acute psychopathological decompensation in patients suffering from psychotic disorders, major affective disorder, obsessive compulsive disorder, personality disorder and other severe mental disorders causing functional disability, according to ICD-10 diagnostic criteria; (2) Ages between 18-90 years old; (3) Living in the urban area of Vallecas, Madrid; and (4) Counting with sufficient social and family support. The effectiveness of the intervention was evaluated with the SF-36 health questionnaire, the caregiver burden with the Zarit questionnaire, and patient satisfaction with a survey specifically designed for this work.

Results

55 (61.1%) patients completed the SF-36 at baseline and at the end of hospitalization. Statistically significant improvements were observed in the 8 dimensions of the SF-36 (p < 0.05). However, CRHT did not achieve a statistically significant decrease in caregiver burden. Regarding the satisfaction of the patients with the attention and care received, an average score of 47.72/50 was obtained.

Conclusion

The Crisis Resolution Home Treatment intervention resulted in significant improvement in patients' quality of life with high satisfaction scores. However, it did not effectively reduce caregiver burden. Future research should focus on randomized controlled trials with long-term follow-up to assess the effectiveness of CRHT compared to traditional hospitalization and utilize specific assessment scales for different mental disorders.

Quality of Life and Medication Adherence in Patients With Major Depressive Disorder: An Interim Analysis of a Randomized Study

BACKGROUND AND OBJECTIVES

Quality of life and medication adherence worsen in untreated depressed individuals. Studies examining how vilazodone, escitalopram, and vortioxetine affect these factors are few and far between. Our study's objectives were to determine the change in SF-36 at 12 weeks and the association between treatment outcome and medication adherence.

METHODS

This is an interim analysis of a randomized, open-label, three-arm ongoing study. The participants were evaluated at baseline, four, eight, and 12 weeks after being randomly assigned to take either vilazodone (20-40 mg/d), escitalopram (10-20 mg/d), or vortioxetine (5-20 mg/d). This study is registered with CTRI, 2022/07/043808.

RESULTS

Of 71 recruited participants, 49 (69%) completed the 12-week visit. The median scores of physical components of SF-36 for the three groups were 35.5, 35.0, and 35.0 at baseline (p=0.76) and 51.0, 49.5, and 53.0 (p<0.001) at 12 weeks respectively. Their corresponding median SF-36 scores for mental components were 43.0, 43.0, and 44.0 at baseline (p=0.34) and 66.0, 63.5, and 70.0 (p<0.001) at 12 weeks. The post hoc analysis yielded a significant difference (p<0.001) regarding SF-36 scores. MMAS-8 scores among the participants were similar (p=0.22) at 12 weeks. Higher medication adherence was associated with lesser depressive symptoms (r= -0.46, p=0.001).

CONCLUSION

As per this interim analysis, vortioxetine substantially impacted the SF-36 scores, juxtaposed with vilazodone and escitalopram. The participants' clinical improvements were reflected by their adherence levels. These effects need to be probed further.

Multiple aspects of energy poverty are associated with lower mental health-related quality of life: A modelling study in three peri-urban African communities

Objective

Over 900 million people in sub-Saharan Africa (SSA) live in energy poverty, relying on cooking polluting fuels (e.g. wood, charcoal). The association between energy poverty and mental/physical health-related quality of life (HRQoL) among women in SSA, who are primarily tasked with cooking, is unknown.

Methods

Females (n ​= ​1,150) from peri-urban Cameroon, Kenya and Ghana were surveyed on their household energy use and mental/physical health status using the standardized Short-Form 36 (SF-36) questionnaire. Random effects linear regression linked household energy factors to SF-36 mental (MCS) and physical component summary (PCS) scores. A binary outcome of 'likely depression' was derived based on participants' MCS score. Random effects Poisson regression with robust error variance assessed the relationship between household energy factors and odds of likely depression.

Results

The prevalence of likely depression varied by a factor of four among communities (36%-Mbalmayo, Cameroon; 20%-Eldoret, Kenya; 9%-Obuasi, Ghana). In the Poisson model (coefficient of determination (R²) ​= ​0.28), females sustaining 2 or more cooking-related burns during the previous year had 2.7 (95%CI:[1.8,4.1]) times the odds of likely depression as those not burned. Females cooking primarily with charcoal and wood had 1.6 times (95%CI:[0.9,2.7]) and 1.5 times (95%CI:[0.8,3.0]) the odds of likely depression, respectively, as those primarily using liquefied petroleum gas. Women without electricity access had 1.4 (95%CI:[1.1,1.9]) times the odds of likely depression as those with access. In the MCS model (R² ​= ​0.23), longer time spent cooking was associated with a lower average MCS score in a monotonically increasing manner. In the PCS model (R² ​= ​0.32), women injured during cooking fuel collection had significantly lower (-4.8 95%CI:[-8.1,-1.4]) PCS scores.

Conclusion

The burden of energy poverty in peri-urban communities in SSA extends beyond physical conditions. Experiencing cooking-related burns, using polluting fuels for cooking or lighting and spending more time cooking are potential risk factors for lower mental HRQoL among women.

Association Between Depression and Severity of Dry Eye Symptoms, Signs, and Inflammatory Markers in the DREAM Study

Importance

Depression is more prevalent in patients with dry eye disease (DED) than in the general population; however, the association between severity of DED and depression needs further evaluation.

Objective

To investigate the association between depression and severity of DED symptoms and signs, including inflammatory markers.

Design, Setting, and Participants

Secondary cross-sectional and longitudinal analysis performed in April to December 2020 of data from Dry Eye Assessment and Management (DREAM) study, a randomized clinical trial from October 2014 to July 2016 including patients with moderate to severe symptoms and signs of DED. Enrolled from 27 ophthalmology and optometry centers, both academic and private, in 17 US states, 535 patients were followed up for 1 year.

Exposure

Participants screened positive for depression if they scored 42 or less on the Mental Component Summary (MCS) of the 36-Item Short Form Health Survey.

Main Outcomes and Measures

Symptoms of DED were assessed by Ocular Surface Disease Index (OSDI) and Brief Ocular Discomfort Index (BODI) and signs assessed by tear film breakup time, Schirmer test, corneal and conjunctival staining, tear osmolarity, and meibomian gland dysfunction at baseline, 6 months, and 12 months. A composite severity sign score was calculated from all 6 signs. Inflammatory markers (cytokines in tears and HLA-DR expression by conjunctival surface cells) were measured for some trial participants. Features of DED were compared between participants with and without depression and adjusted for age, sex, race, visits, and baseline comorbidities.

Results

Among the 535 participants, mean (SD) age was 58 (13.2) years, 434 participants (81%) were women, and 398 (74.4%) were White. Participants who screened positive for depression had worse DED symptoms by OSDI (effect size = 0.45, P < .001) and BODI (effect size = 0.46, P < .001) and composite DED sign score (effect size = 0.21, P = .006). Lower MCS score (ie, worse depression) was correlated with higher OSDI score (ie, worse DED symptoms) at baseline (Spearman ρ = -0.09, P = .03), 6 months (ρ = -0.20, P < .001), and 12 months (ρ = -0.21, P < .001). Inflammatory markers did not differ by depression status.

Conclusions and Relevance

Depression was associated with more severe dry eye symptoms and overall signs, suggesting that among patients with moderate to severe DED, those with depression may be likely to have more severe DED. These findings support consideration of depression as a comorbidity when managing patients with DED. Further study is needed to elucidate the relationship.

Achieving clinical response in postpartum depression leads to improvement in health-related quality of life

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) burden associated with postpartum depression (PPD), determine the extent to which clinical response impacts HRQoL, and estimate the impact of PPD and clinical response on healthcare resource utilization (HRU) and productivity.

METHODS

Patient data (n = 127) from two multicenter, randomized, double-blind, placebo-controlled phase 3 clinical trials evaluating the safety and efficacy of brexanolone injection in adults with PPD were employed for these posthoc analyses. HRQoL and health utility was assessed with the SF-36-v2 Health Survey (SF-36v2) acute version. The 17-item Hamilton Rating Scale for Depression (HAMD-17) total score was used to identify clinical response (≥50% reduction in HAMD-17 total score). Baseline HRQoL burden was assessed by comparison to age- and gender-adjusted population normative data from the 2009 QualityMetric PRO Norming study. The impact of clinical response was evaluated by comparing day 7 and day 30 SF-36v2 scores between clinical responders and non-responders. Interpretations of the meaningfulness of clinical response were indirectly estimated via 2017 National Health and Wellness Survey data linking SF-36v2 mental component summary (MCS) scores to (HRU) and productivity.

RESULTS

Baseline HRQoL of patients with PPD was significantly below normative values. Day 7 and day 30 clinical response were associated with large and statistically significant improvements in HRQoL, greater likelihood of meeting SF-36v2 responder definitions, and reduced impairment. MCS levels corresponding to those observed in clinical responders were linked to lower HRU and productivity loss relative to non-responders.

CONCLUSIONS

PPD places a substantial burden on HRQoL. Achievement of rapid clinical response (at day 7) and clinical response sustained several weeks following the end of treatment (day 30) led to significant improvement in HRQoL, suggesting the importance of identifying women with PPD and providing effective treatment options.

Effects of a 12-week yoga versus a 12-week educational film intervention on symptoms of restless legs syndrome and related outcomes: an exploratory randomized controlled trial

STUDY OBJECTIVES

To assess the effects of a yoga versus educational film (EF) program on restless legs syndrome (RLS) symptoms and related outcomes in adults with RLS.

METHODS

Forty-one community-dwelling, ambulatory nonpregnant adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or EF program (n = 22). In addition to attending classes, all participants completed practice/treatment logs. Yoga group participants were asked to practice at home 30 minutes per day on nonclass days; EF participants were instructed to record any RLS treatments used on their daily logs. Core outcomes assessed pretreatment and posttreatment were RLS symptoms and symptom severity (International RLS Study Group Scale (IRLS) and RLS ordinal scale), sleep quality, mood, perceived stress, and quality of life (QOL).

RESULTS

Thirty adults (13 yoga, 17 EF), aged 24 to 73 (mean = 50.4 ± 2.4 years), completed the 12-week study (78% female, 80.5% white). Post-intervention, both groups showed significant improvement in RLS symptoms and severity, perceived stress, mood, and QOL-mental health (P ≤ .04). Relative to the EF group, yoga participants demonstrated significantly greater reductions in RLS symptoms and symptom severity (P ≤ .01), and greater improvements in perceived stress and mood (P ≤ .04), as well as sleep quality (P = .09); RLS symptoms decreased to minimal/mild in 77% of yoga group participants, with none scoring in the severe range by week 12, versus 24% and 12%, respectively, in EF participants. In the yoga group, IRLS and RLS severity scores declined with increasing minutes of homework practice (r = .7, P = .009 and r = .6, P = .03, respectively), suggesting a possible dose-response relationship.

CONCLUSIONS

Findings of this exploratory RCT suggest that yoga may be effective in reducing RLS symptoms and symptom severity, decreasing perceived stress, and improving mood and sleep in adults with RLS.

CLINICAL TRIAL REGISTRATION

Registry: Clinicaltrials.gov; Title: Yoga vs. Education for Restless Legs: a Feasibility Study; Identifier: NCT03570515; URL: https://clinicaltrials.gov/ct2/show/NCT03570515.

Impact of Completion Lymphadenectomy on Quality of Life for Head and Neck Cutaneous Melanoma

OBJECTIVE

Recent randomized data suggest that completion lymph node dissection after a positive sentinel lymph node biopsy (SLNB) improves locoregional control but does not improve survival for melanoma patients. Locoregional recurrences of head and neck cutaneous melanoma (HNCM) may result in significant morbidity. A better understanding of morbidity is thus important to inform decisions about whether to pursue completion neck dissection (ND).

STUDY DESIGN

Cross-sectional study.

SETTING

Academic tertiary care hospital.

METHODS

Clinical data were collected for patients with HNCM seen between 2016 and 2019 who were at least 1-year disease free. Each patient completed the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS), Neck Dissection Impairment Index, and SF-36 (Short Form-36). Scores were compared by surgical treatment: wide local excision (WLE) only, SLNB, and ND. Univariate and multivariable regression was performed.

RESULTS

Of 474 patients, 140 returned questionnaires (29.5% response rate; WLE, n = 49; SLNB, n = 76; ND, n = 15). No significant differences in SLANSS or Neck Dissection Impairment Index scores were found between the WLE and SLNB groups. SLANSS scores differed by 2 SD (P = .001) in the ND cohort, which had a 36% rate of neuropathy. Neck impairment was worse by 1 SD (P = .01) in the ND cohort. No differences were found in SF-36 domains.

CONCLUSION

Neuropathy and neck impairment are components of morbidity after ND. These risks must be balanced with potential morbidity of locoregional recurrence in HNCM.

Incorporating a Usual Care Comparator into a Study of Meditation and Music Listening for Older Adults with Subjective Cognitive Decline: A Randomized Feasibility Trial

BACKGROUND

Recent studies suggest meditation and music listening (ML) may improve cognitive and psychosocial outcomes in adults with subjective cognitive decline (SCD). However, lack of a usual care group has limited conclusions.

OBJECTIVE

To assess the: 1) feasibility of incorporating an enhanced usual care (EUC) comparator in a trial of Kirtan Kriya meditation (KK) and ML for adults experiencing SCD; and 2) preliminary effects of active treatment (KK/ML) versus an EUC program.

METHODS

Forty participants with SCD were randomized 1:1:2 to a 12-week KK, ML, or EUC program. KK and ML participants were asked to practice 12 minutes/day; EUC participants were given a comprehensive educational packet regarding healthy aging and strategies for improving/maintaining brain health and asked to record any activities or strategies used. Feasibility was assessed using measures of retention, adherence, treatment expectancies, and participant satisfaction, as well as information from exit questionnaires and daily practice/activity logs. Cognitive functioning, stress, mood, sleep-quality, and health-related quality of life (QOL) were measured pre- and post-intervention using well-validated instruments.

RESULTS

Thirty-two participants (80%) completed the 3-month study, with retention highest in the EUC group (p < 0.05). Active treatment participants averaged 6.0±0.4 practice sessions/week, and EUC participants, 7.5±0.6 brain health activities/week. Treatment expectancies were similar across groups. EUC participants indicated high satisfaction with the program and study. Despite limited study power, the active treatment group showed significantly greater gains in subjective memory functioning (ps≤0.025) and nonsignificant improvements in cognitive performance (TMT-B), perceived stress, QOL, and mood (ps≤0.08) compared to the EUC group.

CONCLUSION

Findings of this pilot feasibility trial suggest incorporation of an EUC program is feasible, and that participation in a simple 12-week relaxation program may be helpful for adults with SCD versus engagement in an EUC program.

Health-related quality of life in remitted psychotic depression✰

BACKGROUND

Some patients with major depression continue to demonstrate deficits in health-related quality of life (HRQL) following remission. No data exist, however, regarding HRQL in remitted psychotic depression. In this study, we aimed to characterize HRQL in patients with psychotic depression receiving controlled pharmacotherapy.

METHODS

This is a secondary analysis of a randomized controlled trial studying continuation pharmacotherapy of psychotic depression. We compared participants' HRQL (measured using the SF-36) between baseline and remission and to population norms. We also compared SF-36 scores stratified by age and gender and examined the correlation between SF-36 scores and medical burden, depression score and neuropsychological performance in remission.

RESULTS

SF-36 scores were significantly lower than population norms at baseline, but improved following remission to the level of population norms. Neither SF-36 scores nor magnitude of SF-36 improvement differed substantially between genders or between younger and older participants. In remission, depression scores were correlated with most SF-36 scales and medical burden was correlated with SF-36 scales measuring physical symptoms. Neuropsychological measures were generally not correlated with SF-36 scores.

LIMITATIONS

This study was a secondary analysis not powered specifically to measure HRQL as an outcome variable and the SF-36 was the only HRQL measure used.

CONCLUSIONS

Participants with remitted psychotic depression demonstrated levels of HRQL comparable to population norms, despite marked impairment in HRQL when acutely ill. This finding suggests that, when treated in a rigorous manner, many patients with this severe illness improve significantly from a clinical and HRQL perspective.

Advance Care Plan and Factors Related to Disease Progression in Patients With Spinocerebellar Ataxia Type 1: A Cross-Sectional Study in Thailand

BACKGROUND

Spinocerebellar ataxia type 1 (SCA1) is an autosomal dominant progressive neurodegenerative disease. Few studies have been conducted regarding advance care planning in this population.

OBJECTIVE

This study explores advance care planning preferences of patients with SCA1 and their association with disease progression and quality of life.

METHODS

The study examined 12 Thai patients with SCA1 from 2 families living in Thailand. The advance care plan followed a Gold Standards Framework. The 12 patients were interviewed and recorded in video. The research team evaluated neurocognitive functions as measured by the following tests; Scale for the Assessment and Rating of Ataxia (SARA), Berg Balance Score, Mini-Mental Status Examination, and Digit Span and Category Fluency. The quality of life was measured by a Short-Form Health Survey-36 (SF-36).

RESULTS

Seven of 12 patients with SCA1 rated communication ability as most important for their quality of life. Patients identified becoming a burden on their family members and ventilator dependence as the most undesirable situations. Half of the patients preferred a hospital as their last place of care. Comparing patients prefer hospital to home has significantly high median SARA (23 vs 11.5; P = .03) and low SF-36 (41.4 vs 72.4; P = .02).

CONCLUSIONS

Those patients preferring a hospital for end-of-life care exhibited more physical disability and lower quality of life than those who preferred home care. Making assisted living health-care services in the home more readily available and affordable may alleviate concerns of patients facing more severe physical challenges.

Acceptability and feasibility of a 12-week yoga vs. educational film program for the management of restless legs syndrome (RLS): study protocol for a randomized controlled trial

Background

Restless legs syndrome (RLS) is a common and burdensome sleep disorder associated with profound impairment of health, well-being, and quality of life. Unfortunately, the medications used for RLS management carry risk of serious side effects, including augmentation of symptoms. Yoga, an ancient mind-body discipline designed to promote physical, emotional, and mental well-being, may offer a viable, low-risk new treatment. The primary objectives of this pilot, parallel-arm, randomized controlled trial (RCT) are to assess the acceptability and feasibility of a 12-week yoga vs. educational film program for the management of RLS.

Methods

Forty-four adults with confirmed moderate to severe RLS will be recruited and randomized to a 12-week yoga (n = 22) or standardized educational film program (N = 22). Yoga group participants will attend two 75-min Iyengar yoga classes per week for the first 4 weeks, then one 75-min class per week for the remaining 8 weeks, and will complete a 30-min homework routine on non-class days. Educational film group participants will attend one 75-min class per week for 12 weeks and complete a daily RLS treatment log; classes will include information on: RLS management, including sleep hygiene practices; other sleep disorders; and complementary therapies likely to be of interest to those participating in a yoga and sleep education study.

Yoga and treatment logs will be collected weekly. Feasibility outcomes will include recruitment, enrollment, and randomization rates, retention, adherence, and program satisfaction. Program evaluation and yoga-dosing questionnaires will be collected at week 12; data on exploratory outcomes (e.g., RLS symptom severity (IRLS), sleep quality (PSQI), mood (POMS, PSS), and health-related quality of life (SF-36)) will be gathered at baseline and week 12.

Discussion

This study will lay the essential groundwork for a planned larger RCT to determine the efficacy of a yoga program for reducing symptoms and associated burden of RLS. If the findings of the current trial and the subsequent larger RCTs are positive, this study will also help support a new approach to clinical treatment of this challenging disorder, help foster improved understanding of RLS etiology, and ultimately contribute to reducing the individual, societal, and economic burden associated with this condition.

Trial registration

ClinicalTrials.gov, ID: NCT03570515. Retrospectively registered on 1 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3217-7) contains supplementary material, which is available to authorized users.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Computerized Cognitive Training to Improve Mood in Senior Living Settings: Design of a Randomized Controlled Trial

Purpose

This two-arm, randomized controlled trial was designed to evaluate a computerized cognitive speed of processing (SOP) training known as Road Tour in the generally older group of adults residing in assisted living (AL) and related senior housing. Study aims focused on depression-related outcomes that were observed in earlier SOP studies using Road Tour with younger, home-dwelling seniors. Study design and baseline outcomes are discussed.

Participants and methods

A community-based design engaged AL and related senior living settings as partners in research. Selected staff served as on-site research assistants who were trained to recruit, consent, and train a target of 300 participants from AL and independent living (IL) programs to use the intervention and attention-control computerized training. Ten hours of initial computerized training was followed by two booster sessions at 5 and 11 months. Outcome measures included Useful Field of View (UFOV), 9-item Patient Health Questionnaire (PHQ-9), 12-item Centers for Epidemiological Studies Depression scale (CESD-12), 7-item Generalized Anxiety Disorders GAD-7), Brief Pain Inventory (BPI) and SF-36 Health Survey. Assessments occurred before randomization (pre-training), post-training, 26 and 52 weeks.

Results

A total of 351 participants were randomized to the intervention (n=173) and attention-control (n=178) groups. There were no significant differences between groups in demographic characteristics with the exception of education and reported osteoporosis. There were no significant differences in study outcomes between groups at baseline. Participants in AL had significantly lower SOP and self-rated health, and significantly higher depression, anxiety and pain when compared to those in IL programs on the same campus.

Conclusions

Compared to earlier SOP training studies using Road Tour, this sample of senior living participants were older, reported more health conditions and poorer overall health, had lower UFOV scores and greater depressive symptoms at baseline. Moreover, participants in AL had greater health challenges than those in IL.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

A Systematic Review of the Measurement of Function in Late-Life Depression

Recovery of everyday premorbid function is a primary goal in the treatment of depression. Measurement of function is an important part of achieving this goal. A multitude of scales have been used to measure function in depression, reflecting the complex, multifaceted nature of functioning. Currently, however, there are no evidence-based guidelines to assist the researcher or clinician in deciding which instruments are best suited to measure function in late-life depression (LLD). Thus, the aims of this study are to 1) systematically review and identify the instrumental activities of daily living and social functioning assessment instruments used in the LLD literature; 2) identify and appraise the measurement properties of these instruments; and 3) suggest factors for LLD researchers and clinicians to consider when selecting functional assessment instruments and make pertinent recommendations. We performed a systematic review of MEDLINE and CINAHL to identify studies that i) incorporated subjects aged 60 years and older with a depressive disorder, and ii) measured instrumental activities of daily living and/or social functioning. Our search yielded 21 functional assessment instruments. Only two of these instruments, the 36-Item Short Form Survey and the Performance Assessment of Self-Care Skills, have formal validation data in LLD. Four additional instruments, although not formally validated, have relevant data regarding their measurement properties. The primary finding of this study is that very few functional assessment instruments have been validated in LLD, and the available measurement property data are mixed; there is a need for further instrument validation in late-life depression. With this caveat in mind, we provide evidence-based suggestions for researchers and clinicians assessing functioning in LLD patients.

Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures

Despite the improvement of surgical techniques surgical site infections (SSIs) still remain clinically challenging in high risk patients undergoing osteosynthesis for tibia fractures. The use of an antibiotic coated implant might reduce the adhesion of bacteria on the implant surface and could therefore reduce the rate of implant-related infection or osteomyelitis. A gentamicin-coated tibia nail was evaluated in a prospective study. Four centers enrolled 100 patients (99 treated) with fresh open or closed tibia fractures, or for non-union revision surgery and followed them for 18 months. Data collected included infection events, radiographs, SF-12, EQ-5D, Iowa Ankle score, and the WOMAC questionnaire. Sixty-eight of the 99 treated patients suffered from a fresh fracture, while in 31 patients, the intramedullary nail was implanted for revision purposes, including non-unions due to infection. Fifteen (22%) of the fresh fractures were GA Type III. The follow-up rate was 87% and 82% at 12 months and 18 months, respectively. Deep surgical site infections occurred in 3 fresh fractures and two in revision surgeries. We did not observe any local or systemic toxic effects related to gentamicin during this study. The use of the antibiotic coated nail is an option in patients with a high infection risk, like open factures or infected non unions, in the prevention of the onset of an implant-related infection or osteomyelitis.

Factors Related to the Changes in Quality of Life for Patients With Depression After an Acute Course of Electroconvulsive Therapy

OBJECTIVE

The aim of this study was to examine the effect of electroconvulsive therapy (ECT) on quality of life (QOL), depressive symptoms, and functioning for patients with depression, and to explore the variables related to QOL changes.

METHODS

Ninety-five inpatients with depression receiving at least 6 ECT sessions and completed all measures were included. Quality of life, symptom severity, and functioning were assessed using Short Form 36 (SF-36), the 17-item Hamilton Rating Scale for Depression (HAMD-17), and the Modified Work and Social Adjustment Scale (MWSAS), before and after ECT. The SF-36 includes 8 subscales, physical component summary (PCS), and mental component summary (MCS). Adverse effects after ECT, including headache, muscle pain, and nausea/vomiting, were also recorded.

RESULTS

All 8 SF-36 subscales, PCS, MCS, HAMD-17, and MWSAS improved significantly after treatment. Using multiple linear regression analysis, MWSAS changes predicted PCS changes significantly after adjusting for baseline PCS. Similarly, using multiple linear regression analysis, MWSAS changes were significant variables associated with MCS changes after adjusting for ECT frequency, HAMD-17 changes, and baseline MCS. The ECT improved QOL, depressive symptoms, and functioning.

CONCLUSIONS

Whether strategies to enhance functioning during an acute course of ECT could improve QOL is needed to be examined in a further study.

Analysing use of the Chinese HHIE-S for hearing screening of elderly in a northeastern industrial area of China

OBJECTIVE

The aim of the present study was to investigate the use of Chinese version of HHIE-S as a hearing screening tool for the elderly in an industrial area in northeast China.

DESIGN

Prevalence, sensitivity and specificity of Chinese version of HHIE-S were calculated. Factors that had impact on HHIE-S were analysed.

STUDY SAMPLE

Five hundred and seventy Mandarin speaking participants, aged from 50 to 85 years were included. They were tested with pure tone audiometry and Chinese version of HHIE-S.

RESULTS

The prevalence of hearing handicap was 55.3%. The sensitivity and specificity of HHIE-S were 84.5% and 58.3% respectively when the pass/fail criteria were set at PTA^0.5-4kHz >40 dBHL. In general, HHIE-S total and subscale scores were significantly associated with severity of hearing impairment. After stratified by severity of hearing impairment, both the prevalence of reported handicap and the scores of HHIE-S were not significantly associated with age. Male participants had significantly higher HHIE-S scores than female participants did.

CONCLUSIONS

The Chinese version of HHIE-S contributes useful information to identifying hearing handicap and addressing the rehabilitative needs in the elderly in an industrial city in Mainland China.

Relationship of Medication Use to Health-Related Quality of Life Among a Group of Older American Indians

This cross-sectional study examines the relationship of polypharmacy to health-related quality of life (HRQoL) among a group of older American Indians. An in-home interview and survey were administered to 63 community-dwelling American Indians aged 50 or older who were taking four or more prescription medications regularly. With the component summary scores from the Medical Outcomes Study Short Form-36 instrument analyzed as dependent variables, only the Physical Component Summary (PCS) score (r = .30, p = .02), and not the Mental (r = .06, p = .67), was associated with degree of polypharmacy. This association with PCS score remained significant even after controlling for age, sex, and chronic disease score (adjusted β = -.91, p = .045). This study is the first to describe the relationship between polypharmacy and HRQoL among a group of American Indians, and the results support the need for larger and more comprehensive studies of medication use in this special population.

Effects of Meditation versus Music Listening on Perceived Stress, Mood, Sleep, and Quality of Life in Adults with Early Memory Loss: A Pilot Randomized Controlled Trial

BACKGROUND

Older adults with subjective cognitive decline (SCD) are at increased risk not only for Alzheimer's disease, but for poor mental health, impaired sleep, and diminished quality of life (QOL), which in turn, contribute to further cognitive decline, highlighting the need for early intervention.

OBJECTIVE

In this randomized controlled trial, we assessed the effects of two 12-week relaxation programs, Kirtan Kriya Meditation (KK) and music listening (ML), on perceived stress, sleep, mood, and health-related QOL in older adults with SCD.

METHODS

Sixty community-dwelling older adults with SCD were randomized to a KK or ML program and asked to practice 12 minutes daily for 12 weeks, then at their discretion for the following 3 months. At baseline, 12 weeks, and 26 weeks, perceived stress, mood, psychological well-being, sleep quality, and health-related QOL were measured using well-validated instruments.

RESULTS

Fifty-three participants (88%) completed the 6-month study. Participants in both groups showed significant improvement at 12 weeks in psychological well-being and in multiple domains of mood and sleep quality (p's≤0.05). Relative to ML, those assigned to KK showed greater gains in perceived stress, mood, psychological well-being, and QOL-Mental Health (p's≤0.09). Observed gains were sustained or improved at 6 months, with both groups showing marked and significant improvement in all outcomes. Changes were unrelated to treatment expectancies.

CONCLUSIONS

Findings suggest that practice of a simple meditation or ML program may improve stress, mood, well-being, sleep, and QOL in adults with SCD, with benefits sustained at 6 months and gains that were particularly pronounced in the KK group.

Prevention of depression in patients with acute coronary syndrome (DECARD) randomized trial: effects on and by self-reported health

AIM

Escitalopram may prevent depression following acute coronary syndrome. We sought to estimate the effects of escitalopram on self-reported health and to identify subgroups with higher efficacy.

METHODS

This is a secondary analysis of a 12-month double-blind clinical trial randomizing non-depressed acute coronary syndrome patients to escitalopram (n = 120) or matching placebo (n = 120). The main outcomes were mean scores on Short Form 36 Health Survey (SF-36) domains, and diagnosis of depression was adjusted for baseline SF-36 scores.

RESULTS

Escitalopram did not yield different SF-36 trajectories on any scale compared with placebo (P > 0.28). Efficacy of escitalopram may have been better among those scoring at least the normative score on general health perceptions (hazard ratio (HR) for depression 0.17 (95% confidence interval 0.02-1.42) ) or social functioning (HR = 0.12 (0.02-0.99) ) than in the full sample of patients (HR = 0.20 (0.04-0.90) ), although not statistically significant.

CONCLUSIONS

The SF-36 may be too broad an outcome measure in trials or treatments that seek to prevent depression following acute coronary syndrome. The SF-36 may, however, indicate who is more likely to benefit from treatment.

Distress among caregivers of phase I trial participants: a cross-sectional study

PURPOSE

The number of patients with cancer enrolling in phase I trials is expected to increase as these trials incorporate patient selection and exhibit greater efficacy in the era of targeted therapies. Despite the fact that people with advanced cancer often require a caregiver, little is known about the experience of caregivers of people enrolling in oncology phase I clinical trials. We conducted a cross-sectional study assessing the distress and emotion regulation of caregivers of phase I trial participants to inform the design of future interventions targeting the unique needs of this population.

METHODS

Caregivers of oncology patients were approached at the patient's phase I clinical trial screening visit. Caregiver participants completed a one-time survey incorporating validated instruments to comprehensively assess distress and emotion regulation. Basic demographic information about both the caregiver and patient was collected.

RESULTS

Caregivers exhibited greater distress than population norms. Emotion regulation was also moderately impaired. Respondents identified positive aspects of caregiving despite exhibiting moderate distress.

CONCLUSION

Enrollment of a patient in a phase I clinical trial is a time of stress for their caregivers. This pilot study demonstrates the feasibility of engaging caregivers of phase I trial participants and the need to better support them through this component of their caregiving experience.

Comparing the postpartum quality of life between six to eight weeks and twelve to fourteen weeks after delivery in iran

Background:

Women during the postpartum period experience many physiological, psychological, and social changes. Quality of life (QOL) is a sense of well-being and arises from satisfaction or dissatisfaction with various aspects of life including health, employment, socioeconomic state, psychological-emotional state, and family. Moreover, QOL is an important criteria for assessing healthcare system.

Objectives:

The purpose of this study was to compare the postpartum QOL between six to eight and 12 to 14 weeks after delivery in women referred to public health centers in Dezful City, Iran, in 2011.

Materials and Methods:

This study was a longitudinal study. The study participants were 150 postpartum women referred to public health centers. Quota method was used for sampling. Data collection tools in this study were demographic questionnaire, Edinburgh Postnatal Depression Scale (EPDS), short form health survey questionnaire (SF-36), and Specific Quality of Life after Delivery Questionnaire. Data were analyzed using SPSS.

Results:

The results showed that the mean scores of various dimensions of the SF-36 were significantly higher at 12 to 14 weeks than at six to eight weeks (P < 0.001). The postpartum mean depression score was significantly higher at six to eight weeks than at 12 to 14 weeks (P < 0.001). The mean score of QOL questionnaires at 12 to 14 weeks were increased in all dimensions in comparison with six to eight weeks; however, this increase was significant only in dimension of the mother's feelings toward herself, her husband, and others (P < 0.001).

Conclusions:

Because enormous changes develop in postpartum women, we suggest supportive measures for mother by her mother-in-law, family, and caregivers to improve the QOL and health status of the mother and her child.

Antidepressant use and 10-year incident fracture risk: the population-based Canadian Multicentre Osteoporosis Study (CaMoS)

We used data from a large, prospective Canadian cohort to assess the association between selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) and fracture. We found an increased risk of fractures in individuals who used SSRI or SNRI, even after controlling for multiple risk factors.

INTRODUCTION

Previous studies have suggested an association between SSRIs and increasing risk of fragility fractures. However, the majority of these studies were not long-term analyses or were performed using administrative data and, thus, could not fully control for potential confounders. We sought to determine whether the use of SSRIs and SNRIs is associated with increased risk of fragility fracture, in adults aged 50 + .

METHODS

We used data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective randomly selected population-based community cohort; our analyses focused on subjects aged 50+. Time to event methodology was used to assess the association between SSRI/SNRI use, modeled time-dependently, and fragility fracture.

RESULTS

Among 6,645 subjects, 192 (2.9%) were using SSRIs or/and SNRIs at baseline. During the 10-year study period, 978 (14.7%) participants experienced at least one fragility fracture. In our main analysis, SSRI/SNRI use was associated with increased risk of fragility fracture (hazard ratio (HR), 1.88; 95% confidence intervals (CI), 1.48-2.39). After controlling for multiple risk factors, including Charlson score, previous falls, and bone mineral density hip and lumbar bone density, the adjusted HR for current SSRI/SNRI use remained elevated (HR, 1.68; 95% CI, 1.32-2.14).

CONCLUSIONS

Our results lend additional support to an association between SSRI/SNRI use and fragility fractures. Given the high prevalence of antidepressants use, and the impact of fractures on health, our findings may have a significant clinical impact.

Comparison of the prevalence of psychiatric co-morbidities in hepatitis C patients and hepatitis B patients in Saudi Arabia

BACKGROUND/AIM

Hepatitis C is a major health concern world-wide and is frequently associated with psychiatric co-morbidity. The most common genotype in Saudi Arabia differs from genotypes prevalent elsewhere and thus we aimed to determine if psychiatric disturbances occur in Saudi patients infected with hepatitis C and whether these symptoms extend to those infected with hepatitis B.

MATERIALS AND METHODS

Data were collected from hepatitis C and hepatitis B patients using the general health questionnaire (GHQ-28) and The Short Form Health Survey (SF-36) questionnaires. Tinnitus patients served as control subjects. The Chi-square test was used to examine the relationship between categorical variables. Continuous variables were compared using the Student's t-test or the Wilcoxon-Mann-Whitney test for skewed data, and correlations were evaluated by calculating Spearman's rho. The odds ratio was used to determine the association between variables and the likelihood of being a psychiatric case.

RESULTS

Hepatitis C patients were twice as likely to be labeled as a psychiatric case compared with hepatitis B patients ( P = 0.01). Age and gender were not predictive factors though there was a non-significant tendency toward a higher prevalence of psychiatric cases among females. Hepatitis C patients also scored lower than hepatitis B patients in 3 domains of the SF-36 questionnaire, indicating a greater reduction in quality of life (QoL).

CONCLUSION

We demonstrate an increased incidence of psychiatric symptoms in Saudi Arabian hepatitis C patients compared to hepatitis B patients and controls. This highlights the importance of collaboration between hepatologists and psychiatrists in order to improve the QoL in this patient group.

Elevated peri-transplant distress in caregivers of allogeneic blood or marrow transplant patients

PURPOSE

A full-time 24/7 caregiver is required for 100 days or longer following an allogeneic blood or marrow transplant during which time caregivers have multiple demands. Although distress in caregivers is documented, generalization is limited by small sample sizes, restricted range of assessments, and lack of information as to which caregivers may be more vulnerable to distress. The purpose of this study was to describe the peri-transplant psychological status of a sample of caregivers of allogeneic transplant patients.

METHODS

We assessed caregiver mood, stress, burden, and sleep using valid self-report measures in 109 caregivers of allogeneic transplant patients prior to stem cell transplantation. Caregivers' scores were compared with norms or established cutoff scores for behavioral measures. Additionally, demographic characteristics such as age and sex were tested as predictors of distress.

RESULTS

Caregivers showed significant levels of anxiety, stress, intrusion and avoidance behaviors, and poor sleep at the start of transplant compared with established norms. Younger caregivers were more distressed than older caregivers. There were no differences in levels of distress between male and female caregivers.

CONCLUSION

The peri-transplant period is a time of heightened anxiety and distress for caregivers of allogeneic transplant patients. This study indicates that caregivers would benefit from support programs in the peri-transplant period. Recommendations for types of support that may be helpful to caregivers are provided, but additional research is needed to validate that these programs would help caregivers providing care to patients receiving an allogeneic transplant in the peri-transplant period.

Mindful-Veteran: the implementation of a brief stress reduction course

BACKGROUND

Stress reduction is a focus of healthcare management in Veterans who often faced extreme stressors during military service.

OBJECTIVE

A quality improvement project to evaluate the implementation and effects of a brief mindfulness course delivered to Veterans, Mindful-Veteran (M-Vet), with self-reported mild to severe depressive symptoms in an outpatient setting.

DESIGN

A within-subjects design was used to determine whether depressed Veterans enrolled in a 6-week M-Vet course report improvements in perceived stress, depressive symptoms, and quality of life.

RESULTS

Mental health, general health, emotional role, and social functioning quality of life subscales significantly improved over the 6-week course. Severity of stress and depressive symptom scores, however, did not significantly decrease.

CONCLUSION

The findings suggest that this brief, simplified mindfulness program designed for military Veterans, seen within a community based outpatient clinic, has clinically beneficial effects on psychiatric outcomes.

Life satisfaction and feeling in control: indicators of successful aging predict mortality in old age

Life satisfaction and control beliefs are established indicators of successful aging and predict mortality. However, it has not yet been examined whether they independently predict mortality or interact. We examined main and interaction effects using Cox proportional hazards models in a sample of older adults (N = 1402; age range: 65-91). Only the interaction of life satisfaction and control beliefs significantly predicted mortality when controlling for socio-demographic variables and health. These findings suggest that detrimental effects of low control beliefs can be buffered by life satisfaction, and unexpectedly, that high levels of both factors are not most protective against mortality.

The mediating sex-specific effect of psychological distress on the relationship between adverse childhood experiences and current smoking among adults

Background

Research suggests that ACEs have a long-term impact on the behavioral, emotional, and cognitive development of children. These disruptions can lead to adoption of unhealthy coping behaviors throughout the lifespan. The present study sought to examine psychological distress as a potential mediator of sex-specific associations between adverse childhood experiences (ACEs) and adult smoking.

Method

Data from 7,210 Kaiser-Permanente members in San Diego California collected between April and October 1997 were used.

Results

Among women, psychological distress mediated a significant portion of the association between ACEs and smoking (21% for emotional abuse, 16% for physical abuse, 15% for physical neglect, 10% for parental separation or divorce). Among men, the associations between ACEs and smoking were not significant.

Conclusions

These findings suggest that for women, current smoking cessation strategies may benefit from understanding the potential role of childhood trauma.

Mental health consequences of international migration for Vietnamese Americans and the mediating effects of physical health and social networks: results from a natural experiment approach

Although the existing literature on immigrant mental health is extensive, major substantive and methodological gaps remain. Substantively, there is little population-based research that focuses on the mental health consequences of migration for Vietnamese Americans. More generally, although a wide range of mental health problems among immigrants has been identified, the potential causal or mediating mechanisms underlying these problems remain elusive. This latter substantive shortcoming is related to a key methodological challenge involving the potentially confounding effects of selection on migration-related outcomes. This article addresses these challenges by employing a "natural experiment" design, involving comparisons among three population-based samples of Vietnamese immigrants, never-leavers, and returnees (N=709). Data were collected in Ho Chi Minh City and in New Orleans between 2003 and 2005. The study investigates the long-term impact of international migration on Vietnamese mental health, and the potential mediating effects of social networks and physical health on these migration-related outcomes. The results reveal both mental health advantages and disadvantages among Vietnamese immigrants relative to the two groups of Vietnamese nationals. Selection can be ruled out for some of these differences, and both social networks and physical health are found to play important explanatory roles.

Relation of cumulative low-level lead exposure to depressive and phobic anxiety symptom scores in middle-age and elderly women

BACKGROUND

Different lines of evidence suggest that low-level lead exposure could be a modifiable risk factor for adverse psychological symptoms, but little work has explored this relation.

OBJECTIVE

We assessed whether bone lead--a biomarker of cumulative lead exposure--is associated with depression and anxiety symptoms among middle-age and elderly women.

METHODS

Participants were 617 Nurses' Health Study participants with K-shell X-ray fluorescence bone lead measures and who had completed at last one Mental Health Index 5-item scale (MHI-5) and the phobic anxiety scale of the Crown-Crisp Index (CCI) assessment at mean ± SD age of 59 ± 9 years (range, 41-83 years). With exposure expressed as tertiles of bone lead, we analyzed MHI-5 scores as a continuous variable using linear regression and estimated the odds ratio (OR) of a CCI score ≥ 4 using generalized estimating equations.

RESULTS

There were no significant associations between lead and either outcome in the full sample, but associations were found among premenopausal women and women who consistently took hormone replacement therapy (HRT) between menopause and bone lead measurement (n = 142). Compared with women in the lowest tertile of tibia lead, those in the highest scored 7.78 points worse [95% confidence interval (CI): -11.73, -3.83] on the MHI-5 (p-trend = 0.0001). The corresponding OR for CCI ≥ 4 was 2.79 (95% CI: 1.02, 7.59; p-trend = 0.05). No consistent associations were found with patella lead.

CONCLUSIONS

These results provide support for an association of low-level cumulative lead exposure with increased depressive and phobic anxiety symptoms among older women who are premenopausal or who consistently take postmenopausal HRT.

Walk on the sunny side of life--epidemiology of hypovitaminosis D and mental health in elderly nursing home residents

OBJECTIVES

Old age is a well-known risk factor for both depression and hypovitaminosis D, and an association between both conditions has been postulated. We document the prevalence of vitamin D deficiency in nursing home residents, and we examine the link with self-reported depressive symptoms and pharmacotherapy for depression.

DESIGN

Cross- sectional.

SETTING

nursing homes in Antwerp, Belgium.

PARTICIPANTS

Healthy elderly (n=589), with a mean age of 84 years.

MEASUREMENTS

We detected depressive symptoms by means of SF-36, a validated quality of life assessment; we registered the use of antidepressants and anxiolytics, and we measured serum 25(OH)D concentrations in all participants.

RESULTS

Almost our entire study population appeared to be vit D deficient. Comparison of the most severely and least deficient subgroups showed a consistent tendency towards more depressive symptoms and more use of antidepressants in the group with the lowest vit D level.

CONCLUSION

Nursing home residents are particularly vulnerable to preventable vit D deficiency. The relevance of the association with depressive symptoms and the possibilities for treatment are critically reviewed in the discussion.

Psychometric properties of the community integration questionnaire in a heterogeneous sample of adults with physical disability

OBJECTIVE

To investigate the psychometric properties of the Community Integration Questionnaire (CIQ) in a mixed sample of adults with physical disabilities.

DESIGN

Cross-sectional, survey study.

SETTING

Academic and community medical clinics, national registry, and self-referral.

PARTICIPANTS

Community-dwelling adults with spinal cord injury (n=146), multiple sclerosis (n=174), limb loss (n=158), or muscular dystrophy (n=273).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

CIQ, General Health item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Mental Health Scale from the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Based on the original scoring procedures, the CIQ Total scale and Home Integration subscale demonstrated acceptable internal consistency; however, reliability indices for the Social Integration and Productive Activities subscales were suboptimal. The exploratory factor analysis yielded a 4-factor solution (accounting for approximately 63% of the variance) that did not replicate the original factor structure of the CIQ. The results of the confirmatory factor analyses indicated that a modified 3-factor solution provided the best fit to the data from our samples. Using a revised scoring system based on these findings, the CIQ demonstrated improved reliability relative to the original scoring and good concurrent validity.

CONCLUSIONS

The results provide general support for the validity of the CIQ as a measure of participation in adults with physical disabilities. However, our results indicate that some small modifications to the original scoring system are needed to optimize its use in this patient group. Additional research is needed to refine the measurement of participation in these and other populations.

Short Form (SF-36) Health Survey measures are associated with decreased adherence among urban African Americans with severe, poorly controlled hypertension

The objective of this study was to determine whether an association exists between Short Form (SF-36) Health Survey measures and nonadherence among urban African Americans with poorly controlled hypertension. A total of 158 African Americans were admitted to an urban academic hospital for severe, uncontrolled hypertension. The main outcome measure was self-reported nonadherence to antihypertensive medications using a validated instrument. For every 10-point increase in Physical Component Summary (PCS) score, an individual was almost two times more likely to report being nonadherent (odds ratio, 1.94; 95% confidence interval, 1.30-2.90; P<.01). A significant interaction (P=.05) was observed between the physical functioning and mental health subscales. Individuals with high physical functioning and low mental health scores displayed the lowest adherence rate. These results suggest that high physical functioning, especially if associated with poor mental health, increases the likelihood of nonadherence to antihypertensive regimens among urban African Americans. The SF-36 may serve as an effective clinical tool that identifies patients at risk for nonadherence and, more importantly, may improve clinicians' understanding of nonadherence, allowing for discussions about antihypertensive medications to be tailored to individual patients.

Infliximab, a TNF-α antagonist treatment in patients with ankylosing spondylitis: the impact on depression, anxiety and quality of life level

The objective of this study was to assess the effect of infliximab on depression, anxiety and quality of life in patients with active ankylosing spondylitis (AS). In this 6-week longitudinal study, 16 patients with AS were assessed. Active disease as defined by BASDAI ≥4.0 was sought for inclusion. Infliximab was administered 5 mg/kg at 0, 2 weeks and 6 weeks. Collected data included age, sex and date of onset of rheumatologic disease. Activity of disease was measured using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Biological activity was evaluated with erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). ESR and CRP were assessed at baseline and day 42. The Hospital Anxiety and Depression scale (HADS), Beck Depression Inventory (BDI) and 36-item Short Form Health Survey (SF-36) were used to evaluate anxiety, depression and quality of life. BASDAI, SF-36, HADS and BDE were assessed prior to the initial infliximab dose and at 2nd, 14th and 42nd day. Seven (43.8%) AS patients had depression scores above the cut off value for both the HADS depression (HADS-D) and BDI and 4 (25 %) had high HADS anxiety scores at baseline. Significant time effect for BDI and HADS-D scores were observed. Although significantly lower BDI scores were found after first, second and third infusions of infliximab, compared to initial score, the significant decrease in HADS-D appeared after second and third infusions. A significant time effect for HADS-anxiety scores were found as well. All of the subscales of SF-36 improved significantly during the course, with an exception of role emotional, for which the difference approached to the significance. The change in BASDAI scores and CRP and ESR, in the treatment process, were not correlated with the change in depression and anxiety scores. Infliximab which is an anti-TNF-α drug, may be effective in the treatment of depression accompanying AS. Possible implications for the treatment of major depressive disorder were discussed, as well.

Sudden gains in depressed cancer patients treated with behavioral activation therapy

Many patients who receive cognitive-behavioral therapy experience sudden gains that are associated with improved treatment response and decreased risk of relapse. Extending prior research, this study examined sudden gains among depressed cancer patients receiving brief (9-session) behavioral activation therapy. Fifty percent of patients experienced sudden gains of large magnitude (M=11.8 BDI-II points), with sudden gains associated with improved treatment response and maintenance of gains at 3-month follow-up. Relative to those without sudden gains, at pretreatment assessment, cancer patients with sudden gains were more likely to present with less severe depression, less somatic anxiety, fewer coexistent anxiety disorders, as well as less bodily pain, better overall physical functioning, and fewer problems with daily activities as a result of emotional problems. These findings provide increasing support for behavioral activation with a difficult-to-treat population but raise important questions regarding mechanism of change. Clinical implications for treating depressed cancer patients are discussed.

Clinically significant depressive symptoms and associated factors in community elderly subjects from Sao Paulo, Brazil

OBJECTIVES

To determine the frequency of clinically significant depressive symptoms (CSDS) in a community sample of Brazilian elderly and to assess their relationship with sociodemographic factors, cognitive and functional impairment (CFI), and clinical diseases.

DESIGN

Cross-sectional study of a community-based sample of elderly subjects.

SETTING

City of Sao Paulo, State of Sao Paulo, Brazil.

PARTICIPANTS

A total of 1,563 elderly subjects aged 60 years or older.

MEASUREMENTS

A 10-item scale for screening of depressive symptoms in elderly people (D-10), the Mini Mental State Examination, the Fuld Object Memory Evaluation, the Informant Questionnaire on Cognitive Decline in the Elderly, the Bayer Activities of Daily Living Scale, and a sociodemographic and clinical questionnaire.

RESULTS

The frequency of CSDS was 13.0%. Univariate analysis identified independent factors associated with these symptoms in our sample. Logistic regression analysis indicated that being female, brown skinned, previously depressed, having CFI, using psychotropics, and not practicing physical exercise were related to CSDS. On the other hand, being older, clinically sick, employed, or married were not associated with CSDS.

CONCLUSIONS

: Consistent with previous reports, female gender, lack of physical activity, and CFI were significantly associated with higher frequencies of CSDS. Further investigations are necessary to clarify the occurrence of depression and possible modifiable factors in developing countries such as Brazil.

Depressive symptomatology and fracture risk in community-dwelling older men and women

BACKGROUND AND AIMS

Previous studies suggest that depression increases risk of falls, low bone mineral density, and fractures. Our aim was to evaluate whether depressive symptomatology alone predicts 5- year clinical fracture risk in older adults.

METHODS

In this secondary analysis of a community-based, prospective cohort study including 4175 women and 1652 men in Canada, depressive symptomatology was assessed at baseline by the mental health inventory-5 (MHI-5) and the mental component score (MCS) of the short form 36 questionnaire (SF-36). Fracture events were assessed annually for five years; all reported incident fragility fractures were confirmed radiographically.

RESULTS

Depressive symptomatology did not predict time to first fracture in men (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.45-1.65) or women (HR 1.09, 95% CI 0.86-1.39). Results were similar after controlling for potential confounders. Depressive symptoms were not significantly associated with baseline bone mineral density at the lumbar spine or femoral neck. Women with depressive symptoms were more likely to report falls in the previous month (odds ratio [OR] 1.52, 95% CI 1.12-2.06, p=0.01). This association did not achieve statistical significance in men (OR 1.71, 95% CI 0.96-3.04, p=0.07).

CONCLUSION

In this large, community cohort, depressive symptomatology did not predict five-year risk of clinical fracture. Further research is needed to determine if individuals with major depressive disorder (MDD) are at higher fracture risk and whether neuroendocrine or hormonal dysregulation might contribute to such risk in MDD.

Severity of depression risk predicts health outcomes and recovery following surgery for hip-fractured elders

This study examined how depression risk interfaces with health outcomes of hip-fractured patients during the first year after hospital discharge. Physical function recovery and health outcome trajectories were much poorer for hip-fractured elders with persistent depression risk than for those with transitory and no risk for depression.

INTRODUCTION

This study examined how depression risk interfaces with the trajectories of physical activities and health-related quality of life (HRQoL) among hip-fractured elderly patients during the first 12 months after hospital discharge.

METHODS

Based on 12-month scores for the Chinese version of Geriatric Depression Scale, patients over age 60 years (N = 147) were classified as (a) at persistent risk for depression, (b) at transitory risk for depression, and (c) at no risk for depression. Outcomes were measured by the Chinese Barthel Index and Medical Outcomes Study Short Form, Taiwan version, and analyzed by the generalized estimating equations approach.

RESULTS

Patients who were at persistent risk for depression (n = 46, 31.3%) had much less chance of recovering activities of daily living (OR = 0.16, CI = 0.06-0.42) and walking ability (OR = 0.09, CI = 0.04-0.21) than patients at no risk for depression (n = 36, 24.5%). The trajectories of SF-36 scores for the physical and mental health summary scales were significantly different among the three depression groups; those "at persistent risk for depression" were the poorest and those "at no risk for depression" were the best.

CONCLUSION

These results may provide a reference for developing timely assessments and interventions for hip-fractured elders at risk of depression.

Depressive symptoms moderated the effect of chronic illness self-management training on self-efficacy

BACKGROUND

Identifying moderators of the effects of self-efficacy enhancing interventions could facilitate their refinement and more targeted, cost-effective delivery. Current theories and data concerning the potential moderating effect of depressive symptoms on interventions to enhance patient chronic illness self-management self-efficacy are conflicting.

OBJECTIVES

To explore the moderating effect of depressive symptoms on the effect of an intervention to enhance patient self-efficacy for self-managing chronic illness.

RESEARCH DESIGN

Regression analyses using baseline and postintervention (6 weeks) data from an ongoing randomized controlled trial.

SUBJECTS

Patients (N = 415) aged >or=40 years recruited from a primary care network in Northern California with arthritis, asthma, chronic obstructive pulmonary disease, congestive heart failure, depression, and/or diabetes mellitus, plus impairment in >or=1 basic activity, and/or a score of >or=4 on the 10-item Center for Epidemiologic Studies Depression Scale (CES-D).

MEASURES

Stanford self-efficacy scale, self-reported depression, CES-D, and Medical Outcomes Study Short Form health status questionnaire (SF-36) Mental Component Summary score.

RESULTS

Regression analyses revealed the intervention was effective primarily in those with self-reported depression (interaction effect F = 8.24, P = 0.0003), highest CES-D score category (F = 5.68, P = 0.0037), and lowest (most depressed) Mental Component Summary-36 tercile (F = 4.36, P = 0.0135).

CONCLUSIONS

Individuals with more depressive symptoms seem more likely to experience self-efficacy gains from chronic illness self-management training than individuals with less depressive symptoms. Future self-management training studies should stratify subjects within study groups by depressive symptom level to further explore its potential moderating effect.

Primary care after psychiatric crisis: a qualitative analysis

PURPOSE

Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients' experiences with health care after a psychiatric crisis.

METHODS

A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients' responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA).

RESULTS

At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group.

CONCLUSIONS

This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.

Power spectral analysis of EEG activity during sleep in cigarette smokers

BACKGROUND

Research on the effects of cigarette smoking on sleep architecture is limited. The objective of this investigation was to examine differences in sleep EEG between smokers and nonsmokers.

METHODS

Smokers and nonsmokers who were free of all medical comorbidities were matched on different factors, including age, gender, race, body mass index, and anthropometric measures. Home polysomnography was conducted using a standard recording montage. Sleep architecture was assessed using visual sleep-stage scoring. The discrete fast Fourier transform was used to calculate the EEG power spectrum for the entire night within contiguous 30-s epochs of sleep for the following frequency bandwidths: delta (0.8 to 4.0 Hz); theta (4.1 to 8.0 Hz); alpha (8.1 to 13.0 Hz); and beta (13.1 to 20.0 Hz).

RESULTS

Conventional sleep stages were similar between the two groups. However, spectral analysis of the sleep EEG showed that, compared to nonsmokers, smokers had a lower percentage of EEG power in the delta-bandwidth (59.7% vs 62.6%, respectively; p < 0.04) and higher percentage of EEG power in alpha-bandwidth (15.6% vs 12.5%, respectively; p < 0.001). Differences in the EEG power spectrum between smokers and nonsmokers were greatest in the early part of the sleep period and decreased toward the end. Subjective complaints of lack of restful sleep were also more prevalent in smokers than in nonsmokers (22.5% vs 5.0%, respectively; p < 0.02) and were explained, in part, by the differences in EEG spectral power.

CONCLUSIONS

Cigarette smokers manifest disturbances in the sleep EEG that are not evident in conventional measures of sleep architecture. Nicotine in cigarette smoke and withdrawal from it during sleep may contribute to these changes and the subjective experience of nonrestorative sleep.

Major depression in older medical inpatients predicts poor physical and mental health status over 12 months

OBJECTIVE

The aim of this study was to determine the 12-month effects upon physical and mental health status of a diagnosis of major or minor depression among older medical inpatients.

METHODS

Patients 65 years and older, admitted to the medical wards of two university-affiliated hospitals, with at most mild cognitive impairment, were screened for major and minor depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria). All depressed patients and a random sample of nondepressed patients were invited to participate. The physical functioning and mental health subscales of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were measured at baseline and at 3, 6 and 12 months.

RESULTS

Two hundred ten patients completed the SF-36 at baseline and at one or more follow-ups. In multiple linear regression analysis for longitudinal data, adjusting for baseline level of the SF-36 subscale outcome, severity of physical illness, premorbid disability, age, sex and other covariates, patients with major depression at baseline had lower SF-36 scores at follow-up, in comparison to patients with no depression [physical health, 9.22 (95% CI -15.52 to -2.93); mental health, 6.28 (95% CI -11.76 to -0.79)].

CONCLUSION

A diagnosis of major depression in cognitively intact older medical inpatients is associated with sustained poor physical and mental health status over the following 12 months.

Critical evaluation of the use of research tools in evaluating quality of life for people with schizophrenia

Schizophrenia may lead to impairments in many aspects of life, including physical, cognitive, and role functioning. The subjective quality of life of people with schizophrenia has been shown to be lower than in the general population and appropriate patient-assessed health outcome measures are necessary to capture the distress and disability experienced by people living with a serious mental illness. Although psychiatry has been slow to become involved in quality of life measurement, the use of quality of life instruments has now been recognized as a means of evaluating the outcome of care interventions, in terms of symptoms and functioning. This paper evaluates the effectiveness of two widely used instruments: The Medical Outcomes Study Short Form Health Survey (SF-36) and The Lancashire Quality of Life Profile (LQoLP) in terms of reliability and validity in measuring the quality of life of people with schizophrenia. The LQoLP appeared to be best suited for evaluation of care programmes, whereas the SF-36 was more appropriate for medical trials, comparisons between patient groups, and assessment of the direct consequences of treatment on health and function. Subjective quality of life should, however, be considered to be distinct from clinical status and quality of life assessment should include the broadest range of indicators, to reflect the holistic ethos of mental health nursing.

Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Palmar hyperhidrosis is a benign functional disorder regarded as a psychological and social handicap. Improvement of the quality of life is a major goal of treatment. However, little attention has been given to quality of life after thoracoscopic sympathectomy, which is the first line of treatment for palmar hyperhidrosis. This study investigated the impact of thoracoscopic sympathectomy on subjective health-related quality of life (HRQoL) and psychological properties.

METHODS

Forty patients who underwent thoracoscopic sympathectomy were followed up for 6 months. The HRQoL measures were the Medical Outcomes Study Short Form 36 (SF-36), the Spielberger State Trait Anxiety Inventory (STAI), and the Zung Self-Rating Depression Scale (SDS). Patients were administered these questionnaires before procedure and then again at 1, 3, and 6 months after sympathectomy.

RESULTS

A comparison between the current sample and Japanese normative data for the SF-36 showed mild impairment of HRQoL before sympathectomy. However, it also showed significant improvement of the social functioning domain after sympathectomy. While there was worsening of the bodily pain and role physical domains 1 month after sympathectomy, both domains recovered in 3 months. The results of STAI showed significant improvement of both trait and state anxiety after sympathectomy. However, the results of SDS showed patients remained neurotic.

CONCLUSIONS

This study is the first to show the pattern of impairment in health status and therapeutic impact in palmar hyperhidrosis patients. Hyperhidrosis is associated with impaired HRQoL. It was also demonstrated that thoracoscopic sympathectomy is safe, minimally invasive, and improves HRQoL, even if compensatory hyperhidrosis occurs.

Health-related quality of life in postpartum depressed women

The objectives of this study were a) to evaluate health-related quality of life (HRQoL) among women with postpartum depression, b) examine the association between severity of depressive symptoms and level of impairment in physical and mental HRQoL and c) to identify contributors to physical and mental HRQoL. Seventy-eight women scoring > or =10 on the Edinburgh Postnatal Depression Scale completed the questionnaires measuring: HRQoL (Medical Outcomes Study 36-item short form SF-36), sleep quality, life stress, and social support. All women underwent a cardiovascular stress test to determine aerobic capacity. Compared to Canadian normative data, women experiencing postpartum depressed mood scored significantly lower on all SF-36 domains, as well as on the SF-36 physical and mental component summary score. Severity of depressed mood was not associated to worse physical health status, while poorer aerobic capacity emerged as a significant independent contributor of physical health status. Severity of depressed mood contributed to worse mental health status. After controlling for severity of depressed mood, the occurrence of pregnancy complications, cesarean delivery, poorer sleep quality, life stress, and less social support predicted poorer mental health status.

Posttraumatic Stress Disorder and Health Status

This article examines the association between self-reported prevalence of posttraumatic stress disorder (PTSD) and health status in a sample of 2425 male Department of Veterans Affairs (VA) ambulatory care patients who participated in the Veterans Health Study. Participants were recruited at 1 of 4 VA outpatient clinics in the Boston area. They completed self-report measures of PTSD (using the PTSD Checklist and measures of exposure to traumatic events), depression (using the Center for Epidemiologic Studies--Depression scale), and health status (using the Short-Form-36) and a medical history interview assessing 22 conditions and a history of psychiatric treatment. The screening prevalence of PTSD was 20.2% among all patients (24.3% among those exposed to traumatic events); another 15.5% met the criteria for depression but not PTSD. The health status of patients with either PTSD or depression was significantly worse than that of patients with neither disorder, even after controlling for age, education, and number of comorbid medical conditions. Patients with PTSD reported more medical conditions than did other patients. Patients with PTSD currently in mental health treatment had worse health status than did those who reported no treatment; the health status of patients who reported past mental health treatment was generally comparable to that of those with no treatment. The prevalence and comorbidity of PTSD among this sample of VA ambulatory care patients were higher than previously reported among samples of community-residing adults. The association of PTSD with health status was substantial, suggesting that the burden of PTSD is at least comparable to, and may be worse than, that of depression. Mental health treatment alleviated some of this burden. The potential impact of PTSD on health status should be more widely recognized.