Changes in patient health questionnaire (PHQ-9) scores in adults with medical authorization for cannabis

An observational study of safety and clinical outcome measures across patient groups in the United Kingdom Medical Cannabis Registry

BACKGROUND

There is a paucity of high-quality data on patient outcomes and safety after initiating treatment with cannabis-based medicinal products (CBMPs). The aim of this study was to assess the clinical outcomes and safety of CBMPs by analyzing patient-reported outcome measures and adverse events across a broad spectrum of chronic conditions.

RESEARCH DESIGN AND METHODS

This study analyzed patients enrolled in the UK Medical Cannabis Registry. Participants completed the EQ-5D-5L to assess health-related quality of life, Generalized Anxiety Disorder-7 (GAD-7) questionnaire to measure anxiety severity, and the Single-item Sleep Quality Scale (SQS) to rate sleep quality at baseline and follow-up after 1, 3, 6, and 12 months.

RESULTS

A total of 2833 participants met inclusion criteria. The EQ-5D-5L index value, GAD-7, and SQS all improved at each follow-up (p < 0.001). There was no difference in EQ-5D-5L index values between former or current illicit cannabis consumers and naïve patients (p > 0.050). Adverse events were reported by 474 (16.73%) participants.

CONCLUSIONS

This study suggests that CBMPs are associated with an improvement in health-related quality of life in UK patients with chronic diseases. Treatment was tolerated well by most participants, but adverse events were more common in female and cannabis-naïve patients.

Mental health risk factors for shift work disorder in paramedics: A longitudinal study

OBJECTIVES

Depression and anxiety are prominent in paramedics, as is the prevalence of shift work disorder (SWD), a circadian sleep condition comorbid with mental health disorders. However, the role of mental health risk factors for SWD is largely unknown. This study investigated whether mental health levels in recruit paramedics before shift work predicted greater risk of SWD at 6-months into their career and explored whether shift and sleep factors mediated this relationship.

DESIGN

A longitudinal study.

SETTING

Victoria, Australia.

PARTICIPANTS

Recruit paramedics were assessed at baseline (n = 101; ie, pre-shift work) and after 6-months (n = 93) of shift and emergency work.

MEASUREMENTS

At both time points, participants completed self-reported measures of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder Questionnaire-7), and SWD (SWD-Screening Questionnaire). Participants also filled a sleep and work diary for 14-days at each timepoint.

RESULTS

After 6-months of emergency work 21.5% of paramedics had a high SWD risk. Logistic regression models showed baseline depression predicted 1.24-times greater odds for SWD at 6-months. Through Lavaan path analysis we found shift and sleep variables did not mediate the relationship between baseline mental health and SWD risk. Baseline depression was associated with increased sleepiness levels following paramedics' major sleep periods at 6-months. Pre-existing depression levels also predicted greater perceived nightshift workload.

CONCLUSIONS

Our results highlight depression symptoms before emergency work are a risk factor for SWD within 6-months of work. Depression represents a modifiable risk factor amenable to early interventions to reduce paramedics' risk of SWD.

Smoking and Depression Risk Reduction in a Primary Care Setting

INTRODUCTION

Smoking is associated with many diseases and is a target for primary preventive efforts in numerous morbidities. Studies show that smoking and depression may be associated. Never-smokers are at significantly lower risk than current and former smokers. Despite this observation, the effect of smoking on depression risk reduction has not been adequately explored. The purpose of this study was to explore the effect of smoking on depression risk reduction in adult patients seen in a primary care clinic at an academic medical center 6 months after they were identified as being at risk for depression. Findings may influence the direction and intensity of our smoking cessation endeavors in patients at risk of depression who smoke.

METHODS

We conducted an analytic cross-sectional study using electronic medical records of patients 18 years and older seen a primary care setting between January 1, 2019 and December 31, 2020. All participants included had an initial depression risk score (assessed by the 9-item Patient Health Questionnaire (PHQ-9)) of 5 or higher, information on smoking status and a PHQ-9 score at 6 months. We determined the percentage of patients with PHQ-9 score decrease of 5 or more at 6 months and used logistic regression to determine the association depression risk reduction (of 5 units or more) at 6 months and smoking, adjusting for demographic, clinical, and behavioral characteristics.

RESULTS

Number of patients included were 120, mean age was 55 (16), years, 88 (74%) were female, 68 (57%) were African American, and 31 (26%) were Caucasian. Fifty (44%) had a history of smoking and 31 (25.8%) had improvement (ie, a decrease of 5 units or more) in their PHQ-9 score at 6 months. Smoking was associated with decreased odds of improvement in depressive symptoms (Odds ratio = 0.32, 95% Confidence interval: 0.12-0.87).

CONCLUSION

Risk of depression was more likely to persist in smokers than non-smokers at 6 months. Addressing smoking behavior in those with risk of depression may be beneficial.

Assessment of clinical outcomes of medicinal cannabis therapy for depression: analysis from the UK Medical Cannabis Registry

BACKGROUND

Although pre-clinical experiments associate cannabinoids with reduced depressive symptoms, there is a paucity of clinical evidence. This study aims to analyze the health-related quality of life changes and safety outcomes in patients prescribed cannabis-based medicinal products (CBMPs) for depression.

METHODS

A series of uncontrolled cases from the UK Medical Cannabis Registry were analyzed. The primary outcomes were changes from baseline in the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Sleep Quality Scale (SQS), and EQ-5D-5 L at 1, 3, and 6 months. Secondary outcomes included adverse events incidence.

RESULTS

129 patients were identified for inclusion. Median PHQ-9 at baseline was 16.0 (IQR: 9.0-21.0). There were reductions in PHQ-9 at 1-month (median: 8.0; IQR: 4.0-14.0; p < 0.001), 3-months (7.0; 2.3-12.8; p < 0.001), and 6-months (7.0; 2.0-9.5; p < 0.001). Improvements were also observed in GAD-7, SQS, and EQ-5D-5L Index Value at 1, 3, and 6 months (p < 0.050). 153 (118.6%) adverse events were recorded by 14.0% (n = 18) of participants, 87% (n = 133) of which were mild or moderate.

CONCLUSION

CBMP treatment was associated with reductions in depression severity at 1, 3, and 6 months. Limitations of the study design mean that a causal relationship cannot be proven. This analysis provides insights for further study within clinical trial settings.

Description and Disposition of Patients With Cancer Accessing a Novel, Pharmacist-Led Cannabis Consultation Service

PURPOSE

The Cannabis Consultation Service (CCS) is an innovative pharmacist-led resource at the Sunnybrook Odette Cancer Centre. Its mandate is to provide education and guide patients through access and appropriate use of high-quality plant-derived cannabinoids (PDCs). Our objective was to describe the CCS, explain its processes, and characterize patient disposition with respect to use of PDCs.

METHODS

We retrospectively reviewed the charts of patients referred to the CCS from July 13, 2020, to March 05, 2021. We used descriptive statistics to report on the patient population and service metrics.

RESULTS

During the 34-week period, 96 patients accessed the CCS (median age, 61 years). The top reasons for CCS consultation were management of cancer pain, insomnia, and general interest. Medical cannabis was supported as an option in 44/96 patients. Reasons for not supporting PDC use included lack of indication, potential drug interaction/contraindication, or requiring treatment with first-line therapy. Of the 40 patients requiring a medical document, 22 initiated therapy. The most common product used was a 2:50 THC:CBD (Tetrahydrocannabinol:Cannabidiol) cannabis oil. At the date of last contact, few patients remained on therapy because of lack of benefit, patient choice, and/or hesitancy.

CONCLUSION

Despite patients with cancer having interest in seeking PDCs for symptom management, only a few initiated and continued therapy. Pharmacists have an opportunity to advise patients and the oncology team on the risks and benefits of PDCs. These results can be used to support the development of medical cannabis programs by oncology centers and focus future research priorities.

Impact of adalimumab on disease burden in moderate-to-severe ulcerative colitis patients: The one-year, real-world UCanADA study

BACKGROUND

A gap remains in documenting the impact of anti-tumor necrosis factor therapy on disease burden in ulcerative colitis (UC) patients treated in a real-world setting. The use of patient-reported outcomes (PROs) has been discussed as a primary endpoint in the context of the FDA PRO Guidance, for labelling purposes. Specifically, the efficacy and safety of adalimumab have been demonstrated in pivotal trials; however, data are needed to understand how clinical results translate into improvements in key aspects of the daily lives of UC patients, such as symptoms, health-related quality of life (HRQoL), and disability.

AIM

To assess real-world effectiveness of adalimumab on PRO measures in patients with moderate-to-severe UC.

METHODS

UCanADA was a single arm, prospective, 1-year multicenter Canadian post-marketing observational study in which multiple PRO questionnaires were completed—with psychologic distress/depression symptoms as the primary endpoint—by patients with moderate-to-severe UC. Assessments were performed during patients’ routine care visit schedule, which was at the initiation of adalimumab (baseline), after induction (approximately 8 wk), and 52 wk after baseline. Additional optional assessments between weeks 8 and 52 were collected at least once but no more than two times during this period. Serious safety events and per-protocol adverse events were collected.

RESULTS

From 23 Canadian centres, 100 patients were enrolled and 48 completed the study. Measured with the Patient Health Questionnaire–9 items at week 52, 61.5% (40/65) [95% confidence interval (CI): 49.7%-73.4%] of the patients improved in psychologic distress/depression symptoms, which was slightly higher in completers [65.9% (29/44); 95%CI: 51.9%-79.9%)]. At week 52, clinical response and clinical remission were achieved respectively by 65.7% (44/73) and 47.8% (32/73) of the patients. The odds of improving depressive symptoms for those achieving a clinical remission at week 52 was 7.94 higher compared with those not achieving a clinical remission (CI: 1.42, 44.41; P = 0.018). Significant changes from baseline to weeks 8 and 52 were observed in disability, HRQoL, and fatigue. Meaningful improvement was reported in work impairment.

CONCLUSION

At week 52, over 60% of the UCanADA patients had depressive symptoms significantly reduced, as well as HRQoL, fatigue symptoms, and work impairment improved. No new safety signals were detected.

Visual-stress-related cortical excitability as a prospective marker for symptoms of depression and anxiety in young people

Visual stress is thought to reflect cortical excitability and has been associated with many neurological, neuropsychiatric, and neurodevelopmental conditions. However, its relationships with symptoms of depression and anxiety have not yet been elucidated. We conducted two separate studies to first examine visual stress in a longitudinal community sample of 104 participants (aged 12-24) in association with prospective symptoms of depression, anxiety, and distress after 3 months, and subsequently in a cross-sectional epidemiological sample of 530 participants (aged 15-24) to validate its associations with current mood and distress symptoms. The Pattern Glare Test was used to examine visual stress to three grating patterns with the spatial frequencies (SF) of 0.3, 2.3, and 9.4 cycles per degree (cpd). Other known factors of mental health, including functioning, as well as resilience, hopelessness, and loneliness, were also assessed at baseline. In both studies, we showed that perceptual distortions were highest toward the pattern with mid-SF (2.3 cpd). Multiple linear regression analyses revealed that greater visual stress was significantly associated with not only baseline but also 3-month symptom outcomes, even when accounting for age, years of education, days of no functioning, resilience, hopelessness, and loneliness. Our findings suggest the importance of visual stress in understanding and predicting poor mental health outcomes. As mental health can lead to far-reaching consequences that extend to adulthood, our findings may inform state-of-the-art innovative strategies for the prediction of poor mental health outcomes and suggest visual stress as a potential marker for early risk detection among young people.

Medical cannabis use in Canada and its impact on anxiety and depression: A retrospective study

This was a retrospective study of patients utilizing medical cannabis who received their medical cannabis documentation and allotment from a Harvest Medicine clinic in Canada to determine the impact of medical cannabis on anxiety and depression outcomes. Patients included in the study were at least 18 years of age with completed validated questionnaires for anxiety (GAD-7) and depression (PHQ-9) at their initial evaluation and at least one follow-up visit. There were 7,362 patients included in the sample, of which the average age was 49.8 years, and 53.1% were female. There were statistically significant improvements between baseline and follow-up scores for both the GAD-7 and PHQ-9, with larger improvements seen for patients who were actively seeking medical cannabis to treat anxiety or depression. From 12 months on, those reporting anxiety had an average decrease in GAD-7 scores that was greater than the minimum clinically important difference of 4, and the same was seen for patients reporting depression from 18 months on, with the average decrease in PHQ-9 scores more than the MCID minimum clinically important difference of 5. This study provides some evidence to support the effectiveness of medical cannabis as a treatment for anxiety and depression.

The longitudinal association between depression, anxiety symptoms and HIV outcomes, and the modifying effect of alcohol dependence among ART clients with hazardous alcohol use in Vietnam

INTRODUCTION

Mental health disorders may negatively impact HIV outcomes, such as viral suppression (VS) and antiretroviral (ART) adherence among people with HIV (PWH) with hazardous alcohol use. This study evaluates the longitudinal association between depression, anxiety symptoms, VS and complete ART adherence among ART clients with hazardous alcohol use in Vietnam; and examines alcohol dependence as a modifier in this association.

METHODS

This was a secondary data analysis of a trial for hazardous drinking ART clients in Thai Nguyen, Vietnam. From March 2016 to May 2018, 440 ART clients with an Alcohol Use Disorders Identification Test-Concise (AUDIT-C) score ≥4 for men and ≥3 for women were enrolled. Individuals were randomized to either a combined intervention, a brief intervention or a standard of care. Data on sociodemographics, depression, anxiety symptoms, alcohol use, VS and ART adherence were collected at baseline, three, six, and twelve months. Generalized estimating equation models controlling for intervention exposure were used to estimate time-lagged associations. Risk ratios were estimated using Poisson regression with robust variance estimation.

RESULTS

The mean age of participants was 40.2. The majority was male (96.8%), had at least some secondary school education (85.0%) and had a history of injection drug use (80.9%). No overall effect of depression and anxiety symptoms on VS was observed. When stratified by time, increased anxiety symptoms at six months were associated with VS at 12 months (adjusted risk ratio (aRR) = 1.09; 95% CI 1.02 to 1.17). An increase in depression or anxiety symptoms was associated with a decreased probability of complete ART adherence (depression symptoms: aRR = 0.95; 95% CI: 0.91 to 0.99; anxiety symptoms: aRR = 0.93; 85% CI: 0.88 to 0.99). The negative effects of anxiety symptoms on ART adherence were stronger among participants with alcohol dependence, compared to those without.

CONCLUSIONS

Depression and anxiety symptoms had no overall effect on VS, although they were associated with a lower probability of complete ART adherence. Interventions focusing on mental healthcare for PWH with hazardous alcohol use are needed, and integration of mental healthcare and alcohol reduction should be implemented in HIV primary care settings.