The relationship between admission to hospital with chest pain and psychiatric disorder

Comorbid risks of psychological disorders and gastroesophageal reflux disorder using the national health insurance service-National Sample Cohort: A STROBE-compliant article

This study was performed to examine the comorbidity risks between psychological disorders, such as depression, and gastroesophageal reflux disease (GERD) using nationally representative data from a National Sample Cohort of the National Health Insurance Service in Korea.The National Health Insurance Service-National Sample Cohort (NHIS-NSC) database from 2010 to 2012 was used in this study. GERD patients were defined as those diagnosed with specific tests, with screened medication, and without any other gastrointestinal diseases. Propensity score matching for age, sex, and economic status was applied to form a control cohort. Incidence rate, relative risks, Cox proportional-hazards modeling, and Kaplan-Meier analysis were applied to examine the differences between the GERD and control cohorts with regard to the risk of subsequent psychological disorders.The results showed that patients in the GERD cohort (n = 9503) had significantly higher risks of psychological disorders than those without GERD (adjusted hazard ratio [HR] 1.25, 95% confidence interval [CI] 1.07-1.47, P = .006). Specifically, the risk of depressive disorder was significantly higher for patients in the GERD cohort than in the control cohort (adjusted HR 1.41, 95% CI 1.04-1.91, P = .027). Kaplan-Meier analysis showed that the estimated probability of psychological disorders was significantly higher in the GERD cohort compared with the control cohort (log-rank test, P = .007).This study suggested that GERD may be a risk factor for subsequent psychological disorders, specifically, depressive disorder. The results of this study in GERD patients compared with non-GERD patients in Korea suggested that psychological disorders and GERD may be inter-related.

Psychiatric Characteristics of the Cardiac Outpatients with Chest Pain

Background and Objectives

A cardiologist's evaluation of psychiatric symptoms in patients with chest pain is rare. This study aimed to determine the psychiatric characteristics of patients with and without coronary artery disease (CAD) and explore their relationship with the intensity of chest pain.

Subjects and Methods

Out of 139 consecutive patients referred to the cardiology outpatient department, 31 with atypical chest pain (heartburn, acid regurgitation, dyspnea, and palpitation) were excluded and 108 were enrolled for the present study. The enrolled patients underwent complete numerical rating scale of chest pain and the symptom checklist for minor psychiatric disorders at the time of first outpatient visit. The non-CAD group consisted of patients with a normal stress test, coronary computed tomography angiogram, or coronary angiogram, and the CAD group included those with an abnormal coronary angiogram.

Results

Nineteen patients (17.6%) were diagnosed with CAD. No differences in the psychiatric characteristics were observed between the groups. "Feeling tense", "self-reproach", and "trouble falling asleep" were more frequently observed in the non-CAD (p=0.007; p=0.046; p=0.044) group. In a multiple linear regression analysis with a stepwise selection, somatization without chest pain in the non-CAD group and hypochondriasis in the CAD group were linearly associated with the intensity of chest pain (β=0.108, R²=0.092, p=0.004; β= -0.525, R²=0.290, p=0.010).

Conclusion

No differences in psychiatric characteristics were observed between the groups. The intensity of chest pain was linearly associated with somatization without chest pain in the non-CAD group and inversely linearly associated with hypochondriasis in the CAD group.

Mental symptoms in patients with cardiac symptoms and normal coronary arteries

Objectives

Patients with chest pain and normal coronary arteries often suffer from physical and psychological symptoms. Therefore, this study aimed to examine the incidence of mental symptoms in patients with angiographic exclusion of a coronary heart disease.

Design

In 253 patients with angiographic exclusion of a coronary heart disease the type and intensity of their symptoms were evaluated before and after coronary angiography. In addition, the incidence of psychopathological symptoms was quantified by standardised questionnaires such as general anxiety and depression (HADS), heart-focused anxiety (CAQ), hypochondria (Whiteley Index) and somatoform disorder (SOMS) and quality of life (SF-12). Finally, the incidence of psychological symptoms in these patients was compared to the incidence in the normal population.

Results

Despite the absence of a coronary artery disease, 70% of patients continue to suffer from cardiac symptoms. The incidence of general anxiety was increased by 37% in women and by 22% in men in comparison to the normal population. Heart-focused anxiety was raised by 27%. Somatoform disorder appeared 120% more often in patients after cardiac catheterisation in comparison to the normal population. In addition, the incidence of hypochondria was elevated by 68% in patients after coronary angiography compared to normal population. This increased appearance of psychological symptoms was reflected in a significantly lower quality of life (SF-12) in patients with inconspicuous coronary angiography.

Conclusions

Patients with cardiac symptoms and normal coronary arteries more often suffer from mental symptoms in comparison to the healthy population.

Prescribing trends of antipsychotics in youth receiving income assistance: results from a retrospective population database study

BACKGROUND

Prescribing of antipsychotics (AP) to young people has increased in the last decade internationally. We aimed to characterize AP prescribing in a population of low-income youth in Nova Scotia, Canada.

METHODS

We conducted a population database study of AP prescription claims and health services utilization by young people aged 25 years and younger receiving drug benefits through the publicly funded Pharmacare program between October 1, 2000 to September 30, 2007.

RESULTS

Four percent (1715/43888) of youth receiving Pharmacare benefits filled AP prescriptions. The use of second generation antipsychotics (SGAs) significantly increased (p < 0.0001) in all age groups except 0-5 year olds, whereas first generation antipsychotic use significantly decreased. Pharmacare beneficiaries aged 21-25 years represented 45.2% of AP users. The majority (66%) of youth filling AP prescriptions had 2 or more psychiatric diagnoses. Most youth (76%) filled prescriptions for only one type of AP during the study period. Psychotic disorders were the most common indication for AP use except with risperidone, in which ADHD was the most likely reason for use. Co-prescribing of psychotropics was prevalent with antidepressants and mood stabilizers prescribed in 42% and 27% of AP users, respectively. General practitioners (GPs) prescribed incident APs most often (72%) followed by psychiatrists (16%). The age- and gender-adjusted rate of death was higher in AP users as compared to the age-matched general population of Nova Scotia.

CONCLUSIONS

SGA use increased significantly over seven years in a cohort of 0 to 25 years olds receiving Pharmacare benefits. Off-label use of APs was prevalent with ADHD and other non-psychotic disorders being common reasons for AP use. GPs initiated most AP prescriptions. Co-prescribing of other psychotropics, especially antidepressants and mood stabilizers, was prevalent even in younger age strata. This study raises further questions about AP prescribing in those 25 years of age and under, especially given the range of diagnoses and psychotropic co-prescribing.

Prevalence and prognosis of non-specific chest pain among patients hospitalized for suspected acute coronary syndrome - a systematic literature search

BACKGROUND

The term non-specific chest pain (NSCP) is applied to hospitalized patients in order to designate that they neither have an acute coronary syndrome (ACS) nor display evidence of a coronary ischemia. The number of NSCP patients is increasing and comprehensive guidelines specifying their optimal management have not yet been introduced. The objective of this review was to explore the prevalence and prognosis of NSCP versus ACS among patients recruited in consecutive series hospitalized for chest pain suspected to be ACS.

METHODS

This is a systematic literature search where three databases were searched from 1990 to 14 November 2011. In addition, one database was searched for Epub ahead of print per 24 March 2012. Three inclusion criteria were applied: 1. documentation of an unselected consecutive series of patients admitted for chest pain, where this review is based upon two groups of patients defined as follows: a) 'ACS/high-risk' and b) NSCP; 2. at least 100 cases with NSCP; and 3. follow-up of hospital readmissions and mortality for at least six months.

RESULTS

A total of 2,204 citations were screened after removal of duplicates. Out of 80 full text articles assessed for eligibility 12 studies were included, comprising 24,829 patients (inter-study range 250 to 13,762), with 11,008 (44%) categorized as NSCP and 13,821 (56%) as 'ACS/high-risk'. The mean one-year total mortality rate among patients with NSCP in nine studies was 3.2% (inter-study range 1.4% to 8.1%), with the highest mortality among patients with pre-existing coronary heart disease (CHD). The mean one-year mortality rate among 'ACS/high-risk' patients was 18.0% (inter-study range 14.0% to 19.9%) in four studies with available data. In six studies the mean one-year readmission rate for patients with NSCP was 17.5% (inter-study range 2.5% to 40%).

CONCLUSIONS

Patients with NSCP represent a large, heterogeneous and important group. Due to co-existing CHD in nearly 40% of these patients, their prognosis is not necessarily benign. Although their average one-year mortality rate was almost six times lower than those with 'ACS/high-risk', the subset with concomitant CHD had a relatively poor prognosis when compared with NSCP patients without evidence of CHD.

Unexplained somatic symptoms during major depression: prevalence and clinical impact in a national sample of Italian psychiatric outpatients

BACKGROUND

The aim of this study was to explore the prevalence and impact of unexplained somatic symptoms during major depression.

SAMPLING AND METHODS

A total of 560 consecutive outpatients with a major depressive episode according to the DSM-IV (text revision) were evaluated in 30 psychiatric facilities throughout Italy. 'Unexplained' somatic symptoms were evaluated using the 30-item Somatic Symptoms Checklist (SSCL-30). Somatic symptoms were considered explained if they were best accounted for as coming from a concomitant physical illness or side effects. Patients evaluated their own mood symptomatology using the Zung questionnaires for depression and anxiety and the Hypomania Checklist-32.

RESULTS

According to the SSCL-30, only 90 subjects (16.1%) had no unexplained somatic symptoms, while 231 (41.3%) had 1-5 unexplained symptoms and 239 (42.7%) had more than 5. Asthenia was the most commonly observed unexplained somatic symptom (53% of patients). Unexplained somatic symptoms were more common in females and among those suffering from major depression and depression not otherwise specified rather than in patients with recurrent major depression and bipolar disorders. No relationship between unexplained somatic symptoms and hypomanic features was observed.

CONCLUSIONS

The presence of a large number of unexplained somatic symptoms is associated with more severe depression and higher rates of misdiagnosis and inappropriate treatment.

Taking consultation-liaison psychiatry into primary care

Up to 50% of patients seen in primary care have mental health problems, the severity and duration of their problems often being similar to those of individuals seen in the specialized sector. This article describes the reasons, advantages, and challenges of collaborative or shared care between primary and mental health teams, which are similar to those of consultation-liaison psychiatry. In both settings, clinicians deal with the complex interrelationships between medical and psychiatric disorders. Although initial models emphasized collaboration between family physicians, psychiatrists, and nurses, collaborative care has expanded to involve patients, psychologists, social workers, occupational therapists, pharmacists, and other providers. Several factors are associated with favorable patient outcomes. These include delivery of interventions in primary care settings by providers who have met face-to-face and/or have pre-existing clinical relationships. In the case of depression, good outcomes are particularly associated with approaches that combined collaborative care with treatment guidelines and systematic follow-up, especially for those with more severe illness. Family physicians with access to collaborative care also report greater knowledge, skills, and comfort in managing psychiatric disorders, even after controlling for possible confounders such as demographics and interest in psychiatry. Perceived medico-legal barriers to collaborative care can be addressed by adequate personal professional liability protection on the part of each practitioner, and ensuring that other health care professionals with whom they work collaboratively are similarly covered.

An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome

OBJECTIVE

Cross-sectional studies show an association between somatic symptoms and psychiatric morbidity in primary care. However, medically explained and unexplained symptoms have been considered separately as distinct and unrelated. In addition, data on outcome in primary care are equivocal. We compare the effect of both constructs (medically explained and unexplained symptoms) on psychiatric morbidity and disability (social and physical) at 1 year follow-up.

METHOD

Of 5447 patients presenting for primary care in 14 countries, 3201 participants were followed up (72% compliance). We measured physical, psychiatric, and social status using standardised instruments.

RESULTS

Patients with five or more somatic symptoms had increased psychosocial morbidity and physical disability at follow-up, even after controlling for confounders such as sociodemographics and recognition or treatment by general practitioners. There was little difference in outcome between medically explained and unexplained symptoms.

CONCLUSIONS

Somatic symptoms-irrespective of aetiology-are associated with adverse psychosocial and functional outcome in diverse cultures.

A randomised controlled trial to measure the effect of chest pain unit care upon anxiety, depression, and health-related quality of life [ISRCTN85078221]

BACKGROUND

The chest pain unit (CPU) has been developed to provide a rapid and accurate diagnostic assessment for patients attending hospital with acute, undifferentiated chest pain. We aimed to measure the effect of CPU assessment upon psychological symptoms and health-related quality of life.

METHODS

We undertook a single-centre, cluster-randomised controlled trial. Days (N = 442) were randomised in equal numbers to CPU or routine care. Patients with acute chest pain, undiagnosed by clinical assessment, ECG and chest radiograph, were recruited and followed up with self-completed questionnaires (SF-36 and HADS) at two days and one month after hospital attendance.

RESULTS

Patients receiving CPU assessment had significantly higher scores on the physical functioning (difference 5.1 points; 95% CI 1.1 to 9.0), vitality (4.6; 1.3 to 8.0), and general health (5.7; 2.3 to 9.2) dimensions of the SF-36 at two days, and significantly higher scores on all except the emotional role dimension at one month. They also had significantly lower depression scores on the HADS depression scale at two days (0.93; 0.34 to 1.51) and one month (1.0; 0.36 to 1.66). However, initially lower anxiety scores at two days (0.89; 0.21 to 1.56) were not maintained at one month (0.48; -0.26 to 1.23). CPU assessment was associated with reduced prevalence (OR 0.71; 95% CI 0.52 to 0.97) and severity (6.5 mm on 100 m visual analogue scale; 95% CI 2.2 to 10.8) of chest pain at one month, but no significant difference in the proportion of patients taking time off work (OR 0.82; 95% CI 0.54 to 1.04).

CONCLUSION

CPU assessment is associated with improvements in nearly all dimensions of quality of life and with reduced symptoms of depression.

The UCSD Statin Study: a randomized controlled trial assessing the impact of statins on selected noncardiac outcomes

There has been persistent controversy regarding possible favorable or adverse effects of statins or of cholesterol reduction on cognition, mood and behavior (including aggressive or violent behavior), muscle function, and quality of life. The UCSD Statin Study seeks to ascertain the beneficial or adverse effects of statin cholesterol-lowering drugs on a set of noncardiac endpoints, including cognition, behavior, and serotonin biochemistry. The study will enroll 1000 subjects (minimum 20% female) of mixed ethnicity from San Diego. Subjects must be age 20 and older, postmenopausal if female, without known cardiovascular disease or diabetes, and with LDL-cholesterol between 115 and 190 mg/dl. Subjects will be randomized to a double-blind, placebo-controlled trial with assignment 1/3, 1/3, 1/3 to placebo, simvastatin 20 mg, or pravastatin 40 mg (equipotent LDL-cholesterol-lowering doses for drug arms with simvastatin and pravastatin chosen to represent the extremes of the lipophilicity spectrum) for 6 months of treatment followed by 2 months postcessation follow-up. Primary outcomes are cognition (cognitive battery), irritability/aggression (behavior measure), and serotonin (gauged by whole blood serotonin), assessed as the difference between baseline and 6 months, judging combined statin groups vs. placebo. Secondary outcomes include mood (CES-D and Wakefield depression inventory), quality of life (SF-12V), sleep (Leeds sleep scale, modified), and secondary aggression measures (Conflict Tactics Scale; Overt Aggression Scale, Modified). Cardiovascular reactivity will be examined in a 10% subset. As additional secondary endpoints, primary and selected secondary outcomes will be assessed by statin assignment (lipophilic simvastatin vs. hydrophilic pravastatin). "Reversibility" of changes, if any, at 2 months postcessation will be determined. If effects (favorable or unfavorable) are identified, we will seek to ascertain whether there are baseline variables that predict who will be most susceptible to these favorable or adverse noncardiac effects (i.e., effect modification).