1
|
Salas J, Wang W, Schnurr PP, Cohen BE, Freedland KE, Jaffe AS, Lustman PJ, Friedman M, Scherrer JF. Severity of posttraumatic stress disorder, type 2 diabetes outcomes and all-cause mortality: A retrospective cohort study. J Psychosom Res 2023; 175:111510. [PMID: 37827022 PMCID: PMC10842322 DOI: 10.1016/j.jpsychores.2023.111510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Some evidence suggests patients with comorbid PTSD and type 2 diabetes (T2D) have worse T2D outcomes than those with T2D alone. However, there is no evidence regarding PTSD severity and risk for starting insulin, hyperglycemia, microvascular complications, and all-cause mortality. METHODS In this retrospective cohort study, Veterans Health Affairs (VHA) medical record data from fiscal year (FY) 2012 to FY2022 were used to identify eligible patients (n = 23,161) who had a PTSD diagnosis, ≥1 PTSD Checklist score, controlled T2D (HbA1c ≤ 7.5) without microvascular complications at baseline. PTSD Checklist for DSM-5 (PCL-5) scores defined mild, moderate, and severe PTSD. Competing risk and survival models estimated the association between PTSD severity and T2D outcomes before and after controlling for confounding. RESULTS Most (70%) patients were ≥ 50 years of age, 88% were male, 64.2% were of white race and 17.1% had mild, 67.4% moderate and 15.5% severe PTSD. After control for confounding, as compared to mild PTSD, moderate (HR = 1.05; 95% CI:1.01-1.11) and severe PTSD (HR = 1.15; 95%CI:1.07-1.23) were significantly associated with increased risk for microvascular complication. Hyperarousal was associated with a 42% lower risk of starting insulin. Negative mood was associated with a 16% increased risk for any microvascular complication. Severe PTSD was associated with a lower risk for all-cause mortality (HR = 0.76; 95%CI:0.63-0.91). CONCLUSIONS Patients with comorbid PTSD and T2D have an increased risk for microvascular complications. However, they have lower mortality risk perhaps due to more health care use and earlier chronic disease detection. PTSD screening among patients with T2D may be warranted.
Collapse
Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, United States; The Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, United States
| | - Wenjin Wang
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, United States
| | - Paula P Schnurr
- National Center for PTSD, White River Junction, VT, and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, San Francisco, CA, United States
| | - Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Allan S Jaffe
- Department of Cardiovascular Medicine and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew Friedman
- National Center for PTSD, White River Junction, VT, and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, United States; The Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, United States; Department of Psychiatry and Behavioral Neuroscience, School of Medicine, Saint Louis University, St. Louis, MO, United States.
| |
Collapse
|
2
|
Nguyen N, Holmes LM, Pravosud V, Cohen BE, Ling PM. Changes in perceived harms of tobacco and cannabis and their correlations with use: A panel study of young adults 2014-2020. Addict Behav 2023; 144:107758. [PMID: 37263178 PMCID: PMC10330743 DOI: 10.1016/j.addbeh.2023.107758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/24/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE Perceived harm is associated with substance use. Changes in product and policy landscapes may impact perceived harms of tobacco and cannabis. This study aimed to examine changes in young adults' perceived harms of tobacco and cannabis and their associations with use behavior during a period including both before and after legalization of cannabis. METHODS We conducted a panel survey of California Bay Area young adults (mean age = 23.5 years old, 64.4% female) in 2014 and 2019-2020. Participants (N = 306) reported past 30-day use and perceived harms of tobacco and cannabis at both waves. Perceived harms to health of cannabis and tobacco (cigarettes, e-cigarettes, hookah, smokeless tobacco, and secondhand tobacco smoke) were measured from 1-"Not at all harmful" to 7-"Extremely harmful." Mixed-effects logistic regressions examined associations between perceived harms and use of tobacco and cannabis, controlling for demographics. RESULTS Participants perceived lower harm for cannabis than for tobacco products. Perceived harms of e-cigarettes, hookah, and smokeless tobacco significantly increased over time; while perceived harms of cigarettes, secondhand tobacco smoke, and cannabis did not change. Increased perceived harm of e-cigarettes was associated with lower odds of any tobacco use (OR = 0.72, 95%CI = 0.56, 0.92), and increased perceived harm of cannabis was associated with lower odds of any cannabis use (OR = 0.51, 95%CI = 0.42, 0.62). CONCLUSIONS Findings suggest that perceived harms of e-cigarettes and cannabis play important roles in driving young adult use behaviors. Risk communication efforts that increase perceptions of health harms related to e-cigarettes and cannabis may decrease use of tobacco and cannabis among young people.
Collapse
Affiliation(s)
- Nhung Nguyen
- Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, CA, USA; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Louisa M Holmes
- Departments of Geography and Demography and the Consortium on Substance Use and Addiction, The Pennsylvania State University, PA, USA
| | - Vira Pravosud
- Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Pamela M Ling
- Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, CA, USA; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
3
|
Chambers J, Keyhani S, Ling PM, Hoggatt KJ, Hasin D, Nguyen N, Woods A, Ryder A, Cohen BE. Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure, 2017-2021. JAMA Netw Open 2023; 6:e2328691. [PMID: 37566411 PMCID: PMC10422186 DOI: 10.1001/jamanetworkopen.2023.28691] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023] Open
Abstract
Importance While rates of cigarette use are declining, more US adults are using cannabis. Perceptions of safety are important drivers of substance use and public policy; however, little is known about the comparative views of US adults on tobacco and cannabis safety. Objective To compare public perceptions of safety of cannabis vs tobacco smoke and evaluate how perceptions may be changing over time. Design, Setting, and Participants This longitudinal survey study was conducted using a web-based survey administered in 2017, 2020, and 2021. US adults participating in Ipsos KnowledgePanel, a nationally representative, population-based survey panel, were included. Data were analyzed from March 2021 through June 2023. Main Outcomes and Measures Two questions directly compared the perception of safety of cannabis vs tobacco in terms of daily smoking and secondhand smoke exposure. Additional questions assessed perceptions of safety of secondhand tobacco smoke for adults, children, and pregnant women, with an analogous set of questions for secondhand cannabis smoke. Results A total of 5035 participants (mean [SD] age, 53.4 [16.2] years; 2551 males [50.7%]) completed all 3 surveys and provided responses for tobacco and cannabis risk questions. More than one-third of participants felt that daily smoking of cannabis was safer than tobacco, and their views increasingly favored safety of cannabis vs tobacco over time (1742 participants [36.7%] in 2017 vs 2107 participants [44.3%] in 2021; P < .001). The pattern was similar for secondhand cannabis smoke, with 1668 participants (35.1%) responding that cannabis was safer than tobacco in 2017 vs 1908 participants (40.2%) in 2021 (P < .001). Participants who were younger (adjusted odds ratio [aOR] for ages 18-29 years vs ≥60 years, 1.4 [95% CI, 1.1-1.8]; P = .01) or not married (aOR, 1.2 [95% CI, 1.0-1.4]; P = .01) were more likely to move toward safer views of cannabis use over time, while those who were retired (aOR vs working, 0.8 [95% CI, 0.7-0.9]; P = .01) were less likely to move toward a safer view of cannabis. Participants were also more likely to rate secondhand smoke exposure to cannabis vs tobacco as completely or somewhat safe in adults (629 participants [12.6%] vs. 119 participants [2.4%]; P < .001), children (238 participants [4.8%] vs. 90 participants [1.8%]; P < .001), and pregnant women (264 participants [5.3%] vs. 69 participants [1.4%]; P < .001). Conclusions and Relevance This study found that US adults increasingly perceived daily smoking and secondhand exposure to cannabis smoke as safer than tobacco smoke from 2017 to 2021. Given that these views do not reflect the existing science on cannabis and tobacco smoke, the findings may have important implications for public health and policy as the legalization and use of cannabis increase.
Collapse
Affiliation(s)
- Julia Chambers
- Department of Medicine, University of California San Francisco
| | - Salomeh Keyhani
- Department of Medicine, University of California San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Pamela M Ling
- Center for Tobacco Control Research and Education, and Division of General Internal Medicine, University of California San Francisco
| | - Katherine J Hoggatt
- Department of Medicine, University of California San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Deborah Hasin
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nhung Nguyen
- Center for Tobacco Control Research and Education, and Division of General Internal Medicine, University of California San Francisco
| | - Anne Woods
- Northern California Institute for Research and Education - the Veterans Health Research Institute, San Francisco, California
| | - Annie Ryder
- Department of Psychology, University of Kansas, Lawrence
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| |
Collapse
|
4
|
Neylan TC, Cohen BE. Nightmares and Cardiovascular Disease: An Emerging Risk Factor? Sleep 2023:7086073. [PMID: 36964910 DOI: 10.1093/sleep/zsad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Indexed: 03/26/2023] Open
Affiliation(s)
- Thomas C Neylan
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco,USA
- Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, USA
| | - Beth E Cohen
- Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, USA
| |
Collapse
|
5
|
Koraishy FM, Cohen BE, Scherrer JF, Whooley M, Hajagos J, Robinson-Cohen C, Hou W. The association of post-traumatic stress disorder with glomerular filtration rate decline. Nephrology (Carlton) 2023; 28:181-186. [PMID: 36594760 PMCID: PMC9974752 DOI: 10.1111/nep.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
While major depression is known to be associated with glomerular filtration rate (GFR) decline, there is a lack of data on the association of other mental illnesses like posttraumatic stress disorder (PTSD) with kidney disease. In 640 adult participants of the Heart and Soul Study (mean baseline age of 66.2 years) with a high prevalence cardiovascular disease, hypertension and diabetes, we examined the association of PTSD with GFR decline over a 5-year follow-up. We observed a significantly greater estimated (e) GFR decline over time in those with PTSD compared to those without (2.97 vs. 2.11 ml/min/1.73 m2 /year; p = .022). PTSD was associated with 91% (95% CI 12%-225%) higher odds of 'rapid' versus 'mild' (>3.0 vs. <3.0 ml/min/1.73 m2 /per year) eGFR decline. These associations remained consistent despite controlling for demographics, medical comorbidities, other mental disorders and psychiatric medications. In conclusion, our study provides evidence that PTSD is independently associated with GFR decline in middle-aged adults with a high comorbidity burden. This association needs to be examined in larger cohorts with longer follow-ups.
Collapse
Affiliation(s)
- Farrukh M. Koraishy
- Division of Nephrology, Department of Medicine, Stony Brook University, NY
- Northport VA Medical Center, Northport, NY
| | - Beth E. Cohen
- Department of Medicine, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco
| | | | - Mary Whooley
- Department of Medicine, University of California, San Francisco
- San Francisco VA Health Care System, San Francisco
| | - Janos Hajagos
- Department of Medical Bioinformatics, Stony Brook University, NY
| | | | - Wei Hou
- Department of Family, Population, and Preventive Medicine, Program in Public Health, Stony Brook University
| |
Collapse
|
6
|
Affiliation(s)
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, USA
- San Francisco Veterans Affairs Healthcare System, 4150 Clement Street, San Francisco, CA, 94121, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, USA.
- San Francisco Veterans Affairs Healthcare System, 4150 Clement Street, San Francisco, CA, 94121, USA.
| |
Collapse
|
7
|
Ranney R, Maguen S, Woods A, Seal KH, Neylan TC, Bernardy N, Wiechers I, Ryder A, Cohen BE. Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study. J Eval Clin Pract 2023; 29:191-202. [PMID: 35709244 DOI: 10.1111/jep.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. AIMS AND OBJECTIVES We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication. METHOD We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. RESULTS Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. CONCLUSION Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.
Collapse
Affiliation(s)
- Rachel Ranney
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, California, USA
| | - Shira Maguen
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Anne Woods
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Northern California Institute for Research and Education, San Francisco, California, USA
| | - Karen H Seal
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Thomas C Neylan
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Nancy Bernardy
- Veterans Affairs White River Junction Health Care System, White River Junction, Vermont, USA
| | - Ilse Wiechers
- Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Department of Veterans Affairs, Northeast Program Evaluation Center, Office of Mental Health and Suicide Prevention, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, New Haven, USA
| | - Annie Ryder
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Beth E Cohen
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| |
Collapse
|
8
|
Khan AJ, Ryder AL, Maguen S, Cohen BE. Emotion regulation and combat severity differentiates PTSD diagnostic status among veterans. Psychol Trauma 2023; 15:271-278. [PMID: 36716133 DOI: 10.1037/tra0001408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study examined whether posttraumatic stress disorder (PTSD) diagnostic groups in veterans were differentiated by combat severity and specific avoidance and approach-related emotion regulation (ER) strategies. METHOD In a cohort study, 725 participants (Mage = 58.39, SD = 11.27, 94.5% male, 58.2% White) recruited from VHA facilities completed the Clinician Administered PTSD Scale (CAPS), Combat Exposure Scale (CES), and Emotion Regulation Questionnaire (ERQ). Participants were categorized into three PTSD groups: Current, Remitted, and Never. RESULTS Multinomial logistic regressions adjusting for age, sex, and race, showed combat severity significantly differentiated all groups from each other (ps < .001). Specifically, combat severity was significantly associated with increased odds of Current PTSD versus Remitted (OR: 1.02, 95% CI [1.01, 1.05]) and Never PTSD (OR: 1.14, [1.12, 1.17]) and odds of Remitted compared with Never PTSD (OR: 1.11, [1.09, 1.14]). Suppression, but not reappraisal, was significantly associated with increased odds of Current PTSD compared with Remitted (OR: 1.15, [1.06, 1.24]) and Never PTSD (OR: 1.14, [1.06, 1.22]; ps < .001). Lower reappraisal was only significantly associated with the likelihood of Remitted PTSD compared with Never PTSD (OR: 0.93, [0.88, 0.99], p = .03). CONCLUSIONS Increasing levels of combat severity differentiated veterans with current, remitted, and no history of PTSD, suggesting screening for severity of combat may be helpful. Greater habitual suppression distinguished current versus non-current PTSD status, whereas only less reappraisal distinguished non-current groups from each other. Lower suppression may be an important treatment target for veterans with moderate and high combat severity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Collapse
|
9
|
Pierce B, Kirsh T, Ferguson AR, Neylan TC, Ma S, Kummerfeld E, Cohen BE, Nielson JL. Causal discovery replicates symptomatic and functional interrelations of posttraumatic stress across five patient populations. Front Psychiatry 2023; 13:1018111. [PMID: 36793783 PMCID: PMC9924232 DOI: 10.3389/fpsyt.2022.1018111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction Approximately half of individuals with posttraumatic stress disorder (PTSD) may meet criteria for other psychiatric disorders, and PTSD symptoms are associated with diminished health and psychosocial functioning. However, few studies examine the longitudinal progression of PTSD symptoms concurrent with related symptom domains and functional outcomes, such that may neglect important longitudinal patterns of symptom progression beyond PTSD specifically. Methods Therefore, we used longitudinal causal discovery analysis to examine the longitudinal interrelations among PTSD symptoms, depressive symptoms, substance abuse, and various other domains of functioning in five longitudinal cohorts representing veterans (n = 241), civilians seeking treatment for anxiety disorders (n = 79), civilian women seeking treatment for post-traumatic stress and substance abuse (n = 116), active duty military members assessed 0-90 days following TBI (n = 243), and civilians with a history of TBI (n = 43). Results The analyses revealed consistent, directed associations from PTSD symptoms to depressive symptoms, independent longitudinal trajectories of substance use problems, and cascading indirect relations from PTSD symptoms to social functioning through depression as well as direct relations from PTSD symptoms to TBI outcomes. Discussion Our findings suggest PTSD symptoms primarily drive depressive symptoms over time, tend to show independence from substance use symptoms, and may cascade into impairment in other domains. The results have implications for refining conceptualization of PTSD co-morbidity and can inform prognostic and treatment hypotheses about individuals experiencing PTSD symptoms along with co-occurring distress or impairment.
Collapse
Affiliation(s)
- Benjamin Pierce
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
| | - Thomas Kirsh
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Adam R. Ferguson
- Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Thomas C. Neylan
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Psychiatry and Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Sisi Ma
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Erich Kummerfeld
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Beth E. Cohen
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jessica L. Nielson
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| |
Collapse
|
10
|
Hargrave AS, Sumner JA, Ebrahimi R, Cohen BE. Posttraumatic Stress Disorder (PTSD) as a Risk Factor for Cardiovascular Disease: Implications for Future Research and Clinical Care. Curr Cardiol Rep 2022; 24:2067-2079. [PMID: 36306020 DOI: 10.1007/s11886-022-01809-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research. RECENT FINDINGS PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.
Collapse
Affiliation(s)
- Anita S Hargrave
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, 94110, USA. .,Medical Service, San Francisco VA Health Care System, San Francisco, CA, 94121, USA.
| | - Jennifer A Sumner
- Department of Psychology, University of California Los Angeles (UCLA), Los Angeles, CA, 90095-1563, USA
| | - Ramin Ebrahimi
- Department of Medicine, Cardiology Section, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA, USA.,Department of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, 90095, USA
| | - Beth E Cohen
- Department of Internal Medicine, University of California San Francisco (UCSF), San Francisco, CA, 94110, USA.,Medical Service, San Francisco VA Health Care System, San Francisco, CA, 94121, USA
| |
Collapse
|
11
|
Nguyen N, Keyhani S, Ling PM, Hoggatt KJ, Hasin D, Cohen BE. Self-reported Changes in Cannabis Use Due to the COVID-19 Pandemic among US Adults. J Psychoactive Drugs 2022; 54:295-299. [PMID: 35356866 PMCID: PMC9522913 DOI: 10.1080/02791072.2022.2058897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Cannabis use may confer high COVID-19 risk. This study examined self-reported changes in cannabis use that US adults attributed to the pandemic and factors associated with any changes. We conducted a national, cross-sectional survey among US adults in August 2020. The analytic sample included 957 past-year cannabis users (Mage = 43 years old; 51% male). Weighted multinomial regression examined associations between forms and reasons of cannabis used, perceived addictiveness and safety, co-use of cannabis with tobacco/alcohol, state legalization, and the outcome (self-reported increase/decrease in cannabis use vs. no change). Overall, 14.8% reported decreasing cannabis use due to the pandemic, 16.1% reported increasing, and 65.4% reported not changing. Factors associated with increased cannabis use included past-year use of vaporized (AOR = 1.7, 95% CI = 1.0, 3.0) or edible cannabis (AOR = 2.4, CI = 1.3, 4.3), and simultaneous use of cannabis and tobacco (AOR = 2.6; CI = 1.4, 5.2). Young adults (18-29 years old) had higher odds of self-reporting both increased (AOR = 4.8; CI = 1.8, 13.1) and decreased use (AOR = 3.3; CI = 1.5, 7.5). The pandemic has had a mixed impact on cannabis use, with participants reporting both increased and decreased use. Efforts may target users of vaporized and edible cannabis, co-users of cannabis and tobacco, and young adults to prevent increased cannabis use during the pandemic.
Collapse
Affiliation(s)
- Nhung Nguyen
- Center for Tobacco Control Research and Education, and Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Salomeh Keyhani
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Pamela M. Ling
- Center for Tobacco Control Research and Education, and Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Katherine J. Hoggatt
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Deborah Hasin
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Beth E. Cohen
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| |
Collapse
|
12
|
Judson GL, Cohen BE, Muniyappa A, Raitt MH, Shen H, Tarasovsky G, Whooley MA, Dhruva SS. Implantable cardioverter-defibrillator placement among patients with left ventricular ejection fraction ≤35 % at least 40 days after acute myocardial infarction. Am Heart J Plus 2022; 19:100186. [PMID: 37886349 PMCID: PMC10601204 DOI: 10.1016/j.ahjo.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 10/28/2023]
Abstract
Background Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death among patients with persistently reduced (≤35 %) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). Few prior studies have used LVEF measured after the 40-day waiting period to examine primary prevention ICD placement. Methods We sought to determine factors associated with ICD placement among patients who met LVEF criteria post-MI within a large integrated health care system in the U.S by conducting a retrospective cohort study of Veteran patients hospitalized for AMI from 2004 to 2017 who had documented LVEF ≤35 % from echocardiograms performed between 40 and 455 (90 days +1 year) days post-MI. We used multivariable logistic regression to examine factors associated with ICD placement. Results Of 12,893 patients with LVEF ≤35 % at least 40 days post-MI, 2176 (16.9 %) received an ICD between 91- and 455-days post-MI. Younger age, fewer comorbidities, revascularization with PCI, and greater use of GDMT were associated with increased odds of receiving an ICD. However, half of patients treated with a beta-blocker, ACE inhibitor or angiotensin receptor blocker, and mineralocorticoid receptor antagonist prior to LVEF assessment did not receive an ICD. Eligible Black patients were less likely (odds ratio 0.80, 95 % confidence interval 0.69-0.92) to receive an ICD than White patients. Conclusion Many factors affect ICD placement among Veteran patients with a confirmed LVEF ≤35 % at least 40 days post-MI. Greater understanding of factors influencing ICD placement would help clinicians ensure guideline-concordant care.
Collapse
Affiliation(s)
- Gregory L. Judson
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Beth E. Cohen
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Anoop Muniyappa
- Clinical Informatics, University of California, San Francisco, CA, United States of America
| | - Merritt H. Raitt
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, OR, United States of America
- Portland Veterans Affairs Health Care System, OR, United States of America
| | - Hui Shen
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Gary Tarasovsky
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Mary A. Whooley
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Sanket S. Dhruva
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| |
Collapse
|
13
|
Wulsin LR, Sagui-Henson SJ, Roos LG, Wang D, Jenkins B, Cohen BE, Shah AJ, Slavich GM. Stress Measurement in Primary Care: Conceptual Issues, Barriers, Resources, and Recommendations for Study. Psychosom Med 2022; 84:267-275. [PMID: 35067657 PMCID: PMC8976751 DOI: 10.1097/psy.0000000000001051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Exposure to stressors in daily life and dysregulated stress responses are associated with increased risk for a variety of chronic mental and physical health problems, including anxiety disorders, depression, asthma, heart disease, certain cancers, and autoimmune and neurodegenerative disorders. Despite this fact, stress exposure and responses are rarely assessed in the primary care setting and infrequently targeted for disease prevention or treatment. METHOD In this narrative review, we describe the primary reasons for this striking disjoint between the centrality of stress for promoting disease and how rarely it is assessed by summarizing the main conceptual, measurement, practical, and reimbursement issues that have made stress difficult to routinely measure in primary care. The following issues will be reviewed: a) assessment of stress in primary care, b) biobehavioral pathways linking stress and illness, c) the value of stress measurements for improving outcomes in primary care, d) barriers to measuring and managing stress, and e) key research questions relevant to stress assessment and intervention in primary care. RESULTS On the basis of our synthesis, we suggest several approaches that can be pursued to advance this work, including feasibility and acceptability studies, cost-benefit studies, and clinical improvement studies. CONCLUSIONS Although stress is recognized as a key contributor to chronic disease risk and mortality, additional research is needed to determine how and when instruments for assessing life stress might be useful in the primary care setting, and how stress-related data could be integrated into disease prevention and treatment strategies to reduce chronic disease burden and improve human health and well-being.
Collapse
Affiliation(s)
- Lawson R Wulsin
- From the Departments of Psychiatry and Family Medicine, University of Cincinnati, and Cincinnati Veterans Administration Medical Center (Wulsin), Cincinnati, Ohio; Osher Center for Integrative Medicine (Sagui-Henson), University of California, San Francisco, San Francisco, California; Health Psychology PhD Program (Roos), University of North Carolina at Charlotte, Charlotte, North Carolina; Center for Economic and Social Research (Wang), University of Southern California, Los Angeles; Department of Psychology, Chapman University, Center on Stress & Health, and Department of Anesthesiology and Perioperative Care (Jenkins), University of California, Irvine; Department of Medicine, University of California, San Francisco, and San Francisco Veterans Affairs Healthcare System (Cohen), San Francisco, California; Department of Epidemiology (Shah), Rollins School of Public Health, Emory University; Department of Medicine, Division of Cardiology (Shah), Emory University School of Medicine, Atlanta; and Atlanta Veterans Affairs Healthcare System (Shah), Decatur, Georgia; and Cousins Center for Psychoneuroimmunology and Department of Psychiatry and Biobehavioral Sciences (Slavich), University of California, Los Angeles, Los Angeles, California
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Nishimi K, Borsari B, Marx BP, Tripp P, Woodward E, Rosen RC, Cohen BE, Maven D, Jiha A, Woolley JD, Neylan TC, O’Donovan A. Posttraumatic stress disorder symptoms associated with protective and risky behaviors for coronavirus disease 2019. Health Psychol 2022; 41:104-114. [PMID: 35238581 PMCID: PMC8932400 DOI: 10.1037/hea0001157] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Psychiatric disorders increase risk for contracting coronavirus disease 2019 (COVID-19), but we know little about relationships between psychiatric symptoms and COVID-19 risky and protective behaviors. Posttraumatic stress disorder (PTSD) has been associated with increased propensity to engage in risky behaviors, but may also be associated with increased COVID-19 protective behaviors due to increased threat sensitivity and social isolation. METHOD We examined associations of PTSD symptoms with COVID-19-related protective and risky behaviors using data from a cross-sectional online United States study among 845 US adults in August through September 2020. PTSD symptoms (PTSD Checklist-5), sociodemographics, COVID-19-related experiences and vulnerabilities, and past 30-day engagement in 10 protective and eight risky behaviors for COVID-19 were assessed via self-report. We examined associations between PTSD symptoms and COVID-19 protective and risky behaviors with linear regressions, adjusting for covariates. RESULTS Probable PTSD and higher PTSD symptom severity were associated with greater engagement in protective behaviors, but also greater engagement in risky behaviors. Associations were only slightly attenuated by adjustment for COVID-19 exposures and perceived likelihood and severity of COVID-19. Associations varied by PTSD clusters: intrusions and arousal were associated with both more protective and more risky behaviors, whereas negative cognitions or mood was associated only with more risky, and avoidance only with more protective, behaviors. CONCLUSION Higher PTSD symptoms were associated with engagement in more protective but also more risky behaviors for COVID-19. Mental health should be considered in the design of public health campaigns dedicated to limiting infectious disease spread. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Collapse
Affiliation(s)
- Kristen Nishimi
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Brian Borsari
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Brian P Marx
- Department of Psychiatry, Boston University School of Medicine
- National Center for PTSD, VA Boston Healthcare System
| | - Paige Tripp
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Eleanor Woodward
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Raymond C Rosen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
| | - Beth E Cohen
- Medical Service, San Francisco Veterans Affairs Healthcare System
- Department of Medicine, University of California San Francisco
| | - David Maven
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Ahmad Jiha
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Joshua D Woolley
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| | - Aoife O’Donovan
- Mental Health Service, San Francisco Veterans Affairs Healthcare System
- Department of Psychiatry and Behavioral Sciences and Weill Institute for Neurosciences, University of California San Francisco
| |
Collapse
|
15
|
Hargrave AS, Kimberg L, Machtinger EL, Kushel MB, Cohen BE. The Association Between Interpersonal Violence and Unstable Housing Among Veterans. Mil Med 2022; 188:usab557. [PMID: 35018446 PMCID: PMC10362995 DOI: 10.1093/milmed/usab557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness. METHODS Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness. RESULTS Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2-3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91-2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2-2.5; mugging/physical attack AOR 1.8, 95% CI 1.2-2.7; sexual violence AOR 1.4, 95% CI 0.89-2.2), but were no longer significant in the fully adjusted model. CONCLUSIONS Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship-highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.
Collapse
Affiliation(s)
- Anita S Hargrave
- Department of Internal Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Leigh Kimberg
- Department of Internal Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Edward L Machtinger
- Department of Internal Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Margot B Kushel
- Department of Internal Medicine, University of California San Francisco, San Francisco, CA 94110, USA
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Beth E Cohen
- Department of Internal Medicine, University of California San Francisco, San Francisco, CA 94110, USA
- Department of Internal Medicine, San Francisco VA Health Care System, San Francisco, CA 94121, USA
| |
Collapse
|
16
|
Nishimi K, Borsari B, Marx BP, Rosen RC, Cohen BE, Woodward E, Maven D, Tripp P, Jiha A, Woolley JD, Neylan TC, O'Donovan A. Clusters of COVID-19 protective and risky behaviors and their associations with pandemic, socio-demographic, and mental health factors in the United States. Prev Med Rep 2021; 25:101671. [PMID: 34926133 PMCID: PMC8669937 DOI: 10.1016/j.pmedr.2021.101671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/02/2021] [Accepted: 12/12/2021] [Indexed: 11/11/2022] Open
Abstract
Protective and risky behaviors for COVID-19 cluster in a U.S.-based sample. Behavior classes had differing patterns of socio-demographics and pandemic exposure. Posttraumatic stress and anxiety were elevated among protective and risky classes.
Individual behaviors are critical for preventing the spread of coronavirus disease 2019 (COVID-19) infection. Given that both protective and risky behaviors influence risk of infection, it is critical that we understand how such behaviors cluster together and in whom. Using a data-driven approach, we identified clusters of COVID-19-related protective and risky behaviors and examined associations with socio-demographic, pandemic, and mental health factors. Data came from a cross-sectional online U.S. nationwide study of 832 adults with high levels of pre-pandemic trauma. Latent class analysis was performed with ten protective (e.g., washing hands, wearing masks) and eight risky (e.g., attending indoor restaurants, taking a flight) behaviors for COVID-19. Then, we examined distributions of socio-demographic and pandemic factors across behavior classes using ANOVA or Chi-square tests, and associations between mental health factors (depressive, anxiety, posttraumatic stress symptoms) and behavior classes using multinomial logistic regression. We identified four classes, including three classes with relatively low risky but high (28.8%), moderate (33.5%) and minimal (25.5%) protective behaviors and one high risky behaviors class with associated moderate protective behaviors (12.1%). Age, sexual orientation, political preference, and most pandemic factors differed significantly across behavior classes. Anxiety and posttraumatic stress symptoms, but not depression, were higher in the High Risk, but also Highly and Moderately Protective classes, relative to Minimally Protective. Prevention and intervention efforts should examine constellations of protective and risky behaviors to comprehensively understand risk, and consider current anxiety and posttraumatic stress symptoms as potential risk indicators.
Collapse
Key Words
- ANOVA, analysis of variance
- AWE, Approximate Weight of Evidence Criterion
- AvePP, average posterior class probability
- BF, Bayes Factors
- BIC, Bayesian Information Criterion
- COVID-19
- COVID-19, coronavirus disease 2019
- DASS, Depression Anxiety Stress Scale
- LCA, latent class analysis
- Latent class analysis
- Mental health
- OCC, odds of correct classification
- PTSD Checklist-5, PCL-5
- PTSD, posttraumatic stress disorder
- Protective behaviors
- Risky behaviors
- cAIC, consistent Akaike's Information Criterion
- mcaP, modal class assignment proportion
Collapse
Affiliation(s)
- Kristen Nishimi
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Brian Borsari
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Brian P Marx
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Raymond C Rosen
- Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Medical Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Eleanor Woodward
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - David Maven
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Paige Tripp
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Ahmad Jiha
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Joshua D Woolley
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Aoife O'Donovan
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
17
|
Koraishy FM, Coca SG, Cohen BE, Scherrer JF, Mann F, Kuan PF, Luft BJ, Clouston S. The Association of Posttraumatic Stress Disorder With Longitudinal Change in Glomerular Filtration Rate in World Trade Center Responders. Psychosom Med 2021; 83:978-986. [PMID: 34297009 PMCID: PMC8578353 DOI: 10.1097/psy.0000000000000968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE High levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease. METHODS World Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL <50), and "severe" PTSD (PCL ≥50). Subtypes of PTSD by symptom clusters were analyzed. Multinomial logistic regression was used to estimate the association of PTSD with two GFR change outcomes (decline or increase) compared with the stable GFR outcome. RESULTS In 2266 participants, the mean age was 53.1 years, 8.2% were female, and 89.1% were White. Individuals with PTSD (n = 373; 16.5%) did not differ in mean baseline GFR from individuals without PTSD (89.73 versus 90.56 mL min-1 1.73 m-2; p = .29). During a 2.01-year mean follow-up, a mean GFR decline of -1.51 mL min-1 1.73 m-2 per year was noted. In multivariable-adjusted models, PTSD was associated with GFR decline (adjusted relative risk [aRR] = 1.74 [1.32-2.30], p < .001) compared with stable GFR, with "hyperarousal" symptoms showing the strongest association (aRR =2.11 [1.40-3.19]; p < .001). Dose-response effects were evident when comparing mild with severe PTSD and comparing PTSD with versus without depression. PTSD was also associated with GFR rise (aRR = 1.47 [1.10-1.97], p < .009). The association between PTSD and GFR change was stronger in participants older than 50 years. CONCLUSIONS PTSD may be a novel risk factor for exaggerated longitudinal GFR change in young, healthy adults. These findings need to be validated in other cohorts.
Collapse
Affiliation(s)
- Farrukh M. Koraishy
- Department of Medicine, Division of Nephrology, Stony Brook University
- Stony Brook WTC Wellness Program
| | - Steven G. Coca
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai
| | - Beth E. Cohen
- Department of Medicine, University of California, San Francisco
| | | | - Frank Mann
- Department of Family, Population, and Preventative Medicine, Program in Public Health, Stony Brook University
| | - Pei-Fen Kuan
- Stony Brook WTC Wellness Program
- Department of Applied Mathematics and Statistics, Stony Brook University
| | - Benjamin J. Luft
- Stony Brook WTC Wellness Program
- Department of Medicine, Division of Infectious Diseases, Stony Brook University
| | - Sean Clouston
- Stony Brook WTC Wellness Program
- Department of Family, Population, and Preventative Medicine, Program in Public Health, Stony Brook University
| |
Collapse
|
18
|
Salas J, Gebauer S, Gillis A, van den Berk-Clark C, Schneider FD, Schnurr PP, Friedman MJ, Norman SB, Tuerk PW, Cohen BE, Lustman PJ, Scherrer JF. Increased Smoking Cessation among Veterans with Large Decreases in Posttraumatic Stress Disorder Severity. Nicotine Tob Res 2021; 24:178-185. [PMID: 34477205 DOI: 10.1093/ntr/ntab179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/01/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. METHODS Veterans Health Affairs (VHA) medical record data (2008 to 2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement, was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥ 50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2-years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. RESULTS On average, patients were 39.4 (SD=12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with vs. without clinically meaningful PTSD improvement stopped smoking (n=36, cumulative incidence=40.5% vs. 111, cumulative incidence=30.8%; respectively). After controlling for confounding, patients with vs. without clinically meaningful PTSD improvement were more likely to stop smoking within 2-years (HR=1.57; 95%CI:1.04-2.36). CONCLUSIONS Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. IMPLICATIONS Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking related disease.
Collapse
Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
| | - Sarah Gebauer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
| | - Auston Gillis
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States
| | - F David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Paula P Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Matthew J Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Sonya B Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego, United States
| | - Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA. United States
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, United States
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO. and The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, St. Louis, MO, United States
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104, United States.,Harry S. Truman Veterans Administration Medical Center. Columbia, MO, United States
| |
Collapse
|
19
|
Borsari B, Li Y, Tighe J, Manuel JK, Gökbayrak NS, Delucchi K, Morasco BJ, Abadjian L, Cohen BE, Baxley C, Seal KH. A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management. Addiction 2021; 116:2387-2397. [PMID: 33405304 DOI: 10.1111/add.15401] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/20/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use. DESIGN Small pilot study of a randomized controlled trial. SETTING An urban Veterans Affairs (VA) Medical Center in the United States. PARTICIPANTS One hundred adult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy. INTERVENTION AND COMPARATOR During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n = 100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12 weeks) of either CCMI (n = 51) or attention control psychoeducation (ACP; n = 49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12 weeks. MEASUREMENTS Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals. FINDINGS At 12 weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12 weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d = 0.54). CONCLUSIONS US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.
Collapse
Affiliation(s)
- Brian Borsari
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jennifer Tighe
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jennifer K Manuel
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - N Simay Gökbayrak
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
| | - Linda Abadjian
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Catherine Baxley
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Department of Medicine, University of California, San Francisco, CA, USA
| |
Collapse
|
20
|
O'Donnell CJ, Schwartz Longacre L, Cohen BE, Fayad ZA, Gillespie CF, Liberzon I, Pathak GA, Polimanti R, Risbrough V, Ursano RJ, Vander Heide RS, Yancy CW, Vaccarino V, Sopko G, Stein MB. Posttraumatic Stress Disorder and Cardiovascular Disease: State of the Science, Knowledge Gaps, and Research Opportunities. JAMA Cardiol 2021; 6:1207-1216. [PMID: 34259831 DOI: 10.1001/jamacardio.2021.2530] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Posttraumatic stress disorder (PTSD) is characterized by a persistent maladaptive reaction after exposure to severe psychological trauma. Traumatic events that may precipitate PTSD include violent personal assaults, natural and human-made disasters, and exposure to military combat or warfare. There is a growing body of evidence for associations of PTSD with major risk factors for cardiovascular disease (CVD), such as hypertension and diabetes, as well as with major CVD outcomes, such as myocardial infarction and heart failure. However, it is unclear whether these associations are causal or confounded. Furthermore, the biological and behavioral mechanisms underlying these associations are poorly understood. Here, the available evidence on the association of PTSD with CVD from population, basic, and genomic research as well as from clinical and translational research are reviewed, seeking to identify major research gaps, barriers, and opportunities in knowledge acquisition and technology as well as research tools to support and accelerate critical research for near-term and longer-term translational research directions. Large-scale, well-designed prospective studies, capturing diverse and high-risk populations, are warranted that include uniform phenotyping of PTSD as well as broad assessment of biological and behavioral risk factors and CVD outcomes. Available evidence from functional brain imaging studies demonstrates that PTSD pathophysiology includes changes in specific anatomical brain regions and circuits, and studies of immune system function in individuals with PTSD suggest its association with enhanced immune inflammatory activity. However, establishment of animal models and human tissue biobanks is also warranted to elucidate the potential causal connection of PTSD-induced brain changes and/or inflammation with CVD pathophysiology. Emerging large-scale genome-wide association studies of PTSD will provide an opportunity to conduct mendelian randomization studies that test hypotheses regarding the presence, magnitude, and direction of causal associations between PTSD and CVD outcomes. By identifying research gaps in epidemiology and genomics, animal, and human translational research, opportunities to better justify and design future interventional trials are highlighted that may test whether treatment of PTSD or underlying neurobiological or immune dysregulation may improve or prevent CVD risk or outcomes.
Collapse
Affiliation(s)
- Christopher J O'Donnell
- Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lisa Schwartz Longacre
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Beth E Cohen
- UCSF Department of Medicine, University of California, San Francisco
| | - Zahi A Fayad
- Biomedical Engineering and Medical Institute, Icahn Mount Sinai School of Medicine, New York, New York.,Department of Cardiology, Icahn Mount Sinai School of Medicine, New York, New York
| | | | - Israel Liberzon
- Department of Psychiatry, Texas A&M University, College Station
| | - Gita A Pathak
- Yale University School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven
| | - Renato Polimanti
- Yale University School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven
| | - Victoria Risbrough
- Department of Psychiatry, UC San Diego School of Medicine, University of California, San Diego, La Jolla.,VA Center of Excellence for Stress and Mental Health, San Diego, California
| | - Robert J Ursano
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland
| | | | - Clyde W Yancy
- Department of Cardiology, Northwestern Medicine, Chicago, Illinois.,Deputy Editor, JAMA Cardiology
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Murray B Stein
- Department of Psychiatry, UC San Diego School of Medicine, University of California, San Diego, La Jolla.,Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla.,VA San Diego Healthcare System, San Diego, California
| |
Collapse
|
21
|
Affiliation(s)
- Annie L Ryder
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
22
|
Cohen BE. Exploring Posttraumatic Stress Disorder as a Cardiovascular Risk Factor in Women Veterans: The Heart of the Matter. JAMA Cardiol 2021; 6:651-652. [PMID: 33729434 DOI: 10.1001/jamacardio.2021.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Beth E Cohen
- Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California.,Department of Medicine, University of California, San Francisco
| |
Collapse
|
23
|
Holder N, Woods A, Neylan TC, Maguen S, Seal KH, Bernardy N, Wiechers I, Ryder A, Urbieta AM, Cohen BE. Trends in Medication Prescribing in Patients With PTSD From 2009 to 2018: A National Veterans Administration Study. J Clin Psychiatry 2021; 82. [PMID: 34004087 DOI: 10.4088/jcp.20m13522] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. METHODS Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined. RESULTS From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (-4.3%) occurring from 2009 to 2013. CONCLUSIONS Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.
Collapse
Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Psychiatry, San Francisco, California.,Corresponding author: Nicholas Holder, PhD, 4150 Clement St, San Francisco, CA 94121
| | - Anne Woods
- Northern California Institute for Research and Education, San Francisco, California
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Psychiatry, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Neurology, San Francisco, California
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,Sierra Pacific Mental Illness Research, Education, and Clinical Center, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Psychiatry, San Francisco, California
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Psychiatry, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Medicine, San Francisco, California
| | - Nancy Bernardy
- National Center for Posttraumatic Stress Disorder, Executive Division, White River Junction, Vermont.,Geisel School of Medicine at Dartmouth, Department of Psychiatry, Hanover, New Hampshire
| | - Ilse Wiechers
- University of California San Francisco, School of Medicine, Department of Psychiatry, San Francisco, California.,Northeast Program Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, West Haven, Connecticut.,Yale University School of Medicine, Department of Psychiatry, New Haven, Connecticut
| | - Annie Ryder
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Medicine, San Francisco, California
| | - Ana-Marie Urbieta
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Beth E Cohen
- San Francisco Veterans Affairs Health Care System, San Francisco, California.,University of California San Francisco, School of Medicine, Department of Medicine, San Francisco, California
| |
Collapse
|
24
|
Khan AJ, Maguen S, Straus LD, Nelyan TC, Gross JJ, Cohen BE. Expressive suppression and cognitive reappraisal in veterans with PTSD: Results from the mind your heart study. J Affect Disord 2021; 283:278-284. [PMID: 33578339 DOI: 10.1016/j.jad.2021.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/14/2021] [Accepted: 02/01/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study examined whether expressive suppression (ES), a maladaptive regulation strategy, was more strongly associated with PTSD diagnosis and symptom clusters in veterans than cognitive reappraisal (CR), an adaptive regulation strategy. METHOD In a cohort study, 746 participants recruited from VHA facilities completed Clinician Administered PTSD Scale-IV, Emotion Regulation Questionnaire, and Patient Health Questionnaire. Participants were categorized into groups: Current, Remitted/Lifetime, and Never PTSD. RESULTS One-way ANOVA revealed significant differences between Current PTSD and both Remitted and Never PTSD for ES, but not CR. The Remitted and Never PTSD groups did not vary significantly from each other and were collapsed into one group for regressions. Adjusting for sex, race, employment, and comorbid depression, binary logistic regression showed ES, but not CR, was associated with increased likelihood of Current PTSD (p < .001, OR: 1.43). ES was also significantly associated with increased odds of meeting criteria for all symptom clusters (ps < 0.001). CR was not significantly associated with meeting criteria for Current PTSD or any symptom cluster. LIMITATIONS Cross-sectional design and use of self-report limit causality inferences that can be drawn. CONCLUSIONS ES is associated with increased odds of Current PTSD diagnosis and symptom clusters. Veterans in the Remitted and Never PTSD groups did not differ significantly. Greater suppression of emotional expression is more strongly linked with PTSD criteria in veterans than decreased cognitive reappraisal.
Collapse
Affiliation(s)
- A J Khan
- San Francisco VA Health Care System, San Francisco, CA; Department of Psychiatry, University of California, San Francisco, CA.
| | - S Maguen
- San Francisco VA Health Care System, San Francisco, CA; Department of Psychiatry, University of California, San Francisco, CA.
| | - L D Straus
- San Francisco VA Health Care System, San Francisco, CA; Department of Psychiatry, University of California, San Francisco, CA.
| | - T C Nelyan
- San Francisco VA Health Care System, San Francisco, CA; Department of Psychiatry, University of California, San Francisco, CA.
| | - J J Gross
- Department of Psychology, Stanford University, Stanford, CA.
| | - B E Cohen
- San Francisco VA Health Care System, San Francisco, CA; Department of Medicine, University of California, San Francisco, CA.
| |
Collapse
|
25
|
Arenson M, Bernat E, De Los Reyes A, Neylan TC, Cohen BE. Social support, social network size, and suicidal ideation: A nine-year longitudinal analysis from the Mind Your Heart Study. J Psychiatr Res 2021; 135:318-324. [PMID: 33545566 DOI: 10.1016/j.jpsychires.2021.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/04/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Substantial research has investigated the impact of social support on the development and course of suicidal thoughts and behaviors. However, its measurement has been inconsistent, and different facets of social support may have differential effects on suicidal ideation (SI). The present study used data from 743 veterans recruited between 2008 and 2010 as part of the Mind Your Heart Study to investigate the relationship between two aspects of social support (social network size and perceived social support) and SI over 9 years. Using the 9th item of the PHQ-9, we created two composite scores: (1, chronicity) the proportion of years the participant endorsed SI and (2, severity) the severity of SI across the follow-up period. We found that, when modeled individually, both larger social network size and greater perceived social support predicted lower SI chronicity (β=-.16, β = -0.19 respectively; ps < .001) and lower SI severity (β=-0.15 and β = -0.19, respectively; ps < .001). However, when modeled together and controlling for PTSD and depression symptoms, increased social network size but not perceived social support predicted lower SI chronicity (β=-0.09, p = .01 and β = 0.02, p = .48, respectively) and SI severity (β=-0.07, p = .045 and β = 0.01, p = .71, respectively). These findings suggest that social network size may be an important target for intervention, and that future work is needed to better delineate the effect of different features of social support on risk for suicide.
Collapse
Affiliation(s)
- Melanie Arenson
- University of Maryland, College Park, 4094 Campus Drive, Campus Park, MD, 20742, USA; San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA, 94121, USA.
| | - Edward Bernat
- University of Maryland, College Park, 4094 Campus Drive, Campus Park, MD, 20742, USA
| | - Andres De Los Reyes
- University of Maryland, College Park, 4094 Campus Drive, Campus Park, MD, 20742, USA
| | - Thomas C Neylan
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA, 94121, USA; University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Beth E Cohen
- San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA, 94121, USA; University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| |
Collapse
|
26
|
Levine GN, Cohen BE, Commodore-Mensah Y, Fleury J, Huffman JC, Khalid U, Labarthe DR, Lavretsky H, Michos ED, Spatz ES, Kubzansky LD. Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e763-e783. [PMID: 33486973 DOI: 10.1161/cir.0000000000000947] [Citation(s) in RCA: 209] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.
Collapse
|
27
|
Ramirez JL, Zarkowsky DS, Ramirez FD, Gasper WJ, Cohen BE, Conte MS, Grenon SM, Iannuzzi JC. Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 74:131-140. [PMID: 33503503 DOI: 10.1016/j.avsg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. METHODS Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis. RESULTS There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87). CONCLUSIONS In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.
Collapse
Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO
| | - Faustine D Ramirez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
| |
Collapse
|
28
|
Salas J, Norman SB, Tuerk PW, van den Berk-Clark C, Cohen BE, Schneider FD, Chard KM, Lustman PJ, Schnurr PP, Friedman MJ, Grucza R, Scherrer JF. PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data. Drug Alcohol Depend 2021; 218:108365. [PMID: 33109460 PMCID: PMC7750304 DOI: 10.1016/j.drugalcdep.2020.108365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization. METHODS We used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008-2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits. RESULTS The 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04-2.33) but there was no association with number of SUD treatment visits. CONCLUSIONS Clinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.
Collapse
Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States.
| | - Sonya B. Norman
- National Center for PTSD and Department of Psychiatry,
University of California San Diego, United States
| | - Peter W. Tuerk
- Sheila C. Johnson Center for Clinical Services, Department
of Human Services, University of Virginia, Charlottesville, VA. United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States
| | - Beth E. Cohen
- Department of Medicine, University of California San
Francisco School of Medicine and San Francisco VAMC, United States
| | - F. David Schneider
- Department of Family and Community Medicine, University of
Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of
Psychiatry and Behavioral Neuroscience, University of Cincinnati, United
States
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of
Medicine, St. Louis MO. and The Bell Street Clinic Opioid Addiction Treatment
Programs, VA St. Louis Healthcare System, St. Louis, MO, United States
| | - Paula P. Schnurr
- National Center for PTSD and Department of Psychiatry,
Geisel School of Medicine at Dartmouth, United States
| | - Matthew J. Friedman
- National Center for PTSD and Department of Psychiatry,
Geisel School of Medicine at Dartmouth, United States
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States
| | - Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis
University School of Medicine, St. Louis MO. 63104, United States,Harry S. Truman Veterans Administration Medical Center.
Columbia, MO, United States
| |
Collapse
|
29
|
Ahmadian AJ, Lin JE, Neylan TC, Woolley JD, O'Donovan A, Cohen BE. Social integration and inflammation in individuals with and without posttraumatic stress disorder. Brain Behav Immun 2020; 89:168-174. [PMID: 32534985 PMCID: PMC8388310 DOI: 10.1016/j.bbi.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is associated with increased risk for morbidity and mortality, which may be mediated through elevated inflammation. In contrast, social support appears to protect against morbidity and mortality, reduce levels of inflammation, and improve PTSD outcomes. METHODS We examined relationships among social isolation, perceived social support, and inflammation in Veterans Affairs (VA) patients with and without PTSD. Our sample included 735 (35% PTSD+) participants from the Mind Your Heart Study (mean age = 58 ± 11; 94% male). Social isolation was assessed with the Berkman Syme Social Network Index; perceived social support with the Multidimensional Scale of Perceived Social Support; and PTSD with the Clinician Administered PTSD Scale. Inflammation was indexed by high sensitivity C-reactive protein, white blood cell count, and fibrinogen. Hierarchical linear regression was used to examine associations between social measures and inflammation. PROCESS was used to examine the interactive effects of social relationships and PTSD on inflammation. RESULTS Social isolation, but not low perceived social support, trended towards an association with elevated inflammation in the full sample. However, considering groups with and without PTSD separately, social isolation was significantly associated with all inflammatory markers among individuals without PTSD, but not among those with PTSD. CONCLUSIONS Social integration is associated with reduced inflammation in individuals without, but not with, PTSD. Socially integrated individuals with PTSD did not have lower levels of inflammatory markers than socially isolated individuals with PTSD.
Collapse
Affiliation(s)
- Ashkan J Ahmadian
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Internal Medicine, St. Mary's Medical Center, San Francisco, CA, USA
| | - Joy E Lin
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Thomas C Neylan
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Joshua D Woolley
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Aoife O'Donovan
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Beth E Cohen
- San Francisco Veterans Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Internal Medicine, University of California, San Francisco, CA, USA.
| |
Collapse
|
30
|
Azcarate PM, Zhang AJ, Keyhani S, Steigerwald S, Ishida JH, Cohen BE. Medical Reasons for Marijuana Use, Forms of Use, and Patient Perception of Physician Attitudes Among the US Population. J Gen Intern Med 2020; 35:1979-1986. [PMID: 32291715 PMCID: PMC7352011 DOI: 10.1007/s11606-020-05800-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/12/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of marijuana for medical purposes is increasing in parallel with expanding legalization and decreased public perception of harm. Despite this increase in use, it is unclear which medical conditions patients are attempting to treat with marijuana and whether they are communicating with medical providers about their use. OBJECTIVE To understand the medical reasons for marijuana use, forms of marijuana used for medical purposes, and disclosure of use to physicians. DESIGN National, probability-based online survey. SETTING The USA, 2017. PARTICIPANTS 16,280 US adults. MAIN MEASURE Proportion of US adults who agreed with a statement. KEY RESULTS A total of 9003 participants completed the survey (55% response rate). Five hundred ninety-one (7% of US adults) reported using marijuana for medical purposes. The most common medical reasons for marijuana use were anxiety (49%), insomnia (47%), chronic pain (42%), and depression (39%). The most common forms of use for all medical conditions were smoking and edibles, followed by vaping, concentrate, and topical. We found women were more likely to use marijuana for posttraumatic stress disorder, sleep, anxiety, and migraines. We did not find substantial variation in medical reasons for marijuana use by race. Among those using marijuana for medical purposes, 21% did not have a doctor. Among those with doctors, 33% did not inform them, 28% reported their doctor was neutral on their use, 32% reported their doctor was supportive, and 8% reported their doctor was not supportive. Those who lived in states where medical marijuana was illegal were less likely to disclose use to their doctor. LIMITATION The online format of the survey may have caused selection bias. Wording of the questions may have affected interpretation. Doctors were not queried directly, rather participants were asked about their perception of doctor attitudes. CONCLUSION Americans are using marijuana to treat medical conditions despite lack of evidence of efficacy.
Collapse
Affiliation(s)
- Patrick M Azcarate
- Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA. .,Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA. .,Cardiovascular Medicine, University of California San Diego, San Diego, USA.
| | - Alysandra J Zhang
- Northern California Institute for Education and Research, San Francisco VA Medical Center, San Francisco, CA, USA.,Department of Medicine, UCSF Division of General Internal Medicine, San Francisco VA Medical Center, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Salomeh Keyhani
- Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA.,Northern California Institute for Education and Research, San Francisco VA Medical Center, San Francisco, CA, USA.,Department of Medicine, UCSF Division of General Internal Medicine, San Francisco VA Medical Center, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Stacey Steigerwald
- Northern California Institute for Education and Research, San Francisco VA Medical Center, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Julie H Ishida
- Department of Medicine, UCSF Division of Nephrology, San Francisco VA Medical Center, San Francisco, CA, USA.,Department of Nephrology, University of California, San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Medicine, UCSF Division of General Internal Medicine, San Francisco VA Medical Center, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| |
Collapse
|
31
|
Scherrer JF, Salas J, Schneider FD, Friedman MJ, van den Berk-Clark C, Chard KM, Norman SB, Lustman PJ, Tuerk P, Schnurr PP, Cohen BE. PTSD improvement and incident cardiovascular disease in more than 1000 veterans. J Psychosom Res 2020; 134:110128. [PMID: 32403058 PMCID: PMC7274904 DOI: 10.1016/j.jpsychores.2020.110128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown. METHODS Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting. RESULTS Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD. CONCLUSIONS Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.
Collapse
Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104,Harry S. Truman Veterans Administration Medical Center. Columbia, MO.,Corresponding author at: Family and Community Medicine, Saint Louis University School of Medicine, 1402 N. Grand Blvd, St. Louis, MO. 63104,
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104,Harry S. Truman Veterans Administration Medical Center. Columbia, MO
| | - F. David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern, Dallas TX
| | - Matthew J. Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, OH
| | - Sonya B. Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO.,The Bell Street Clinic Opioid Addiction Treatment Program, VA St. Louis Health Care System, St. Louis MO
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA
| | - Paula P. Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Beth E. Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, CA
| |
Collapse
|
32
|
Scherrer JF, Salas J, Friedman MJ, Cohen BE, Schneider FD, Lustman PJ, van den Berk-Clark C, Chard KM, Tuerk P, Norman SB, Schnurr PP. Clinically meaningful posttraumatic stress disorder (PTSD) improvement and incident hypertension, hyperlipidemia, and weight loss. Health Psychol 2020; 39:403-412. [PMID: 32223280 PMCID: PMC8340539 DOI: 10.1037/hea0000855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss). METHOD Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease <10), small (10-19 point PCL decrease), and large (≥20 point PCL decrease) PTSD improvement. To estimate the association between degree of PTSD improvement and incident hypertension (n = 979), incident hyperlipidemia (n = 1,139) and incident ≥5% weight loss (1,330), we computed Cox proportional hazard models, controlling for confounding using inverse probability of exposure weighting (IPEW). RESULTS Overall, patients were about 40 years of age, 80% male and 65% White. Worsening or no PCL change occurred in about 60%, small improvement in 20%, and large improvement in 20%. After weighting data, compared with worsening or no change, both small and large PTSD improvements were associated, albeit not significantly, with lower risks for hypertension (HR = 0.68; 95% confidence interval, CI [0.46, 1.01] and HR = 0.79; 95% CI [0.53, 1.18], respectively). In weighted data, PTSD improvement was not associated with incident hyperlipidemia or ≥5% weight loss. CONCLUSIONS We observed limited evidence for an association between PTSD improvement and decreased hypertension risk. PCL decreases were not associated with hyperlipidemia or ≥5% weight loss. Further studies that measure potential physical health benefits of change in specific PTSD symptoms are needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Collapse
Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104
- Harry S. Truman Veterans Administration Medical Center, Columbia, MO
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104
- Harry S. Truman Veterans Administration Medical Center, Columbia, MO
| | - Matthew J. Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Beth E. Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, San Francisco, CA
| | - F. David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO
- The Bell Street Clinic Opioid Treatment Program, Mental Health Service, VA St. Louis Health Care System, St. Louis, MO
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA
| | - Sonya B. Norman
- National Center for PTSD, VA Center of Excellence for Stress and Mental Health and Department of Psychiatry, University of California San Diego
| | - Paula P. Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| |
Collapse
|
33
|
Scherrer JF, Salas J, Cohen BE, Schnurr PP, Schneider FD, Chard KM, Tuerk P, Friedman MJ, Norman SB, van den Berk‐Clark C, Lustman PJ. Comorbid Conditions Explain the Association Between Posttraumatic Stress Disorder and Incident Cardiovascular Disease. J Am Heart Assoc 2020; 8:e011133. [PMID: 30755078 PMCID: PMC6405681 DOI: 10.1161/jaha.118.011133] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Posttraumatic stress disorder ( PTSD ) is associated with risk of cardiovascular disease ( CVD ). Biopsychosocial factors associated with PTSD likely account for some or all of this association. We determined whether 1, or a combination of comorbid conditions explained the association between PTSD and incident CVD . Methods and Results Eligible patients used 1 of 5 Veterans Health Affairs medical centers distributed across the United States. Data were obtained from electronic health records. At index date, 2519 Veterans Health Affairs ( VA ) patients, 30 to 70 years of age, had PTSD diagnoses and 1659 did not. Patients had no CVD diagnoses for 12 months before index date. Patients could enter the cohort between 2008 and 2012 with follow-up until 2015. Age-adjusted Cox proportional hazard models were computed before and after adjusting for comorbidities. Patients were middle aged (mean=50.1 years, SD ±11.0), mostly male (87.0%), and 60% were white. The age-adjusted association between PTSD and incident CVD was significant (hazard ratio=1.41; 95% CI : 1.21-1.63). After adjustment for metabolic conditions, the association between PTSD and incident CVD was attenuated but remained significant (hazard ratio=1.23; 95% CI : 1.06-1.44). After additional adjustment for smoking, sleep disorder, substance use disorder, anxiety disorders, and depression, PTSD was not associated with incident CVD (hazard ratio=0.96; 95% CI : 0.81-1.15). Conclusions PTSD is not an independent risk factor for CVD . Physical and psychiatric conditions and smoking that co-occur with PTSD explain why this patient population has an increased risk of CVD . Careful monitoring may limit exposure to CVD risk factors and subsequent incident CVD .
Collapse
Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community MedicineSaint Louis University School of MedicineSt. LouisMO
- Harry S. Truman Veterans Administration Medical Center Research ServiceColumbiaMO
| | - Joanne Salas
- Department of Family and Community MedicineSaint Louis University School of MedicineSt. LouisMO
- Harry S. Truman Veterans Administration Medical Center Research ServiceColumbiaMO
| | - Beth E. Cohen
- Department of MedicineUniversity of California San Francisco School of Medicine and San Francisco VAMCSan FranciscoCA
| | - Paula P. Schnurr
- National Center for PTSD and Department of PsychiatryGeisel School of Medicine at DartmouthDarmouthHanover, NH
| | - F. David Schneider
- Department of Family and Community MedicineUniversity of Texas SouthwesternDallasTX
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of Psychiatry and Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOH
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical ServicesDepartment of Human ServicesUniversity of VirginiaCharlottesvilleVA
| | - Matthew J. Friedman
- National Center for PTSD and Department of PsychiatryGeisel School of Medicine at DartmouthDarmouthHanover, NH
| | - Sonya B. Norman
- National Center for PTSD and Department of PsychiatryUniversity of California San DiegoCA
| | | | - Patrick J. Lustman
- Department of PsychiatryWashington University School of MedicineSt. LouisMO
| |
Collapse
|
34
|
Ishida JH, Zhang AJ, Steigerwald S, Cohen BE, Vali M, Keyhani S. Sources of Information and Beliefs About the Health Effects of Marijuana. J Gen Intern Med 2020; 35:153-159. [PMID: 31637640 PMCID: PMC6957653 DOI: 10.1007/s11606-019-05335-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/29/2019] [Accepted: 07/30/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Marijuana is currently legal for recreational use in 10 states and Washington DC while a total of 34 states have implemented varying degrees of medical marijuana. The commercialization of marijuana has been accompanied by a proliferation of false claims regarding the therapeutic potential of marijuana, which are popularized by several different information sources. To date, no study has examined where US adults get their information regarding marijuana. OBJECTIVE To determine the sources of information associated with believing unsupported claims about marijuana. DESIGN Probability-based online survey PARTICIPANTS: 16,820 adults, with a response rate of about 55% (N = 9003) MAIN MEASURES: Most influential sources of information about marijuana and belief of statements consistent with misinformation, for example, smoking marijuana has preventative health benefits, secondhand marijuana smoke or use during pregnancy is completely or somewhat safe, and marijuana is not at all addictive. KEY RESULTS There were 9003 respondents (response rate 55%). Forty-three percent believed unsupported claims about marijuana. The most influential sources of information were health professionals, traditional media, friends/relatives, and social media/internet. Individuals reporting social media or the Internet (1.46 CI [1.30, 1.64]), the marijuana industry (e.g., advertisements, dispensaries) (2.88 CI [2.15, 3.88]), and friends or relatives (1.41 CI[1.26, 1.58]) as the most influential source of information about marijuana were more likely to believe any statement consistent with misinformation about marijuana in comparison with those who reported other sources as most influential. CONCLUSIONS Individuals reporting the most significant source of information regarding marijuana was from social media or the Internet, the marijuana industry, or friends or relatives were more likely to believe unsupported claims about marijuana. Public health campaigns to counter the misinformation about marijuana to the public are needed.
Collapse
Affiliation(s)
- Julie H Ishida
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, CA, USA
| | - Alysandra J Zhang
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Stacey Steigerwald
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Beth E Cohen
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA.,Department of Medicine, UCSF, University of California, San Francisco, San Francisco, CA, USA
| | - Marzieh Vali
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Salomeh Keyhani
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA. .,Department of Medicine, UCSF, University of California, San Francisco, San Francisco, CA, USA.
| |
Collapse
|
35
|
Salas J, Scherrer JF, Tuerk P, van den Berk-Clark C, Chard KM, Schneider FD, Schnurr PP, Friedman MJ, Norman SB, Cohen BE, Lustman P. Large posttraumatic stress disorder improvement and antidepressant medication adherence. J Affect Disord 2020; 260:119-123. [PMID: 31494363 PMCID: PMC6803073 DOI: 10.1016/j.jad.2019.08.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/06/2019] [Accepted: 08/30/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with vs. without posttraumatic stress disorder (PTSD) are more likely to have poor antidepressant medication (ADM) adherence but it is unclear if improved PTSD is associated with ADM adherence. We determined if clinically meaningful PTSD symptom reduction was associated with ADM adherence. METHODS Electronic health record data (2008-2015) was obtained from 742 Veterans Health Affairs (VHA) patients using PTSD specialty clinics with a PTSD diagnosis and PTSD checklist (PCL) score ≥50. The last PCL in the exposure year after the first PCL≥50 was used to identify patients with a clinically meaningful PCL decrease (≥20 point) versus those without (< 20 point). Patients had a depression diagnosis in the 12-months before the exposure year and received an ADM in the exposure year. Proportion of days covered ≥80% in exposure year defined adherence. Confounding was controlled using propensity scores and inverse probability of treatment weighting. RESULTS Patients were 42.2 ± 13.1 years of age, 63.9% white and 18.9% had a clinically meaningful PCL decrease. After controlling for confounding variables, patients with vs. without a clinically meaningful PCL decrease were significantly more likely to be adherent (OR = 1.78; 95% CI:1.16-2.73). However, adherence remained low in both patients with and without meaningful PCL decrease (53.5% vs. 39.3%). LIMITATIONS The sample was limited to VHA patients. Patients may not have taken medication as prescribed. CONCLUSIONS Large reductions in PTSD symptoms are associated with ADM adherence. Prior literature suggests ADM adherence improves depression symptoms. Thus, PTSD symptom reduction may lead to better depression outcomes.
Collapse
Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States.
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA, United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO 63104, United States
| | - Kathleen M Chard
- Trauma Recovery Center Cincinnati VAMC and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, United States
| | - F David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Paula P Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Matthew J Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Sonya B Norman
- National Center for PTSD, VA Center of Excellence for Stress and Mental Health and Department of Psychiatry, University of California San Diego, United States
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, San Francisco, CA, United States
| | - Patrick Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO, United States; The Bell Street Clinic Opioid Treatment Program, Mental Health Service, VA St. Louis Health Care System, St. Louis, MO, United States
| |
Collapse
|
36
|
Scherrer JF, Salas J, Chard KM, Tuerk P, van den Berk-Clark C, Schneider FD, Cohen BE, Lustman PJ, Schnurr PP, Friedman MJ, Norman SB. PTSD symptom decrease and use of weight loss programs. J Psychosom Res 2019; 127:109849. [PMID: 31654900 PMCID: PMC7029788 DOI: 10.1016/j.jpsychores.2019.109849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is associated with poor health behaviors, including low utilization of Veteran Health Affairs (VHA) weight loss programs. It is not known if clinically meaningful PTSD improvement is associated with increased use of weight loss programs. METHODS Medical record data was obtained from VHA patients who received PTSD specialty care between Fiscal Year (FY) 2008 to FY2012. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease between the first PCL ≥ 50 and a second PCL at least 8 weeks later and within 12 months of the first PCL. Eligible patients, n = 993, were followed through FY2015. Propensity scores and inverse probability of exposure weighting controlled confounding. Cox proportional hazard models estimated the association between clinically meaningful PCL decrease and weight loss clinic utilization. Supplemental analysis compared both PTSD groups vs. no PTSD. RESULTS Patients were 44.8 (SD ±14) years of age, 88.9% male and 66.8% white. Patients with vs. without a clinically meaningful PCL decrease were more likely to use a weight loss clinic (HR = 1.37; 95%CI:1.02-1.85). Among those with a weight loss encounter, PCL decrease was not associated with the number of encounters (RR = 1.13; 95%CI:0.70-1.81). Compared to no PTSD, patients with PTSD improvement had more weight loss encounters. CONCLUSIONS Large improvements in PTSD are associated with increased utilization of weight loss programs, and PTSD is not a barrier to seeking weight loss counseling. Research to understand why improvement in PTSD is not related to better weight loss outcomes is needed.
Collapse
Affiliation(s)
- Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States.
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, United States; Harry S. Truman Veterans Administration Medical Center, Columbia, MO, United States
| | - Kathleen M Chard
- Trauma Recovery Center Cincinnati VAMC, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, United States
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA, United States
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, United States
| | - F David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, United States
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO. and The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, St. Louis, MO, United States
| | - Paula P Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Matthew J Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, United States
| | - Sonya B Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego, United States
| |
Collapse
|
37
|
Zahner GJ, Cortez A, Duralde E, Ramirez JL, Wang S, Hiramoto J, Cohen BE, Wolkowitz OM, Arya S, Hills NK, Grenon SM. Association of comorbid depression with inpatient outcomes in critical limb ischemia. Vasc Med 2019; 25:25-32. [DOI: 10.1177/1358863x19880277] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation ( n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (β = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.
Collapse
Affiliation(s)
- Greg J Zahner
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Abigail Cortez
- Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Erin Duralde
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sue Wang
- Department of Surgery, Brigham and Women’s Hospitals, Boston, MA, USA
| | - Jade Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Owen M Wolkowitz
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Shipra Arya
- Department of Surgery, Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Surgical Services, VA Palo Alto Medical Center, Palo Alto, CA, USA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
38
|
Vella M, Meyer CS, Zhang N, Cohen BE, Whooley MA, Wang S, Hope MD. Association of Receipt of Positron Emission Tomography-Computed Tomography With Non-Small Cell Lung Cancer Mortality in the Veterans Affairs Health Care System. JAMA Netw Open 2019; 2:e1915828. [PMID: 31747036 PMCID: PMC6902817 DOI: 10.1001/jamanetworkopen.2019.15828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Positron emission tomography-computed tomography (PET-CT) has been increasingly used in the management of lung cancer, but its association with survival has not been convincingly documented. OBJECTIVE To examine the association of the use of PET-CT with non-small cell lung cancer (NSCLC) mortality in the US Department of Veterans Affairs (VA) health care system from 2000 to 2013. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 64 103 veterans receiving care in the VA health care system who were diagnosed with incident NSCLC between September 2000 and December 2013. Data analysis took place in October 2018. EXPOSURE Use of PET-CT before and/or after diagnosis. MAIN OUTCOMES AND MEASURES All-cause and NSCLC-specific 5-year mortality; secondary outcome was receipt of stage-appropriate treatment. RESULTS A total of 64 103 veterans with the diagnosis of NSCLC were evaluated; 62 838 (98.0%) were men, and 50 584 (78.9%) were white individuals. Among these, 51 844 (80.9%) had a PET-CT performed: 25 735 (40.1%) in the 12 months before diagnosis and 41 242 (64.3%) in the 5 years after diagnosis. Increased PET-CT use (597 of 978 veterans [59.2%] in 2000 vs 3649 of 3915 [93.2%] in 2013) and decreased NSCLC-specific 5-year mortality (879 of 978 veterans [89.9%] in 2000 vs 3226 of 3915 veterans [82.4%] in 2013) were found over time. Increased use of stage-appropriate therapy was also seen over time, from 346 of 978 veterans (35.4%) in 2000 to 2062 of 3915 (52.7%) in 2013 (P < .001). Increased PET-CT use was associated with higher-complexity level VA facilities (26 127 veterans [82.3%] at level 1a vs 1289 [75.2%] at level 3 facilities; P < .001) and facilities with on-site PET-CT compared with facilities without on-site PET-CT (33 081 [82.2%] vs 17 443 [80.3%]; P < .001). Use of PET-CT before diagnosis was associated with increased likelihood of stage-appropriate treatment for all stages of NSCLC (eg, veterans with stage 1 disease: 4837 of 7870 veterans [61.5%] who received PET-CT underwent surgical resection vs 4042 of 7938 veterans [50.9%] who did not receive PET-CT; P < .001) and decreased mortality in a risk-adjusted model among all participants and among veterans undergoing stage-appropriate treatment (all-cause mortality: hazard ratio [HR], 0.78; 95% CI, 0.77-0.79; NSCLC-specific mortality: HR, 0.78; 95% CI, 0.76-0.80). Facilities with on-site PET-CT and higher-complexity level facilities were associated with a mortality benefit, with 16% decreased mortality at level 1a vs level 3 facilities (HR, 0.84; 95% CI, 0.80-0.89) and a 3% decrease in all-cause mortality in facilities with on-site PET-CT (HR, 0.97; 95% CI, 0.96-0.99). CONCLUSIONS In this study, the use of PET-CT among veterans with NSCLC significantly increased from 2000 to 2013, coinciding with decreased 5-year mortality and an increase in stage-appropriate treatment. Variation in use of PET-CT was found, with the highest use at higher-complexity level facilities and those with PET-CT on-site. These facilities were associated with reduced all-cause and NSCLC-specific mortality.
Collapse
Affiliation(s)
- Maya Vella
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Craig S. Meyer
- Department of Medicine, University of California, San Francisco
| | - Ning Zhang
- Department of Medicine, University of California, San Francisco
| | - Beth E. Cohen
- Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Mary A. Whooley
- Department of Medicine, University of California, San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sunny Wang
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Division of Hematology and Oncology, University of California, San Francisco
| | - Michael D. Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| |
Collapse
|
39
|
Arenson MB, McCaslin SE, Cohen BE. Predictors of multiple domains of functioning in Veterans with posttraumatic stress disorder: Results from the Mind Your Heart Study. Depress Anxiety 2019; 36:1026-1035. [PMID: 31356711 DOI: 10.1002/da.22945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/11/2019] [Accepted: 06/26/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Those with posttraumatic stress disorder (PTSD) have lower overall functioning than healthy controls. However, this population is not homogenous, and those with PTSD have a wide range of functional outcomes. To our knowledge, only one other study has evaluated the predictors of better functioning within patients with PTSD. METHODS We examined 254 veterans with likely PTSD, using the Clinician-Administered PTSD Scale to assess PTSD symptom severity, and the SF-36 and single-item question to assess aspects of current functioning and quality of life. RESULTS In fully adjusted models (controlling for age, gender, and PTSD score, and including all significant psychosocial predictors of the outcome of interest), greater sleep quality (p = .03), lower C-reactive protein (p < .01), and lower erythrocyte sedimentation rate (p = 0.04) were associated with greater physical functioning; lower depression (p < .01) and greater perceived social support (p = .05) were associated with greater social functioning; lower depression (p = .02) was associated with greater occupational functioning; and greater combat exposure (p = .04), greater optimism (p < .01) and greater perceived social support (p = .05) were associated with greater quality of life. CONCLUSIONS These findings highlight the differential impact of psychosocial predictors on multiple functional outcomes. As such, they provide important information for clinicians about aspects of veterans' lives that can be targeted during the treatment to improve specific types of functioning.
Collapse
Affiliation(s)
- Melanie B Arenson
- Department of Psychology, University of Maryland, College Park, Maryland.,San Francisco VA Medical Center, San Francisco, California
| | - Shannon E McCaslin
- Dissemination and Training Division, National Center for PTSD, Menlo Park, California.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Beth E Cohen
- San Francisco VA Medical Center, San Francisco, California.,Department of Medicine, University of California, San Francisco, California
| |
Collapse
|
40
|
Scherrer JF, Salas J, Norman SB, Schnurr PP, Chard KM, Tuerk P, Schneider FD, van den Berk-Clark C, Cohen BE, Friedman MJ, Lustman PJ. Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes. JAMA Psychiatry 2019; 76:1159-1166. [PMID: 31433443 PMCID: PMC6704751 DOI: 10.1001/jamapsychiatry.2019.2096] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Posttraumatic stress disorder (PTSD) is associated with increased risk of type 2 diabetes (T2D). Improvement in PTSD has been associated with improved self-reported physical health and hypertension; however, there is no literature, to our knowledge, on whether PTSD improvement is associated with T2D risk. OBJECTIVE To examine whether clinically meaningful PTSD symptom reduction is associated with lower risk of T2D. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined Veterans Health Affairs medical record data from 5916 patients who received PTSD specialty care between fiscal years 2008 and 2012 and were followed up through fiscal year 2015. Eligible patients had 1 or more PTSD Checklist (PCL) scores of 50 or higher between fiscal years 2008 and 2012 and a second PCL score within the following 12 months and at least 8 weeks after the first PCL score of 50 or higher. The index date was 12 months after the first PCL score. Patients were free of T2D diagnosis or an antidiabetic medication use for 12 months before the index date and had at least 1 visit after the index date. Data analyses were completed during January 2019. EXPOSURES Reduction in PCL scores during a 12-month period was used to define patients as those with a clinically meaningful improvement (≥20-point PCL score decrease) and patients with less or no improvement (<20-point PCL score decrease). MAIN OUTCOMES AND MEASURES Incident T2D diagnosed during a 2- to 6-year follow-up. RESULTS Medical records from a total of 1598 patients (mean [SD] age, 42.1 [13.4] years; 1347 [84.3%] male; 1060 [66.3%] white) were studied. The age-adjusted cumulative incidence of T2D was 2.6% among patients with a clinically meaningful PCL score decrease and 5.9% among patients without a clinically meaningful PCL score decrease (P = .003). After control for confounding, patients with a clinically meaningful PCL score decrease were significantly less likely to develop T2DM compared with those without a clinically meaningful decrease (hazard ratio, 0.51; 95% CI, 0.26-0.98). CONCLUSIONS AND RELEVANCE The findings suggest that clinically meaningful reductions in PTSD symptoms are associated with a lower risk of T2D. A decrease in PCL score, whether through treatment or spontaneous improvement, may help mitigate the greater risk of T2D in patients with PTSD.
Collapse
Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, Missouri,Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, Missouri,Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
| | - Sonya B. Norman
- National Center for PTSD, Veterans Affairs (VA) Center of Excellence for Stress and Mental Health, Department of Psychiatry, University of California, San Diego
| | - Paula P. Schnurr
- National Center for PTSD, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kathleen M. Chard
- Trauma Recovery Center, Cincinnati Veterans Affairs Medical Center (VAMC), Cincinnati, Ohio,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville
| | - F. David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, Missouri
| | - Beth E. Cohen
- School of Medicine, Department of Medicine, University of California, San Francisco,San Francisco VAMC, San Francisco, California
| | - Matthew J. Friedman
- National Center for PTSD, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri,The Bell Street Clinic Opioid Treatment Program, Mental Health Service, VA St Louis Health Care System, St Louis, Missouri
| |
Collapse
|
41
|
Ishida JH, Wong PO, Cohen BE, Vali M, Steigerwald S, Keyhani S. Substitution of marijuana for opioids in a national survey of US adults. PLoS One 2019; 14:e0222577. [PMID: 31584957 PMCID: PMC6777788 DOI: 10.1371/journal.pone.0222577] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/02/2019] [Indexed: 01/04/2023] Open
Abstract
Opioid prescriptions for chronic pain and subsequent opioid-related complications have risen dramatically in the US. Recent data suggest that medical marijuana laws have been associated with lower state-level opioid overdose mortality. In a national survey, we examined the prevalence of substitution of marijuana for opioids among US adults taking opioids for pain.Using GfK’s KnowledgePanel, we conducted an Internet-based survey of a nationally representative sample of 16,280 adults in 2017 about individual perceptions and use of marijuana. We developed questions designed to assess the extent and reasons for substitution of marijuana for opioids. We examined opioid substitution among respondents with a history of ever using marijuana who used opioids in the past 12 months. There were 9,003 respondents, corresponding to a 55.3% response rate. The mean age was 48 years. Among the 5% (n = 486) who reported ever using marijuana and using opioids in the past year, 43% used opioids daily, and 23% reported current (past 30 day) marijuana use. Forty-one percent reported a decrease or cessation of opioid use due to marijuana use; 46% reported no change in opioid use; and 8% reported an increase in opioid use. We found that a substantial number of US adults reported that they substituted marijuana for opioids.
Collapse
Affiliation(s)
- Julie H. Ishida
- Department of Medicine, Division of Nephrology, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Peggy O. Wong
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Beth E. Cohen
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Marzieh Vali
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Stacey Steigerwald
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, United States of America
| | - Salomeh Keyhani
- Department of General Internal Medicine, San Francisco VA Medical Center, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
42
|
Abuzaid A, Cohen BE, Pursnani S, Lahsaeizadeh S, Ristow B, Shaw RE, Rosenblatt A, Fang Q, Schiller NB. Who is young at heart and when? Diastolic Doppler data from the mind your heart study. Echocardiography 2019; 36:1744-1746. [PMID: 31573700 DOI: 10.1111/echo.14468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/26/2019] [Accepted: 08/11/2019] [Indexed: 11/27/2022] Open
Abstract
To further define the age-related distribution of diastolic function as defined by E/A ratio, in healthy male adults. The age-sensitive ratio of mitral inflow E-wave to A-wave (E/A) velocity is often considered in the evaluation of diastolic function. To appropriately direct a comprehensive evaluation of diastolic function, we sought to improve the characterization of the influence of age on E/A ratio. We analyzed echocardiographic data from the Mind Your heart Study, a cohort of outpatients recruited from two San Francisco Veterans centers to examine the effect of mental health on cardiovascular outcomes. Individuals with a history of heart disease or hypertension were excluded, leaving 313 veterans for analysis. We examined E/A by 5-year increments and performed linear and logistic regression analysis to predict trends in E/A and E dominance. Within the age ranges of population (54.9 ± 11.5), there is a steady gradual decline in absolute E/A ratio (beta coefficient/year- 0.018, P < .001) and the odds of E dominance similarly declines with age (odds ratio/year = 0.89, P < .001). Despite this decline, 90% of individuals below the age of 50 years maintain E dominance. Beyond age 50, 55% maintain E dominance, and beyond age 70, only 28% have E dominance. In this adequately healthy population, age-related progression of delayed relaxation appears to be a state of normality rather than diastolic dysfunction. Careful attention to specific cutoff points in age and E/A ratio could avoid misinterpretation or inappropriate management.
Collapse
Affiliation(s)
- Ahmed Abuzaid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Seema Pursnani
- Division of Cardiology, Kaiser Permanente, Santa Clara, CA, USA
| | - Seba Lahsaeizadeh
- Division of Cardiology, Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Bryan Ristow
- Division of Cardiology, Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Richard E Shaw
- Division of Cardiology, Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA.,Division of Cardiology, Contra Costa Regional Medical Center, Contra Costa County, CA, USA
| | - Andrew Rosenblatt
- Division of Cardiology, Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Qizhi Fang
- Department of Medicine and Cardiovascular Research Center, University of California, San Francisco, CA, USA
| | - Nelson B Schiller
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Department of Cardiology, University of California San Francisco, San Francisco, CA, USA.,Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,Department of Medicine and Cardiovascular Research Center, University of California, San Francisco, CA, USA
| |
Collapse
|
43
|
Ramirez JL, Ramirez FD, Zarkowsky DS, Gasper WJ, Cohen BE, Conte MS, Grenon SM, Iannuzzi JC. IP039. Depression Predicts Nonhome Discharge After Abdominal Aortic Aneurysm Repair. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
44
|
Scherrer JF, Salas J, Lustman P, Tuerk P, Gebauer S, Norman SB, Schneider FD, Chard KM, van den Berk-Clark C, Cohen BE, Schnurr PP. Combined effect of posttraumatic stress disorder and prescription opioid use on risk of cardiovascular disease. Eur J Prev Cardiol 2019; 27:1412-1422. [PMID: 31084262 DOI: 10.1177/2047487319850717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM Prescription opioid analgesic use (OAU) is associated with increased risk of cardiovascular disease (CVD). OAU is more common in patients with than without posttraumatic stress disorder (PTSD), and PTSD is associated with higher CVD risk. We determined whether PTSD and OAU have an additive or multiplicative association with incident CVD. METHODS AND RESULTS Veterans Health Affairs patient medical record data from 2008 to 2015 was used to identify 2861 patients 30-70 years of age, free of cancer, CVD and OAU for 12 months before index date. We defined a four-level exposure variable: 1) no PTSD/no OAU, 2) OAU alone, 3) PTSD alone and 4) PTSD+OAU. Cox proportional hazard models estimated the association between the exposure variable and incident CVD. The mean age was 49.0 (±11.0), 85.7% were male and 58.3% were White, 34.4% had no PTSD/no OAU, 32.9% had PTSD alone, 10.6% had OAU alone, and 22.1% had PTSD+OAU. Compared with patients with no PTSD/no OAU, those with PTSD alone were not at increased risk of incident CVD (hazard ratio = 0.82; 95% confidence interval (CI): 0.63-1.17); however, OAU alone and PTSD+OAU were both significantly associated with incident CVD (hazard ratio = 1.99; 95% CI:1.36-2.92 and hazard ratio = 2.20; 95% CI: 1.61-3.02). There was no significant additive or multiplicative PTSD and OAU association with incident CVD. CONCLUSION OAU is associated with nearly a two-fold increased risk of CVD in patients with and without PTSD. Despite no additive or multiplicative interaction effects, the high prevalence of OAU in PTSD may represent a novel contributor to the elevated CVD burden among patients with PTSD.
Collapse
Affiliation(s)
- Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, USA.,Harry S. Truman Veterans Administration Medical Center, Columbia, USA
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, USA.,Harry S. Truman Veterans Administration Medical Center, Columbia, USA
| | - Patrick Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis, USA.,The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, USA
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, USA
| | - Sarah Gebauer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, USA.,Harry S. Truman Veterans Administration Medical Center, Columbia, USA
| | - Sonya B Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego, USA
| | - F David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Kathleen M Chard
- Trauma Recovery Center Cincinnati VAMC, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, USA
| | | | - Beth E Cohen
- Department of Medicine, University of California San Francisco School of Medicine, USA.,San Francisco VAMC, USA
| | - Paula P Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, USA
| |
Collapse
|
45
|
Ahmadian AJ, Neylan TC, Metzler T, Cohen BE. Longitudinal association of PTSD symptoms and self-reported physical functioning among Veterans. J Affect Disord 2019; 250:1-8. [PMID: 30818050 DOI: 10.1016/j.jad.2019.02.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Few longitudinal studies have investigated the potentially dynamic relationship between Posttraumatic Stress Disorder (PTSD) and physical functioning, and the number of follow-up timepoints have been limited. We evaluated whether PTSD symptoms predicted future physical functioning and vice versa using five assessments over four years. METHODS Data was used from a longitudinal cohort of 695 participants recruited from Veteran Affairs medical outpatient clinics who experienced a traumatic event. PTSD symptom severity was assessed annually with the PTSD Checklist (PCL). Physical functioning was measured with the 10-item subscale of the SF-36. An autoregressive cross-lagged panel model was used to determine the temporal associations between PTSD and physical functioning, adjusting for age, sex, ethnicity, education and employment. Comorbidities and health behaviors were added to assess their roles in the relationship. RESULTS Greater PTSD symptom severity predicted worse physical functioning the following year (average β = -0.10, P <0.001), where a 10-point increase in PCL score predicted a 0.3-point decline in physical function score over one year. Similarly, better physical functioning also predicted reduced PTSD severity the following year, but to a smaller magnitude (average β = -0.04, P = .003). The pattern of effects was similar after controlling for comorbidities and health behaviors. LIMITATIONS Both primary variables relied on self-report, and generalizability may be limited by the mostly male Veteran sample. CONCLUSIONS Our results support a bidirectional, but unequal, relationship between PTSD and physical functioning over time. They also highlight the importance of long-term control of PTSD symptoms in preventing functional decline.
Collapse
Affiliation(s)
- Ashkan J Ahmadian
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA.
| | - Thomas C Neylan
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Thomas Metzler
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA
| | - Beth E Cohen
- San Francisco Veteran Affairs Medical Center and Mental Illness Research, Education and Clinical Center, San Francisco, CA, USA; Department of Internal Medicine, University of California, San Francisco, CA, USA
| |
Collapse
|
46
|
Ramirez JL, Zahner GJ, Spaulding KA, Khetani SA, Hills NK, Gasper WJ, Harris WS, Cohen BE, Grenon SM. Peripheral Artery Disease Is Associated with a Deficiency of Erythrocyte Membrane n-3 Polyunsaturated Fatty Acids. Lipids 2019; 54:211-219. [PMID: 30883776 DOI: 10.1002/lipd.12140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/31/2022]
Abstract
Population-based data suggest that individuals who consume large dietary amounts of n-3 polyunsaturated fatty acids (PUFA) have lower odds of peripheral artery disease (PAD); however, clinical studies examining n-3 PUFA levels in patients with PAD are sparse. The objective of this study is to compare erythrocyte membrane fatty acid (FA) content between patients with PAD and controls. We conducted a cross-sectional study of 179 vascular surgery outpatients (controls, 34; PAD, 145). A blood sample was drawn and the erythrocyte FA content was assayed using capillary gas chromatography. We calculated the ratio of the n-3 PUFA eicosapentaenoic acid (EPA) to the n-6 PUFA arachidonic acid (ARA) as well as the omega-3 index (O3I), a measure of erythrocyte content of the n-3 PUFA, EPA, and docosahexaenoic acid (DHA), expressed as a percentage of total erythrocyte FA. Compared with controls, patients with PAD smoked more and were more likely to have hypertension and hyperlipidemia (p < 0.05). Patients with PAD had a lower mean O3I (5.0 ± 1.7% vs 6.0 ± 1.6%, p < 0.001) and EPA:ARA ratio (0.04 ± 0.02 vs 0.05 ± 0.05, p < 0.001), but greater mean total saturated fats (39.5 ± 2.5% vs 38.5 ± 2.6%, p = 0.01). After adjusting for several patient characteristics, comorbidities, and medications, an absolute decrease of 1% in the O3I was associated with 39% greater odds of PAD (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.03-1.86, and p = 0.03). PAD was associated with a deficiency of erythrocyte n-3 PUFA, a lower EPA:ARA ratio, and greater mean total saturated fats. These alterations in FA content may be involved in the pathogenesis or development of poor outcomes in PAD.
Collapse
Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Greg J Zahner
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Kimberly A Spaulding
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.,Vascular Surgery Section, Veterans Affairs Medical Center, Mail Code 112G, 4150 Clement St, San Francisco, CA 94121, USA
| | - Sukaynah A Khetani
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.,Vascular Surgery Section, Veterans Affairs Medical Center, Mail Code 112G, 4150 Clement St, San Francisco, CA 94121, USA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA 94158-2549, USA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.,Vascular Surgery Section, Veterans Affairs Medical Center, Mail Code 112G, 4150 Clement St, San Francisco, CA 94121, USA
| | - William S Harris
- OmegaQuant Analytics, LLC, 5009 W. 12th Street, Suite 8, Sioux Falls, SD 57106, USA.,Department of Medicine, Sanford School of Medicine, University of South Dakota, 1400 W. 22nd St, Sioux Falls, SD 57105, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, Box 1211, San Francisco, CA 94143-1211, USA.,Department of Medicine, Veterans Affairs Medical Center, 4150 Clement St, San Francisco, CA 94121, USA
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| |
Collapse
|
47
|
Seal KH, Borsari B, Tighe J, Cohen BE, Delucchi K, Morasco BJ, Li Y, Sachs E, Abadjian L, Watson EC, Manuel JK, Vella L, Trafton J, Midboe A. Optimizing pain treatment interventions (OPTI): A pilot randomized controlled trial of collaborative care to improve chronic pain management and opioid safety-Rationale, methods, and lessons learned. Contemp Clin Trials 2019; 77:76-85. [PMID: 30572163 PMCID: PMC6392081 DOI: 10.1016/j.cct.2018.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 12/17/2022]
Abstract
Veterans seeking care in VA medical facilities have high rates of chronic pain, which often co-occur with mental health and substance use disorders, including prescription opioid misuse. The overall goal of the Optimizing Pain Treatment Interventions (OPTI) study was to pilot a 12-week Collaborative Care intervention to improve opioid safety, chronic pain disability, and use of non-pharmacological pain management strategies in veterans in VA primary care. Between November 2014 and January 2017, 100 veteran patients with chronic pain and high-risk prescription opioid use (e.g., high-dose therapy, early refills, etc.) were enrolled and completed an initial one-hour study visit with a primary care provider (PCP) within 4 weeks of enrollment. Study PCPs were guided by a web-based opioid management decision support program and templated notes in the VA electronic medical record. After assessment and education, study PCPs used Shared Decision-Making to formulate a Pain Care Plan aligned with a participant's personal values and goals. After the initial visit, patients randomized to Collaborative Care received one Motivational Interviewing (MI) session with a Care Manager followed by 3 Care Manager-delivered brief telephone MI sessions at 6, 8, and 12 weeks to reinforce Pain Care Plans; patients randomized to an Attention Control condition met with a Care Manager briefly, followed by 3 brief scripted telephone psychoeducation sessions at 6, 8, and 12 weeks. Masked evaluators assessed outcomes at baseline, end of intervention (12 weeks), and after eight weeks of no contact (20 weeks). We present study rationale, detailed methods, preliminary results and lessons learned.
Collapse
Affiliation(s)
- Karen H Seal
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States.
| | - Brian Borsari
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer Tighe
- San Francisco Veterans Affairs Health Care System, United States
| | - Beth E Cohen
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Kevin Delucchi
- University of California, San Francisco, San Francisco, CA, United States
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, United States; Department of Psychiatry, Oregon Health and Science University, United States
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, United States
| | - Emily Sachs
- San Francisco Veterans Affairs Health Care System, United States
| | - Linda Abadjian
- San Francisco Veterans Affairs Health Care System, United States
| | - Erin C Watson
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer K Manuel
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Lea Vella
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jodie Trafton
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), United States; Program Evaluation and Resource Center (PERC), VA Office of Mental Health Operations, United States
| | - Amanda Midboe
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), United States
| |
Collapse
|
48
|
Koraishy FM, Salas J, Neylan TC, Cohen BE, Schnurr PP, Clouston S, Scherrer JF. "Association of Severity of Posttraumatic Stress Disorder With Inflammation: Using Total White Blood Cell Count as a Marker". Chronic Stress (Thousand Oaks) 2019; 3. [PMID: 32154489 PMCID: PMC7061332 DOI: 10.1177/2470547019877651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Inflammation is known to be associated with posttraumatic stress disorder. It
is not known if total white blood cell count, a routinely checked
inflammatory marker, is associated with posttraumatic stress disorder
symptom trajectories using medical record data. Methods We used latent class growth analysis to identify three-year posttraumatic
stress disorder symptom trajectories using posttraumatic stress disorder
(PTSD) Checklist (PCL) scores. The outcome for each patient was maximum
white blood cell count from index posttraumatic stress disorder diagnosis to
last PCL. Using linear regression analysis, we then
calculated and compared the average white blood cell count for each
trajectory before and after controlling for age, gender, race, obesity,
smoking, diabetes, hypertension, cardiovascular disease, depression, and
other comorbid inflammatory conditions. Results Patients were 40.2 (SD ± 13.5) years of age, 83.7% males and 67.9% white. We
identified three PCL trajectory groups based on symptom severity over time:
“moderate-large decrease,” “moderate-severe-slight decrease,” and
“severe-persistent.” In adjusted analyses, “severe-persistent” versus
“moderate-large decrease” had significantly higher white blood cell count
(B = 0.64; 95%CI = 0.18, 1.09; p = .006). Although non-significant,
“moderate-severe-slight decrease” versus “moderate-large decrease” also had
a higher white blood cell count (B = 0.42; 95% CI: −0.02, 0.86;
p = .061). Conclusion Persistently severe posttraumatic stress disorder is associated with a higher
white blood cell count than improving posttraumatic stress disorder. White
blood cell appears to have utility for measuring the association between
psychiatric disorders and inflammation in retrospective cohort studies
involving large administrative medical record data bases.
Collapse
Affiliation(s)
- Farrukh M Koraishy
- Nephrology Section, VA St. Louis Health Care System, John Cochran Division and Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Thomas C Neylan
- Psychiatry Service, San Francisco VA Health Care System and Department of Psychiatry, University of San Francisco School of Medicine, San Francisco, CA, USA
| | - Beth E Cohen
- General Internal Medicine, San Francisco VA Health Care System and Department of Medicine, University of San Francisco School of Medicine, San Francisco, CA, USA
| | - Paula P Schnurr
- National Center for PTSD, White River Junction, VT, and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sean Clouston
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
49
|
Eswarappa M, Neylan TC, Whooley MA, Metzler TJ, Cohen BE. Inflammation as a predictor of disease course in posttraumatic stress disorder and depression: A prospective analysis from the Mind Your Heart Study. Brain Behav Immun 2019; 75:220-227. [PMID: 30389462 DOI: 10.1016/j.bbi.2018.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/01/2018] [Accepted: 10/29/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Prior research has focused largely on the pro-inflammatory states of PTSD and depression, with few studies evaluating the direction of inflammation's association with these disorders. To clarify whether inflammation plays a role in the development of PTSD or depression, we assessed the predictive value of inflammatory biomarkers on the courses of these conditions in a cohort of Veterans. METHODS This research was part of the Mind Your Heart Study, a prospective cohort study designed to examine PTSD-related health outcomes. Between 2008 and 2010, 746 San Francisco area Veterans Administration patients were enrolled. At baseline, inflammatory biomarkers were measured from fasting morning venous blood draws, and cortisol and catecholamine levels were measured from 24-hour urine samples. PTSD was diagnosed using the PTSD Checklist at baseline and annual follow-up. Depression was evaluated using the 9-item Patient Health Questionnaire at baseline and follow-up. Ordinal logistic regression models were used to assess the predictive value of baseline biomarker levels on clinically relevant courses of PTSD and depression categorized and ordered as none, resolved, developed, and chronic. RESULTS After adjustment for age and sex, elevated levels of white blood cell count (OR = 1.27(1.10-1.47), p = 0.001), C-reactive protein (OR = 1.20(1.04-1.39), p = 0.02), fibrinogen (OR = 1.19(1.03-1.38), p = 0.02), and ESR (OR = 1.17(1.00-1.36, p = 0.05), and decreased levels of urine cortisol (OR = 0.84(0.71-0.99), p = 0.04) were significant predictors of poorer courses of PTSD. Elevated levels of WBC count (OR = 1.31(1.14-1.50), p < 0.001), CRP (OR = 1.24(1.07-1.43), p = 0.003), fibrinogen (OR = 1.26(1.09-1.46), p = 0.002), and catecholamines (OR = 1.17(1.01-1.36), p = 0.04) were significant predictors of poorer courses of depression. After additionally controlling for physical activity, elevated WBC count (p = 0.002) and decreased levels of urine cortisol (p = 0.05) remained significant predictors of PTSD course, and elevated WBC count (p = 0.001), CRP (p = 0.03), and fibrinogen (p = 0.02) remained significant predictors of depression course. After adjusting for all significant variables, elevated WBC count (p = 0.02) was a significant predictor of a poorer course of PTSD, and elevated WBC count (p = 0.04) and platelet count (p = 0.03) were significant predictors of a poorer course of depression. CONCLUSIONS Increased levels of several inflammatory biomarkers were associated with significantly increased odds of clinically worse courses of PTSD and depression. Inflammation may be a target for prevention and treatment of these mental health disorders.
Collapse
Affiliation(s)
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, CA, USA; Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mary A Whooley
- Department of Medicine, University of California, San Francisco, CA, USA; Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, CA, USA; Veterans Affairs Medical Center, San Francisco, CA, USA.
| |
Collapse
|
50
|
Steigerwald S, Wong PO, Cohen BE, Ishida JH, Vali M, Madden E, Keyhani S. Smoking, Vaping, and Use of Edibles and Other Forms of Marijuana Among U.S. Adults. Ann Intern Med 2018; 169:890-892. [PMID: 30167665 PMCID: PMC6296858 DOI: 10.7326/m18-1681] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Stacey Steigerwald
- Northern California Institute for Research and Education and San Francisco VA Medical Center, San Francisco, California (S.S., P.O.W., M.V., E.M.)
| | - Peggy O Wong
- Northern California Institute for Research and Education and San Francisco VA Medical Center, San Francisco, California (S.S., P.O.W., M.V., E.M.)
| | - Beth E Cohen
- University of California, San Francisco, and San Francisco VA Hospital, San Francisco, California (B.E.C., J.H.I., S.K.)
| | - Julie H Ishida
- University of California, San Francisco, and San Francisco VA Hospital, San Francisco, California (B.E.C., J.H.I., S.K.)
| | - Marzieh Vali
- Northern California Institute for Research and Education and San Francisco VA Medical Center, San Francisco, California (S.S., P.O.W., M.V., E.M.)
| | - Erin Madden
- Northern California Institute for Research and Education and San Francisco VA Medical Center, San Francisco, California (S.S., P.O.W., M.V., E.M.)
| | - Salomeh Keyhani
- University of California, San Francisco, and San Francisco VA Hospital, San Francisco, California (B.E.C., J.H.I., S.K.)
| |
Collapse
|