Reduced effectiveness of repeat influenza vaccination: distinguishing among within-season waning, recent clinical infection, and subclinical infection

Studies have reported that prior-season influenza vaccination is associated with higher risk of clinical influenza infection among vaccinees. This effect might arise from incomplete consideration of within-season waning and recent infection. Using data from the US Flu Vaccine Effectiveness (VE) Network (2011-2012 to 2018-2019 seasons), we found that repeat vaccinees were vaccinated earlier in a season by one week. After accounting for waning VE, repeat vaccinees were still more likely to test positive for A(H3N2) (OR=1.11, 95%CI:1.02-1.21) but not for influenza B or A(H1N1). We found that clinical infection influenced individuals' decision to vaccinate in the following season while protecting against clinical infection of the same (sub)type. However, adjusting for recent clinical infections did not strongly influence the estimated effect of prior-season vaccination. In contrast, we found that adjusting for subclinical infection could theoretically attenuate this effect. Additional investigation is needed to determine the impact of subclinical infections on VE.

Vaccine effectiveness of recombinant and standard dose influenza vaccines against outpatient illness during 2018-2019 and 2019-2020 calculated using a retrospective test-negative design

Newer influenza vaccine formulations have entered the market, but real-world effectiveness studies are not widely conducted until there is sufficient uptake. We conducted a retrospective test-negative case-control study to determine relative vaccine effectiveness (rVE) of recombinant influenza vaccine or RIV4, compared with standard dose vaccines (SD) in a health system with significant RIV4 uptake. Using the electronic medical record (EMR) and the Pennsylvania state immunization registry to confirm influenza vaccination, VE against outpatient medically attended visits was calculated. Immunocompetent outpatients ages 18-64 years seen in hospital-based clinics or emergency departments who were tested for influenza using reverse transcription polymerase chain reaction (RT-PCR) assays during the 2018-2019 and 2019-2020 influenza seasons were included. Propensity scores with inverse probability weighting were used to adjust for potential confounders and determine rVE. Among this mostly white and female cohort of 5,515 individuals, 510 were vaccinated with RIV4 and 557 were vaccinated with SD, with the balance of 4,448 (81%) being unvaccinated. Adjusted influenza VE estimates were 37% overall (95% CI = 27, 46), 40% (95% CI = 25, 51) for RIV4 and 35% (95% CI = 20, 47) for standard dose vaccines. Overall, rVE of RIV4 compared to SD was not significantly higher (11%; 95% CI = -20, 33). Influenza vaccines were moderately protective against medically attended outpatient influenza during the 2018-2019 and 2019-2020 seasons. Although the point estimates are higher for RIV4, the large confidence intervals around VE estimates suggest this study was underpowered to detect significant rVE of individual vaccine formulations.

Incidence and Transmission of SARS-CoV-2 in US Child Care Centers After COVID-19 Vaccines

Importance

SARS-CoV-2 surveillance studies in US child care centers (CCCs) in the post-COVID-19 vaccine era are needed to provide information on incidence and transmission in this setting.

Objective

To characterize SARS-CoV-2 incidence and transmission in children attending CCCs (students) and their child care providers (CCPs) and household contacts.

Design, Setting, and Participants

This prospective surveillance cohort study was conducted from April 22, 2021, through March 31, 2022, and included 11 CCCs in 2 cities. A subset (surveillance group) of CCPs and students participated in active surveillance (weekly reverse transcription-polymerase chain reaction [RT-PCR] swabs, symptom diaries, and optional baseline and end-of-study SARS-CoV-2 serologic testing), as well as all household contacts of surveillance students. Child care center directors reported weekly deidentified self-reported COVID-19 cases from all CCPs and students (self-report group).

Exposure

SARS-CoV-2 infection in CCC students.

Main Outcomes and Measures

SARS-CoV-2 incidence, secondary attack rates, and transmission patterns were determined from diary entries, self-reports to CCC directors, and case logs. Incidence rate ratios were measured using Poisson regression clustering on centers with a random intercept and unstructured matrix.

Results

From a total population of 1154 students and 402 CCPs who self-reported cases to center directors, 83 students (7.2%; mean [SD] age, 3.86 [1.64] years; 55 male [66%]), their 134 household contacts (118 adults [mean (SD) age, 38.39 (5.07) years; 62 female (53%)], 16 children [mean (SD) age, 4.73 (3.37) years; 8 female (50%)]), and 21 CCPs (5.2%; mean [SD] age, 38.5 [12.9] years; 18 female [86%]) participated in weekly active surveillance. There were 154 student cases (13%) and 87 CCP cases (22%), as defined by positive SARS-CoV-2 RT-PCR or home antigen results. Surveillance students had a higher incidence rate than self-report students (incidence rate ratio, 1.9; 95% CI, 1.1-3.3; P = .01). Students were more likely than CCPs to have asymptomatic infection (34% vs 8%, P < .001). The CCC secondary attack rate was 2.7% to 3.0%, with the upper range representing possible but not definite secondary cases. Whether the index case was a student or CCP, transmission within the CCC was not significantly different. Household cumulative incidence was 20.5%, with no significant difference in incidence rate ratio between adults and children. Household secondary attack rates were 50% for children and 67% for adults. Of 30 household cases, only 5 (17%) represented secondary infections caused by 3 students who acquired SARS-CoV-2 from their CCC. Pre- and poststudy seroprevalence rates were 3% and 22%, respectively, with 90% concordance with antigen or RT-PCR results.

Conclusions and Relevance

In this study of SARS-CoV-2 incidence and transmission in CCCs and students' households, transmission within CCCs and from children infected at CCCs into households was low. These findings suggest that current testing and exclusion recommendations for SARS-CoV-2 in CCCs should be aligned with those for other respiratory viruses with similar morbidity and greater transmission to households.

Fracture patterns, associated injuries, management, and treatment outcomes of 530 pediatric mandibular fractures

BACKGROUND

Mandibular fractures account for up to 48.8% of pediatric facial fractures; however, there are a wide range of available treatment modalities, and few studies describe trends in adverse outcomes of these injuries. This study describes fracture etiology, pattern, management, and treatment outcomes in pediatric mandibular fracture patients.

METHODS

A retrospective review was performed of patients under 18 years of age who were evaluated for mandibular fractures at a pediatric level I trauma center between 2006 and 2021. Variables studied included demographics, etiology, medical history, associated facial fractures, other associated injuries, treatments, and outcomes.

RESULTS

A total of 530 pediatric patients with 829 mandibular fractures were included in the analysis. Most isolated mandibular fractures were treated with physical therapy (PT) and rest (n=253, 47.7%). Patients with combination fractures, specifically those involving the parasymphysis and angle, were 2.63 times more likely to undergo surgical management compared to patients with a single facial fracture (p<0.0001). Older age (p<0.001), gender (p=0.042), mechanism (p=0.008) and cause of injury (p=0.002), as well as specific fractures (e.g., isolated angle (p=0.001)) were more associated with adverse outcomes. The odds of adverse outcomes were higher for patients treated with CREF or ORIF compared to conservative management (OR=1.8; 95% Cl 1.0-3.2 and OR=2.1; 95% Cl 1.2-3.5, respectively).

CONCLUSION

Fracture type, mechanism of injury, and treatment modality in pediatric mandibular fractures are associated with distinct rates and types of adverse outcomes. Large scale studies characterizing these injuries are critical for guiding physicians in the management of these patients.

Vaccine effectiveness of recombinant and standard dose influenza vaccines against influenza related hospitalization using a retrospective test-negative design

BACKGROUND

Relative effectiveness of various vaccine formulations provide important input for vaccine policy decisions and provider purchasing decisions. We used electronic databases to conduct a test-negative case control study to determine relative vaccine effectiveness (rVE) of recombinant influenza vaccine (RIV4) compared with standard dose vaccines (SD-IIV4) against influenza hospitalization.

METHODS

Adults 18-64 and ≥65 years of age hospitalized in a large U.S. health system (19 hospitals) in 2018-2019 and 2019-2020 who were clinically tested for influenza using reverse transcription polymerase chain reaction (RT-PCR) assays were included. The hospital system electronic medical record (EMR) and the state immunization registry were used to confirm influenza vaccination. Propensity scores with inverse probability weighting were used to adjust for potential confounders and determine rVE.

RESULTS

Of the 14,590 individuals included in the primary analysis, 3,338 were vaccinated with RIV4 and 976 were vaccinated with SD-IIV4, with the balance of 10,276 being unvaccinated. Most participants were white (80 %), most (70 %) had a high-risk condition, just over half were female (54 %) and age 65 years or older (53 %). Overall RIV4 rVE was significant when adjusted for propensity scores with inverse probability weights (rVE = 31; 95 % CI = 11 %, 46 %). Among younger adults (18-64 years-old), overall rVE of RIV4 was significant (rVE = 29; 95 % CI = 4 %, 47 %).

CONCLUSIONS

Over all adults, both RIV4 and SD-IIV4 were effective against influenza hospitalization, with RIV4 providing better protection compared with SD-IIV4 overall, for females, younger adults, and those with no high-risk conditions.

Blood Inflammatory Biomarkers Differentiate Inpatient and Outpatient Coronavirus Disease 2019 From Influenza

Background

The ongoing circulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) poses a diagnostic challenge because symptoms of coronavirus disease 2019 (COVID-19) are difficult to distinguish from other respiratory diseases. Our goal was to use statistical analyses and machine learning to identify biomarkers that distinguish patients with COVID-19 from patients with influenza.

Methods

Cytokine levels were analyzed in plasma and serum samples from patients with influenza and COVID-19, which were collected as part of the Centers for Disease Control and Prevention's Hospitalized Adult Influenza Vaccine Effectiveness Network (inpatient network) and the US Flu Vaccine Effectiveness (outpatient network).

Results

We determined that interleukin (IL)-10 family cytokines are significantly different between COVID-19 and influenza patients. The results suggest that the IL-10 family cytokines are a potential diagnostic biomarker to distinguish COVID-19 and influenza infection, especially for inpatients. We also demonstrate that cytokine combinations, consisting of up to 3 cytokines, can distinguish SARS-CoV-2 and influenza infection with high accuracy in both inpatient (area under the receiver operating characteristics curve [AUC] = 0.84) and outpatient (AUC = 0.81) groups, revealing another potential screening tool for SARS-CoV-2 infection.

Conclusions

This study not only reveals prospective screening tools for COVID-19 infections that are independent of polymerase chain reaction testing or clinical condition, but it also emphasizes potential pathways involved in disease pathogenesis that act as potential targets for future mechanistic studies.

Estimating the burden of adult hospitalized RSV infection using local and state data - methodology

Respiratory syncytial virus (RSV) is becoming increasingly recognized as a serious threat to vulnerable population subgroups. This study describes the statistical analysis plan for a retrospective cohort study of adults hospitalized for acute respiratory infection (ARI) to estimate the population burden of RSV especially for groups such as the elderly, pregnant women and solid organ transplant patients. Disease burden estimates are essential for setting vaccine policy, e.g., should RSV vaccine become available, burden estimates may inform recommendations to prioritize certain high-risk groups. The study population is residents of Allegheny County, Pennsylvania ≥18 years of age who were hospitalized in Pennsylvania during the period September 1, 2015–August 31, 2018. Data sources will include U.S. Census, Pennsylvania Health Care Cost Containment Council (PHC4) and the electronic medical record for the health system to which the hospitals belong. The algorithm involves: 1) ARI-associated hospitalizations in PHC4 data; 2) adjustment for ARI hospitalizations among county residents but admitted to hospitals outside the county; and 3) RSV detections from respiratory viral panels. Key sensitivity analyses will adjust for undertesting for viruses in the fall and spring quarters. The results will be population-based estimates, stratified by age and risk groups. Adjusting hospitalization data using a multiplier method is a simple means to estimate the impact of RSV in a given area. This algorithm can be applied to other health systems and localities to estimate RSV and other respiratory pathogen burden in adults, to estimate burden following introduction of RSV vaccine and to make cost-effectiveness estimates.

Population-based hospitalization burden estimates for respiratory viruses, 2015-2019

BACKGROUND

Acute respiratory infections (ARIs) result in millions of illnesses and hundreds of thousands of hospitalizations annually in the United States. The responsible viruses include influenza, parainfluenza, human metapneumovirus, coronaviruses, respiratory syncytial virus (RSV), and human rhinoviruses. This study estimated the population-based hospitalization burden of those respiratory viruses (RVs) over 4 years, from July 1, 2015 to June 30, 2019, among adults ≥18 years of age for Allegheny County (Pittsburgh), Pennsylvania.

METHODS

We used population-based statewide hospital discharge data, health system electronic medical record (EMR) data for RV tests, census data, and a published method to calculate burden.

RESULTS

Among 26,211 eligible RV tests, 67.6% were negative for any virus. The viruses detected were rhinovirus/enterovirus (2552; 30.1%), influenza A (2,299; 27.1%), RSV (1082; 12.7%), human metapneumovirus (832; 9.8%), parainfluenza (601; 7.1%), influenza B (565; 6.7%), non-SARS-CoV-2 coronavirus (420; 4.9% 1.5 years of data available), and adenovirus (136; 1.6%). Most tests were among female (58%) and White (71%) patients with 60% of patients ≥65 years, 24% 50-64 years, and 16% 18-49 years. The annual burden ranged from 137-174/100,000 population for rhinovirus/enterovirus; 99-182/100,000 for influenza A; and 56-81/100,000 for RSV. Among adults <65 years, rhinovirus/enterovirus hospitalization burden was higher than influenza A; whereas the reverse was true for adults ≥65 years. RV hospitalization burden increased with increasing age.

CONCLUSIONS

These virus-specific ARI population-based hospital burden estimates showed significant non-influenza burden. These estimates can serve as the basis for several areas of research that are essential for setting funding priorities and guiding public health policy.

Incidence and visual outcomes of acute endophthalmitis post intravitreal injection of anti-vascular endothelial growth factors in a single referral center

BACKGROUND

To describe the incidence and factors predicting visual outcome in patients with infectious endophthalmitis following intravitreal anti-VEGF injection.

METHODS

Retrospective, single-site, cohort study. Patients with acute endophthalmitis within 6 weeks of intravitreal anti-VEGF injection who were referred to our practice after inciting injection or were injected by us between January 2010 and July 2017 were included. All patients received intravitreal antibiotics with either vitreous/anterior chamber tap (TAP) or pars plana vitrectomy. Visual outcomes pre/post treatment, baseline variables (age, gender, ocular disease) and cultures results were studied.

RESULTS

Seventy eyes of 69 patients were included. Presenting VA was the strongest factor associated with final visual outcome after adjusting for other variables including culture status and baseline VA (p = .0002). Cultures were positive in 62.8% of eyes and were associated with worse visual outcome (p = .0087). Growth of Streptococcus or microorganisms other than coagulase negative Staphylococci (CNS) was also associated with worse prognosis, regardless of baseline and presenting VA (p = .0002). The crude incidence of post-injection endophthalmitis was 0.028% in our practice (40 eyes in 143,628 injections) during the study time. No significant difference was found between pre-filled bevacizumab versus ranibizumab or aflibercept drawn from a vial.

CONCLUSIONS

In a large, single center, retrospective study, the incidence of acute endophthalmitis post anti-VEGF injection was relatively low. Worse visual acuity at presentation of endophthalmitis and growth of Streptococcus or organisms other than CNS were associated with the worst visual outcomes.

Estimating the burden of adult hospitalized RSV infection including special populations

BACKGROUND

Numerous studies in the U.S. have made estimates of the RSV burden among adults that vary widely due to differences in methodology, reliance on influenza surveillance, which does not adequately capture all RSV clinical symptoms, and lack of diagnostic methods to identify RSV when viral loads are low. Nevertheless, accurate burden estimates can inform healthcare planning, resource allocation and potentially, RSV vaccine policy.

METHODS

A simple method combined with statewide and local hospitalization, medical record and U.S. Census data were used to estimate population-based RSV hospitalization burden among adults ages 18-64 years, ≥65 years, and including immunocompetent, immunocompromised and pregnant individuals during 2015-2018 for Allegheny County, Pennsylvania. Economic burden of hospitalization was estimated using state-provided average hospitalization charges for comparisons across patient groups.

RESULTS

The largest burden was borne by adults ≥ 65 years of age whose rates per 100,000 population of that age group (939/100,000) were 7.0-9.0 times those of adults 18-64 years of age (118/100,000). Immunosuppressed patients bore the greatest relative burden of RSV hospitalizations (1,288-1,562/100,000 immunosuppressed individuals). RSV burden ranged from 0 to 808/100,000 pregnant women. Average total charges for RSV hospitalization in Allegheny County across all adults increased from $39 million in 2015-2016 to $57 million in 2016-2017 to $89 million in 2017-2018, due to both increased average charges for an acute respiratory hospitalization and increased numbers of RSV cases.

CONCLUSIONS

These RSV burden estimates add to the body of knowledge to guide public health policy makers and offer a method for simply and easily producing population-based burden estimates.

Agreement among sources of adult influenza vaccination in the age of immunization information systems

INTRODUCTION

Many vaccination studies rely on self-reported vaccination status, with its inherent biases. Accuracy of influenza vaccination self-report has been evaluated periodically, typically using the medical record as the gold standard. The burgeoning of electronic medical records (EMRs) and immunization information systems (IISs) and the rise of adult vaccine administration in community pharmacies suggest the need for a reevaluation of self-reported vaccination status.

METHODS

Vaccination data from self-report, the state IIS, the health system EMR and other sources were compared for participants in outpatient and inpatient influenza vaccine effectiveness studies for four seasons (2016-2017 to 2019-2020). Agreement among the sources was calculated along with sensitivity and specificity. Tests for trend assessed changes in completeness of the Pennsylvania - Statewide IIS (PA-SIIS) data over time.

RESULTS

With self-report as the gold standard, agreement with the local EMR, PA-SIIS, and all sources was 62%, 77% and 85%, respectively. Sensitivity of the EMR was 42% (95% CI = 41, 43) and specificity was 91% (90, 92). With PA-SIIS-as the gold standard, agreement with the local EMR and all sources was 77% and 78%, respectively. Sensitivity of all sources combined was 96% (95, 97) and specificity was (63% (62, 64). Capture of influenza vaccinations in the IIS has not consistently improved over time, with a significant increase among children (P = 0.001), no change among working-age adults and a decrease among older adults (P = 0.004). However, PA-SIIS provided the largest percentage of verified vaccines (69.3%) compared with EMR (43.3%) and other sources (12.4%).

CONCLUSION

Both self-report and PA-SIIS are good estimates of actual vaccine uptake. When high accuracy data are required, such as for vaccine effectiveness studies, triangulation using multiple sources should be conducted.

Proposed clinical indicators for efficient screening and testing for COVID-19 infection using Classification and Regression Trees (CART) analysis

The introduction and rapid transmission of SARS-CoV-2 in the United States resulted in methods to assess, mitigate, and contain the resulting COVID-19 disease derived from limited knowledge. Screening for testing has been based on symptoms typically observed in inpatients, yet outpatient symptoms may differ. Classification and regression trees recursive partitioning created a decision tree classifying participants into laboratory-confirmed cases and non-cases. Demographic and symptom data from patients ages 18-87 years enrolled from March 29-June 8, 2020 were included. Presence or absence of SARS-CoV-2 was the target variable. Of 832 tested, 77 (9.3%) tested positive. Cases significantly more often reported diarrhea (12 percentage points (PP)), fever (15 PP), nausea/vomiting (9 PP), loss of taste/smell (52 PP), and contact with a COVID-19 case (54 PP), but less frequently reported sore throat (-27 PP). The 4-terminal node optimal tree had sensitivity of 69%, specificity of 78%, positive predictive value of 20%, negative predictive value of 97%, and AUC of 76%. Among those referred for testing, negative responses to two questions could classify about half (49%) of tested persons with low risk for SARS-CoV-2 and would save limited testing resources. Outpatient symptoms of COVID-19 appear to be broader than the inpatient syndrome.Initial supplies of anticipated COVID-19 vaccines may be limited and administration of first such available vaccines may need to be prioritized for essential workers, the most vulnerable, or those likely to have a robust response to vaccine. Another priority group could be those not previously infected. Those who screen out of testing may be less likely to have been infected by SARS-CoV-2 virus thus may be prioritized for vaccination when supplies are limited.

Comparison of local influenza vaccine effectiveness using two methods

Background

In some settings, research methods to determine influenza vaccine effectiveness (VE) may not be appropriate because of cost, time constraints, or other factors. Administrative database analysis of viral testing results and vaccination history may be a viable alternative. This study compared VE estimates from outpatient research and administrative databases.

Methods

Using the test-negative, case-control design, data for 2017–2018 and 2018–2019 influenza seasons were collected using: 1) consent, specimen collection, RT-PCR testing and vaccine verification using multiple methods; and 2) an administrative database of outpatients with a clinical respiratory viral panel combined with electronic immunization records. Odds ratios for likelihood of influenza infection by vaccination status were calculated using multivariable logistic regression. VE = (1 − aOR) × 100.

Results

Research participants were significantly younger (P < 0.001), more often white (69% vs. 59%; P < 0.001) than non-white and less frequently enrolled through the emergency department (35% vs. 72%; P < 0.001) than administrative database participants. VE was significant against all influenza and influenza A in each season and both seasons combined (37–49%). Point estimate differences between methods were evident, with higher VE in the research database, but insignificant due to low sample sizes. When enrollment sites were separately analyzed, there were significant differences in VE estimates for all influenza (66% research vs. 46% administrative P < 0.001) and influenza A (67% research vs. 49% administrative; P < 0.001) in the emergency department.

Conclusions:

The selection of the appropriate method for determining influenza vaccine effectiveness depends on many factors, including sample size, subgroups of interest, etc., suggesting that research estimates may be more generalizable. Other advantages of research databases for VE estimates include lack of clinician-related selection bias for testing and less misclassification of vaccination status. The advantages of the administrative databases are potentially shorter time to VE results and lower cost.

Using Capture-Recapture Methods to Estimate Local Influenza Hospitalization Incidence Rates

Background

Accurate population estimates of disease incidence and burden are needed to set appropriate public health policy. The capture-recapture (C-R) method combines data from multiple sources to better estimate prevalence than is possible using single sources. This study used the C-R method to estimate influenza cases using research and administrative databases to calculate county-wide influenza hospitalization burden.

Methods

Data were derived from a database of clinical virology test results and research data from an influenza vaccine effectiveness study from seasons 2015-2016 to 2018-2019. Missed influenza cases were estimated using C-R method. These estimates were used to calculate disease burden using the multiplier method to correct for underreporting due to curtailing data collection before the end of influenza circulation.

Results

Over all seasons, 422 influenza cases were reported in the administrative database and 382 influenza cases in the research database. Seventy-five cases (18%) reported in the administrative database were not captured in the research database, and 35 (9%) cases in the research database were not captured in the administrative database. Completeness of the influenza hospitalization was estimated to be 76%. Influenza hospitalizations were higher among unvaccinated (32%) than vaccinated (22%) in the current season and among unvaccinated (28%) than vaccinated (23%) in the previous year. The incidence rates for influenza hospitalizations varied by age and season and averaged 421 cases/100,000 population annually.

Conclusion

The capture-recapture method offers a more accurate method for estimating influenza hospitalization than relying on a single data source. Using the multiplier method with adjustments improves the detection of influenza disease burden through a matched database. The incidence rates are consistent with national estimates.

Relative effectiveness of high dose versus standard dose influenza vaccines in older adult outpatients over four seasons, 2015-16 to 2018-19

BACKGROUND

New influenza vaccine formulations are designed to improve vaccine effectiveness and protect those most vulnerable to infection. High dose trivalent inactivated influenza vaccine (HD-IIV3), licensed for ages ≥65 years, produces greater antibody responses and efficacy in clinical trials, but post-licensure vaccine effectiveness (VE) compared to standard dose (SD-IIV3/4) vaccine remains an open question.

METHODS

Using a test-negative, case control design and propensity analyses to adjust for confounding, US Influenza VE Network data from the 2015-2016 through 2018-2019 seasons were analyzed to determine relative VE (rVE) between HD-IIV3 and SD-IIV3/4 among outpatients ≥65 years old presenting with acute respiratory illness. Influenza vaccination status was derived from electronic medical records and immunization registries.

RESULTS

Among 3861 enrollees, 2993 (78%) were vaccinated; 1573 (53%) received HD-IIV3 and 1420 (47%) received SD-IIV3/4. HD-IIV3 recipients differed from SD-IIV3/4 recipients by race, previous vaccination, number of outpatient visits in the previous year and timing of vaccination, and were balanced in the propensity model except the timing of vaccination. Compared with no vaccination, significant protection against any influenza A was observed from both HD-IIV3 (VE = 29%; 95%CI = 10%, 44%) and SD-IIV3/4 (VE = 24%; 95%CI = 5%, 39%); rVE = 18% (95%CI = 0%, 33%, SD as referent). When stratified by virus type, against A/H1N1, HD-IIV3 VE was 30% (95%CI = -7%, 54%), SD-IIV3/4 VE was 40% (95%CI = 10%, 61%), and rVE = -32%; (95%CI = -94%, 11%); Against A/H3N2, HD-IIV3 VE was 31% (95%CI = 9%, 47%), SD-IIV3/4 VE was 19% (95%CI = -5%, 37%), and rVE = 27%; (95% CI = 9%, 42%).

CONCLUSIONS

Among adults ≥65 years of age, recipients of standard and high dose influenza vaccines differed significantly in their characteristics. After adjusting for these differences, high dose vaccine offered more protection against A/H3N2 and borderline significant protection against all influenza A requiring outpatient care during the 2015-2018 influenza seasons.

Improving Cost-effectiveness and Access to Cognitive Behavior Therapy for Depression: Providing Remote-Ready, Computer-Assisted Psychotherapy in Times of Crisis and Beyond

INTRODUCTION

There is growing evidence that computer-delivered or computer-assisted forms of cognitive behavior therapy (CCBT) are helpful, but cost-effectiveness versus standard therapies is not well established.

OBJECTIVE

To evaluate the cost-effectiveness of a therapist-supported method for CCBT in comparison to standard cognitive behavior therapy (CBT).

METHODS

A total of 154 drug-free major depressive disorder outpatients were randomly assigned to either 16 weeks of standard CBT (up to twenty 50-min sessions) or CCBT using the Good Days Ahead program (including up to 5.5 h of therapist contact). Outcomes were assessed at baseline, weeks 8 and 16, and at 3 and 6 months post-treatment. Economic analyses took into account the costs of services received and work/social role impairment.

RESULTS

In the context of almost identical efficacy, a form of CCBT that used only about one third the amount of therapist contact as conventional CBT was highly cost-effective compared to conventional therapy and reduced the adjusted cost of treatment by USD 945 per patient.

CONCLUSIONS

A method of CCBT that blended internet-delivered modules and abbreviated therapeutic contact reduced the cost of treatment substantially without adversely affecting outcomes. Results suggest that use of this approach can more than double the access to CBT. Because clinician support in CCBT can be provided by telephone, videoconference, and/or email, this highly efficient form of treatment could be a major advance in remote treatment delivery.

Does influenza vaccination status change physician ordering patterns for respiratory viral panels? Inspection for selection bias

Purpose: Hospitalized patients with an acute respiratory illness (ARI) were compared to determine if demographic characteristics, timing or influenza vaccination biased who received clinical respiratory viral panel (RVP) testing.

Methods: 171 enrollees in an influenza vaccine effectiveness study and a sample of non-enrollees (N = 1029) admitted to a community hospital with ARI during December 2015 through April 2016 comprised the study sample. Those who received clinical RVP testing (n = 292) were compared to those who did not by age, sex, influenza vaccination status, and period (pre-peak influenza season vs. peak/post peak influenza season), using Chi square- and t-tests, and logistic regression.

Results: Mean age of participants was 70 years, 58% was female and 45% had been vaccinated against influenza in the 2015–2016 season. Those with clinical RVP testing were significantly younger (67 years) than those without RVP (71 years; P < 0.001), but did not differ with respect to sex or vaccination status. The odds of clinical RVP testing were significantly (P = 0.004) related to younger age (< 65 years) (Odds ratio (OR) = 1.51; 95% CI = 1.14–2.00) and to later period (peak/post peak influenza season; OR = 2.64; 95% CI = 1.84–3.79) but were unrelated to influenza vaccination status or the interaction of time and vaccination status.

Conclusion: RVP testing was significantly higher among younger hospitalized patients with an ARI and during the peak and post peak influenza periods than earlier in the season, but influenza vaccination status was not a significant factor. Studies that enroll based on clinical RVP testing should account for potential differences by age.

Influenza Vaccine Intention After a Medically Attended Acute Respiratory Infection

Background. Little is known about vaccine intention behavior among patients recovering from a medically attended acute respiratory infection. Methods. Adults ≥ 18 years old with an acute respiratory infection in the 2014-2015, 2015-2016, and 2016-2017 influenza seasons were tested for influenza and completed surveys. Across seasons, unvaccinated participants were grouped into those who intended to receive the influenza vaccine in the following season (vaccine intention) and those who did not (no vaccine intention). In 2016-2017, participants were asked the reasons for their vaccination behavior. Results. Of the 837 unvaccinated participants, 308 (37%) intended to be vaccinated the next season. The groups did not differ in demographic or overall health factors. In logistic regression, non-Whites, those reporting wheezing or nasal congestion, and those receiving an antiviral prescription were more likely to be in the vaccine intention group. That group was significantly more likely to cite perceived behavioral control reasons for not being vaccinated (forgot), while the no vaccine intention group was significantly (p < .001) more likely to report knowledge/attitudinal reasons (side effects). Conclusion. Because influenza vaccine is given annually, adults must make a conscious decision to receive the vaccine each year. Understanding the factors related to vaccination behavior and intent can help shape interventions to improve influenza vaccination rates. A medical visit at the time of an acute respiratory illness, especially one in which the provider suspects influenza, as evidenced by an antiviral prescription, is an ideal opportunity to recommend influenza vaccine in the next season, to prevent a similar experience.

Improving the Efficiency of Psychotherapy for Depression: Computer-Assisted Versus Standard CBT

OBJECTIVE

The authors evaluated the efficacy and durability of a therapist-supported method for computer-assisted cognitive-behavioral therapy (CCBT) in comparison to standard cognitive-behavioral therapy (CBT).

METHOD

A total of 154 medication-free patients with major depressive disorder seeking treatment at two university clinics were randomly assigned to either 16 weeks of standard CBT (up to 20 sessions of 50 minutes each) or CCBT using the "Good Days Ahead" program. The amount of therapist time in CCBT was planned to be about one-third that in CBT. Outcomes were assessed by independent raters and self-report at baseline, at weeks 8 and 16, and at posttreatment months 3 and 6. The primary test of efficacy was noninferiority on the Hamilton Depression Rating Scale at week 16.

RESULTS

Approximately 80% of the participants completed the 16-week protocol (79% in the CBT group and 82% in the CCBT group). CCBT met a priori criteria for noninferiority to conventional CBT at week 16. The groups did not differ significantly on any measure of psychopathology. Remission rates were similar for the two groups (intent-to-treat rates, 41.6% for the CBT group and 42.9% for the CCBT group). Both groups maintained improvements throughout the follow-up.

CONCLUSIONS

The study findings indicate that a method of CCBT that blends Internet-delivered skill-building modules with about 5 hours of therapeutic contact was noninferior to a conventional course of CBT that provided over 8 additional hours of therapist contact. Future studies should focus on dissemination and optimizing therapist support methods to maximize the public health significance of CCBT.

Abstract P1-10-01: Utilization and outcomes of post-mastectomy radiotherapy in women with 1-3 positive axillary nodes following neoadjuvant chemotherapy: A multiply-imputed, propensity-adjusted National cancer database analysis

Background: Use of post-mastectomy radiotherapy (PMRT) following neoadjuvant chemotherapy (NAC) varies widely. The combined analysis of NSABP B1724 studies suggests a higher risk of locoregional recurrence for women with persistently positive lymph nodes following NAC. The impact of PMRT on survival in the subset of patients with 1 to 3 positive nodes after NAC is not clear and the goal of the current study is to evaluate practice patterns and the impact of PMRT on survival in this subset of patients.

Methods: The National Cancer Database was queried for women who underwent NAC followed by mastectomy and had 1-3 persistent axillary lymph nodes with or without adjuvant PMRT. A propensity score was generated to account for indication bias under two circumstances: one with the original dataset and one following a multiple imputation to complete the dataset to allow for a more accurate propensity score generation. Factors impacting utilization of PMRT were calculated with backwards-selection binary regression. Kaplan-Meier with log-rank test and Cox-regression analyses were used for survival.

Results: Within the queried cohort of 14,895 women from 2006-2012, 70% of women received PMRT following NAC with 1-3 positive axillary lymph nodes. One lymph node was positive in 56%, 2 in 25.9%, and 3 in 18.1%. PMRT was utilized in 67.3% of women with 1 node positive, 71.5% with 2 nodes positive, and 76.2% with 3 nodes positive. Factors associated with the usage of PMRT were: residence on the east coast in a highly populated region with proximity to the treatment center, later year of diagnosis (71% of women in 2012), younger age, non-African American race, non-Hispanic descent, private insurance, higher clinical stage, triple negative/high grade histology, pathologic T4, greater number of axillary node positive, positive margins or LVSI, greater number of nodes examined, and use of adjuvant hormonal therapy (all p&lt;.05).

Median follow up was 40.1 months (range: 2.6-106.9 months). Prior to multiple imputation, a propensity score was generated which accounted for 28.7% of cases. PMRT did not have an impact on survival within the limited analysis. In a pooled propensity-adjusted Cox analysis following multiple imputation to complete the dataset, PMRT was found to have an OS HR of 0.878 (95%CI 0.806-0.957, p=.003). Five year overall survival rates with and without PMRT were 77.6% and 75.4% (p&lt;.001). For 1-3 positive nodes respectively, 5-year overall survival rates with and without PMRT were: 79.7% vs. 79.1% (p=.041), 77.3% vs. 70.8% (p&lt;.001), and 71.8% vs. 68.0% (p=.004).

Conclusions: In a population-based analysis of women who underwent neoadjuvant chemotherapy prior to mastectomy, post-mastectomy radiotherapy appears to confer a survival advantage in women with 1-3 residual axillary lymph nodes. There continues to be a wide variation in practice nation-wide with a significant number of women with persistently positive 1-3 axillary lymph nodes not receiving PMRT.

Citation Format: Horne ZD, Gebhardt BJ, Balasubramani GK, Beriwal S. Utilization and outcomes of post-mastectomy radiotherapy in women with 1-3 positive axillary nodes following neoadjuvant chemotherapy: A multiply-imputed, propensity-adjusted National cancer database analysis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-01.

Brachytherapy boost for prostate cancer: Trends in care and survival outcomes

PURPOSE

Androgen suppression combined with elective nodal and dose-escalated radiation therapy recently demonstrated an improved biochemical failure-free survival in men who received external beam radiation therapy (EBRT) plus a brachytherapy boost (BB) compared with dose-escalated external beam radiotherapy (DE-EBRT). We sought to analyze the factors predictive for use of EBRT + BB as compared with DE-EBRT and report resulting survival outcomes on a national level using a hospital-based registry.

METHODS AND MATERIALS

We identified 113,719 men from the National Cancer Database from 2004 to 2013 with intermediate- or high-risk prostate cancer who were treated with EBRT + BB or DE-EBRT. We performed univariate and multivariate analyses of all available factors potentially predictive of receipt of treatment selection. Survival was evaluated in a multivariable model with propensity adjustment.

RESULTS

For intermediate-risk patients, utilization of BB decreased from 33.1% (n = 1742) in 2004 to 12.5% (n = 766) in 2013 and for high-risk patients, utilization dropped from 27.6% (n = 879) to 10.8% (n = 479). Numerous factors predictive for use of BB were identified. Cox proportional hazards analysis was performed-adjusting for age, Charlson-Deyo comorbidity score, T stage, prostate-specific antigen, Gleason score, and sociodemographic factors-and demonstrated BB use was associated with a hazard ratio of 0.71 (95% confidence interval, 0.67-0.75; p < 0.0005) and 0.73 (95% confidence interval, 0.68-0.78; p < 0.0005) for intermediate- and high-risk patients, respectively.

CONCLUSIONS

There has been a concerning decline in the utilization of BB for intermediate- and high-risk prostate cancer patients despite an association with improved on overall survival. Numerous factors predictive for use of BB have been identified.

Classification and Regression Tree (CART) analysis to predict influenza in primary care patients

Background

The use of neuraminidase-inhibiting anti-viral medication to treat influenza is relatively infrequent. Rapid, cost-effective methods for diagnosing influenza are needed to enable appropriate prescribing. Multi-viral respiratory panels using reverse transcription polymerase chain reaction (PCR) assays to diagnose influenza are accurate but expensive and more time-consuming than low sensitivity rapid influenza tests. Influenza clinical decision algorithms are both rapid and inexpensive, but most are based on regression analyses that do not account for higher order interactions. This study used classification and regression trees (CART) modeling to estimate probabilities of influenza.

Methods

Eligible enrollees ≥ 5 years old (n = 4,173) who presented at ambulatory centers for treatment of acute respiratory illness (≤7 days) with cough or fever in 2011–2012, provided nasal and pharyngeal swabs for PCR testing for influenza, information on demographics, symptoms, personal characteristics and self-reported influenza vaccination status.

Results

Antiviral medication was prescribed for just 15 % of those with PCR-confirmed influenza. An algorithm that included fever, cough, and fatigue had sensitivity of 84 %, specificity of 48 %, positive predictive value (PPV) of 23 % and negative predictive value (NPV) of 94 % for the development sample.

Conclusions

The CART algorithm has good sensitivity and high NPV, but low PPV for identifying influenza among outpatients ≥5 years. Thus, it is good at identifying a group who do not need testing or antivirals and had fair to good predictive performance for influenza. Further testing of the algorithm in other influenza seasons would help to optimize decisions for lab testing or treatment.

Intention to receive influenza vaccine after an acute respiratory illness

OBJECTIVE

To determine the effects of symptoms and presence of confirmed influenza on intention to receive an influenza vaccine, specifically in patients recovering from a medically-attended acute (≤ 7 days' duration) respiratory illness (ARI).

METHODS

During the 2013-14 influenza season individuals seeking outpatient care for an ARI that included cough were tested for influenza using reverse transcription polymerase chain reaction assays (PCR) and completed surveys. Children (6 months-18 years) and adults (≥ 18 years) were grouped by their combined current season's influenza vaccination status (vaccinated/not vaccinated) and their vaccination intentions for next season (intend/do not intend).

RESULTS

Overall, 41% (323/786) were unvaccinated at enrollment; of those, nearly half (151/323) intended to be vaccinated next season. When adjusting for demographic, health, and other factors, unvaccinated individuals who intended to be vaccinated next season were approximately 1.5 times more likely to have PCR-confirmed influenza compared with vaccinated individuals who intended to be vaccinated next season.

CONCLUSION

The combined experience of not being vaccinated against influenza and seeking medical attention for an ARI seemed to influence approximately one-half of unvaccinated participants to consider influenza vaccination for next season.

Viral infections in outpatients with medically attended acute respiratory illness during the 2012-2013 influenza season

BACKGROUND

While it is known that acute respiratory illness (ARI) is caused by an array of viruses, less is known about co-detections and the resultant comparative symptoms and illness burden. This study examined the co-detections, the distribution of viruses, symptoms, and illness burden associated with ARI between December 2012 and March 2013.

METHODS

Outpatients with ARI were assayed for presence of 18 viruses using multiplex reverse transcriptase polymerase chain reaction (MRT-PCR) to simultaneously detect multiple viruses.

RESULTS

Among 935 patients, 60% tested positive for a single virus, 9% tested positive for ≥1 virus and 287 (31%) tested negative. Among children (<18 years), the respective distributions were 63%, 14%, and 23%; whereas for younger adults (18-49 years), the distributions were 58%, 8%, and 34% and for older adults (≥50 years) the distributions were 61%, 5%, and 32% (P < 0.001). Co-detections were more common in children than older adults (P = 0.01), and less frequent in households without children (P = 0.003). Most frequently co-detected viruses were coronavirus, respiratory syncytial virus, and influenza A virus. Compared with single viral infections, those with co-detections less frequently reported sore throat (P = 0.01), missed fewer days of school (1.1 vs. 2 days; P = 0.04), or work (2 vs. 3 days; P = 0.03); other measures of illness severity did not vary.

CONCLUSIONS

Among outpatients with ARI, 69% of visits were associated with a viral etiology. Co-detections of specific clusters of viruses were observed in 9% of ARI cases particularly in children, were less frequent in households without children, and were less symptomatic (e.g., lower fever) than single infections.

Pulmonary Function in HIV-Infected Recreational Drug Users in the Era of Anti-Retroviral Therapy

BACKGROUND

Individuals with HIV infection commonly have pulmonary function abnormalities, including airflow obstruction and diffusion impairment, which may be more prevalent among recreational drug users. To date, the relationship between drug use and pulmonary function abnormalities among those with HIV remains unclear.

OBJECTIVE

To determine associations between recreational drug use and airflow obstruction, diffusion impairment, and radiographic emphysema in men and women with HIV.

METHODS

Cross-sectional analysis of pulmonary function and self-reported recreational drug use data from a cohort of 121 men and 63 women with HIV. Primary outcomes were the presence (yes/no) of: 1) airflow obstruction, (pre- or post-bronchodilator forced expiratory volume in 1 second/forced vital capacity<0.70); 2) moderate diffusion impairment (diffusing capacity for carbon monoxide <60% predicted); and 3) radiographic emphysema (>1% of lung voxels <-950 Hounsfield units). Exposures of interest were frequency of recreational drug use, recent (since last study visit) drug use, and any lifetime drug use. We used logistic regression to determine associations between recreational drug use and the primary outcomes.

RESULTS

HIV-infected men and women reported recent recreational drug use at 56.0% and 31.0% of their study visits, respectively, and 48.8% of men and 39.7% of women reported drug use since their last study visit. Drug use was not associated with airway obstruction or radiographic emphysema in men or women. Recent crack cocaine use was independently associated with moderate diffusion impairment in women (odds ratio 17.6; 95% confidence interval 1.3-249.6, p=0.03).

CONCLUSIONS

In this cross-sectional analysis, we found that recreational drug use was common among HIV-infected men and women and recent crack cocaine use was associated with moderate diffusion impairment in women. Given the increasing prevalence of HIV infection, any relationship between drug use and prevalence or severity of chronic pulmonary diseases could have a significant impact on HIV and chronic disease management.

Increase in work productivity of depressed individuals with improvement in depressive symptom severity

OBJECTIVE

The authors sought to identify baseline clinical and sociodemographic characteristics associated with work productivity in depressed outpatients and to assess the effect of treatment on work productivity.

METHOD

Employed depressed outpatients 18-75 years old who completed the Work Productivity and Activity Impairment scale (N=1,928) were treated with citalopram (20-40 mg/day) in the Sequenced Treatment Alternatives to Relieve Depression study. For patients who did not remit after an initial adequate antidepressant trial (level 1), either a switch to sertraline, sustained-release bupropion, or extended-release venlafaxine or an augmentation with sustained-release bupropion or buspirone was provided (level 2). Participants' clinical and demographic characteristics and treatment outcomes were analyzed for associations with baseline work productivity and change in productivity over time.

RESULTS

Education, baseline depression severity, and melancholic, atypical, and recurrent depression subtypes were all independently associated with lower benefit to work productivity domains. During level 1 treatment, work productivity in several domains improved with reductions in depressive symptom severity. However, these findings did not hold true for level 2 outcomes; there was no significant association between treatment response and reduction in work impairment. Results were largely confirmed when multiple imputations were employed to address missing data. During this additional analysis, an association was also observed between greater impairment in work productivity and higher levels of anxious depression.

CONCLUSIONS

Patients with clinically significant reductions in symptom severity during initial treatment were more likely than nonresponders to experience significant improvements in work productivity. In contrast, patients who achieved symptom remission in second-step treatment continued to have impairment at work. Patients who have demonstrated some degree of treatment resistance are more prone to persistent impairment in occupational productivity, implying a need for additional, possibly novel, treatments.

Does early-onset chronic or recurrent major depression impact outcomes with antidepressant medications? A CO-MED trial report

BACKGROUND

Prior studies have suggested that major depressive disorder (MDD) with pre-adult onset represents a distinct subtype with greater symptom severity and higher rates of suicidal ideation. Whether these patients have poorer response to various types of antidepressant treatment than those with adult-onset MDD is unclear. Method A total of 665 psychiatric and primary care out-patients (aged 18-75 years) with non-psychotic chronic or recurrent MDD participated in a single-blind, randomized trial that compared the efficacy of escitalopram plus placebo, bupropion sustained-release plus escitalopram, or venlafaxine extended-release plus mirtazapine. We compared participants who self-reported MDD onset (before age 18) to those with a later onset (adult onset) with respect to baseline characteristics and treatment/outcome variables at 12 and 28 weeks.

RESULTS

Early-onset chronic/recurrent MDD was associated with a distinct set of sociodemographic (female, younger age) and clinical correlates (longer duration of illness, greater number of prior episodes, greater likelihood of atypical features, higher rates of suicidality and psychiatric co-morbidity, fewer medical problems, poorer quality of life, greater history of child abuse/neglect). However, results from unadjusted and adjusted analyses showed no significant differences in response, remission, tolerability of medications, quality of life, or retention at 12 or 28 weeks.

CONCLUSIONS

Although early-onset chronic/recurrent MDD is associated with a more severe clinical picture, it does not seem to be useful for predicting differential treatment response to antidepressant medication. Clinicians should remain alert to an increased risk of suicidality in this population.

The impact of HAART on the respiratory complications of HIV infection: longitudinal trends in the MACS and WIHS cohorts

OBJECTIVE

To review the incidence of respiratory conditions and their effect on mortality in HIV-infected and uninfected individuals prior to and during the era of highly active antiretroviral therapy (HAART).

DESIGN

Two large observational cohorts of HIV-infected and HIV-uninfected men (Multicenter AIDS Cohort Study [MACS]) and women (Women's Interagency HIV Study [WIHS]), followed since 1984 and 1994, respectively.

METHODS

Adjusted odds or hazards ratios for incident respiratory infections or non-infectious respiratory diagnoses, respectively, in HIV-infected compared to HIV-uninfected individuals in both the pre-HAART (MACS only) and HAART eras; and adjusted Cox proportional hazard ratios for mortality in HIV-infected persons with lung disease during the HAART era.

RESULTS

Compared to HIV-uninfected participants, HIV-infected individuals had more incident respiratory infections both pre-HAART (MACS, odds ratio [adjusted-OR], 2.4; 95% confidence interval [CI], 2.2-2.7; p<0.001) and after HAART availability (MACS, adjusted-OR, 1.5; 95%CI 1.3-1.7; p<0.001; WIHS adjusted-OR, 2.2; 95%CI 1.8-2.7; p<0.001). Chronic obstructive pulmonary disease was more common in MACS HIV-infected vs. HIV-uninfected participants pre-HAART (hazard ratio [adjusted-HR] 2.9; 95%CI, 1.02-8.4; p = 0.046). After HAART availability, non-infectious lung diseases were not significantly more common in HIV-infected participants in either MACS or WIHS participants. HIV-infected participants in the HAART era with respiratory infections had an increased risk of death compared to those without infections (MACS adjusted-HR, 1.5; 95%CI, 1.3-1.7; p<0.001; WIHS adjusted-HR, 1.9; 95%CI, 1.5-2.4; p<0.001).

CONCLUSION

HIV infection remained a significant risk for infectious respiratory diseases after the introduction of HAART, and infectious respiratory diseases were associated with an increased risk of mortality.

Is prior course of illness relevant to acute or longer-term outcomes in depressed out-patients? A STAR*D report

BACKGROUND

Major depressive disorder (MDD) is commonly chronic and/or recurrent. We aimed to determine whether a chronic and/or recurrent course of MDD is associated with acute and longer-term MDD treatment outcomes.

METHOD

This cohort study recruited out-patients aged 18-75 years with non-psychotic MDD from 18 primary and 23 psychiatric care clinics across the USA. Participants were grouped as: chronic (index episode >2 years) and recurrent (n = 398); chronic non-recurrent (n=257); non-chronic recurrent (n=1614); and non-chronic non-recurrent (n = 387). Acute treatment was up to 14 weeks of citalopram (≤ 60 mg/day) with up to 12 months of follow-up treatment. The primary outcomes for this report were remission [16-item Quick Inventory of Depressive Symptomatology - Self-Rated (QIDS-SR(16)) ≤ 5] or response (≥ 50% reduction from baseline in QIDS-SR(16)) and time to first relapse [first QIDS-SR16 by Interactive Voice Response (IVR) ≥ 11].

RESULTS

Most participants (85%) had a chronic and/or recurrent course; 15% had both. Chronic index episode was associated with greater sociodemographic disadvantage. Recurrent course was associated with earlier age of onset and greater family histories of depression and substance abuse. Remission rates were lowest and slowest for those with chronic index episodes. For participants in remission entering follow-up, relapse was most likely for the chronic and recurrent group, and least likely for the non-chronic, non-recurrent group. For participants not in remission when entering follow-up, prior course was unrelated to relapse.

CONCLUSIONS

Recurrent MDD is the norm for out-patients, of whom 15% also have a chronic index episode. Chronic and recurrent course of MDD may be useful in predicting acute and long-term MDD treatment outcomes.

Medical conditions associated with out-of-hospital endotracheal intubation

BACKGROUND

While prior studies describe the clinical presentation of patients requiring paramedic out-of-hospital endotracheal intubation (ETI), limited data characterize the underlying medical conditions or comorbidities.

OBJECTIVE

To characterize the medical conditions and comorbidities of patients receiving successful paramedic out-of-hospital ETI.

METHODS

We used Pennsylvania statewide emergency medical services (EMS) clinical data, including all successful ETIs performed during 2003-2005. Using multiple imputation triple-match algorithms, we probabilistically linked EMS ETI to statewide death and hospital admission data. Each hospitalization record contained one primary and up to eight secondary diagnoses, classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We determined the proportion of patients in each major ICD-9-CM diagnostic group and subgroup. We calculated the Charlson Comorbidity Index score for each patient. Using binomial proportions with confidence intervals (CIs), we analyzed the data and combined imputed results using Rubin's method.

RESULTS

Across the imputed sets, we linked 25,733 (77.7% linkage) successful ETIs to death or hospital records; 56.3% patients died before and 43.7% survived to hospital admission. Of the 14,478 patients who died before hospital admission, most (92.7%; 95% CI: 92.5-93.3%) had presented to EMS in cardiac arrest. Of the 11,255 hospitalized patents, the leading primary diagnoses were circulatory diseases (32.0%; 95% CI: 30.2-33.7%), respiratory diseases (22.8%; 95% CI: 21.9-23.7%), and injury or poisoning (25.2%; 95% CI: 22.7-27.8%). Prominent primary diagnosis subgroups included asphyxia and respiratory failure (15.2%), traumatic brain injury and skull fractures (11.3%), acute myocardial infarction and ischemic heart disease (10.9%), poisonings and drug and alcohol disorders (6.7%), dysrhythmias (6.7%), hemorrhagic and nonhemorrhagic stroke (5.9%), acute heart failure and cardiomyopathies (5.6%), pneumonia and aspiration (4.9%), and sepsis, septicemia, and septic shock (3.2%). Most of the admitted ETI patients had a secondary circulatory (70.8%), respiratory (61.4%), or endocrine, nutritional, or metabolic (51.4%) secondary diagnosis. The mean Charlson Index score was 1.6 (95% CI: 1.5-1.7).

CONCLUSIONS

The majority of successful paramedic ETIs occur on patients with cardiac arrest and circulatory and respiratory conditions. Injuries, poisonings, and other conditions compromise smaller but important portions of the paramedic ETI pool. Patients undergoing ETI have multiple comorbidities. These findings may guide the systemic planning of paramedic airway management care and education.

Out-of-hospital endotracheal intubation experience and patient outcomes

STUDY OBJECTIVE

Previous studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation.

METHODS

We analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates.

RESULTS

During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92 (95% CI 0.67 to 1.26).

CONCLUSION

Rescuer procedural experience is associated with improved patient survival after out-of-hospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer procedural experience is not associated with patient survival after out-of-hospital tracheal intubation of trauma nonarrest patients.

Income and attrition in the treatment of depression: a STAR*D report

BACKGROUND

Attrition, or dropping out of treatment, remains a major issue in the care of depressed outpatients. Whether different factors are associated with attrition for different socioeconomic groups is not known. This report assessed whether attrition rates and predictors of attrition differed among depressed outpatients with different income levels.

METHODS

Outpatients with nonpsychotic major depressive disorder treated for up to 14 weeks with citalopram in the first step of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study were divided by household incomes of <$20,000, $20,000-<$40,000, and >or=$40,000. Attrition rates and sociodemographic and clinical correlates of attrition were identified for each group.

RESULTS

Regardless of income level, remission rates were lower for participants who dropped out of treatment. Attrition rates increased as income decreased. For all income levels, younger age was independently associated with attrition. For the lowest income level, less education, better mental health functioning, being on public insurance, and having more concurrent Axis I conditions were associated with a greater likelihood of attrition. For the middle income group, less education, better mental health functioning, being Black or of another non-White race, and treatment in a psychiatric versus primary-care setting predicted greater attrition. For the highest income group, being Hispanic, having a family history of drug abuse, and melancholic features predicted attrition. Atypical symptom features (middle income group) and recurrent depression (highest income group) were associated with retention.

CONCLUSIONS

Efforts to retain patients in antidepressant treatment should focus especially on less educated patients with lower household incomes and younger patients.

Sociodemographic, clinical, and treatment characteristics associated with worsened depression during treatment with citalopram: results of the NIMH STAR(*)D trial

CONTEXT

Outcomes of antidepressant medication treatment for major depressive disorder include remission, response, and nonresponse. But nonresponse can include depression that worsened over the course of treatment, an outcome that has received scant attention.

OBJECTIVE

To describe baseline sociodemographic, clinical, and treatment characteristics associated with worsened depression during a trial of citalopram. DESIGN, PARTICIPANTS, AND SETTINGS: Open-label clinical trial of 2,876 adult outpatients seen in 18 primary and 23 psychiatric-care settings.

INTERVENTION

Citalopram was delivered using measurement-based care and flexible dosing with the aim of achieving symptom remission. Symptom and side effect ratings were obtained at each treatment visit.

MAIN OUTCOME MEASURES

Worsened depression was defined as an exit score >or=3 points above the pretreatment (baseline) score on the 16-item QIDS-SR. Baseline sociodemographic, clinical, and treatment characteristics were examined for association with worsened depression.

RESULTS

Of 2,864 outpatients who returned for >or=2 post baseline visits, 150 (5.2%) had worsened depression at study exit. Baseline characteristics independently associated with increased worsened depression included African-American race (OR=2.02), having less than a college education (OR=2.36), posttraumatic stress disorder (OR=1.78), drug abuse (OR=1.97), hypochondriasis (OR=2.74). Participants with worsened depression spent less time in treatment; had fewer treatment visits; exited the study sooner; had more frequent, intense, and burdensome adverse effects; and were more intolerant of medication.

CONCLUSIONS

The presence of certain baseline characteristics indicated a greater likelihood of worsened depression during antidepressant treatment. Patients with these characteristics should be monitored closely during treatment and may be candidates for more aggressive treatment.

Diurnal mood variation in outpatients with major depressive disorder

BACKGROUND

Diurnal mood variation (DMV) with early morning worsening is considered a classic symptom of melancholic features of major depressive disorder (MDD) according to the Diagnostic and Statistical Manual. This report used data from the sequenced treatment alternatives to relieve depression study to determine whether DMV was associated with treatment outcome to citalopram.

METHODS

Two thousand eight hundred and seventy-five outpatients with nonpsychotic MDD were evaluated during a 14-week trial of the selective serotonin reuptake inhibitor citalopram. Participants were divided into three groups: those with "classic" DMV (early morning worsening), those with any form of DMV (morning, afternoon, or evening worsening), and those with no DMV. Participants with classic DMV and those with any form of DMV were compared to those with no DMV in terms of baseline sociodemographic and clinical characteristics, treatment outcomes, and treatment features.

RESULTS

Minor baseline clinical characteristics and treatment feature differences were found between participants with and without DMV. Participants with classic morning DMV had slightly higher response rates than those without DMV. However, no differences were found in response or remission between either group of participants with DMV and those with no DMV.

CONCLUSION

DMV does not appear to be associated with a unique prominent pattern of response to selective serotonin reuptake inhibitor treatment in patients with depression, and does not appear to be a serotonergically modulated process. Further evaluation is necessary to determine if this relationship holds true for dopaminergic and noradrenergic antidepressant agents, such as dual-acting agents or antidepressant medication combinations.

Identifying risk for attrition during treatment for depression

BACKGROUND

Understanding patients' ambivalence about treatment persistence may be useful in tailoring retention interventions for individual patients with major depressive disorder.

METHODS

Participants (n = 265) with major depressive disorder were enrolled into an 8-week trial with a selective serotonin reuptake inhibitor. At baseline and week 2, the participants were asked about their intent to return for the next visit, complete the study and continue in the study should they experience side effects or no improvement. Dropouts were defined as participants who discontinued attending clinic visits before completing the trial.

RESULTS

Participants who at baseline reported an uncertain/negative intent to continue if they experienced side effects or no improvement dropped out at a significantly higher rate by weeks 6 and 8. Uncertain/negative intent at week 2 predicted attrition at all following visits. Dropouts without side effects were more likely to have reported an uncertain/negative intent to attend at both baseline and week 2, while dropouts who experienced side effects were more likely to have reported an uncertain/negative intent to attend only at baseline. Positive intent to continue was associated with greater symptom improvement in both dropouts and completers despite the possibility of lack of efficacy.

CONCLUSIONS

Participants' pretreatment concerns about continuing antidepressant treatment in the presence of side effects signals challenges to the completion of a full 8-week acute phase treatment, even if the participant does not develop side effects. Individualized review of concerns and tailoring appropriate interventions may be necessary to reduce attrition.

Family history of depression and therapeutic outcome: findings from STAR*D

OBJECTIVE

It is unclear whether a positive family history of depression affects the clinical presentation or effectiveness of treatment for major depressive disorder (MDD). We aimed to determine whether depressed patients with a positive family history of depression differed from those without in terms of baseline sociodemographic and clinical characteristics, including concurrent comorbid conditions and treatment outcome with citalopram in a large, multicenter effectiveness trial.

METHOD

Clinical outcome and sociodemographic information were collected on 2876 participants with DSM-IV MDD enrolled from July 2001 through April 2004 in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Participants with and without a family history of depression, as determined by self-report at initial assessment, were compared.

RESULTS

Over half (55.6%) (1585/2853) of the evaluable sample reported a positive family history of depression. A positive family history of depression was associated with an earlier age at onset of MDD, a longer length of illness, and more comorbid generalized anxiety disorder and prior suicide attempts. These participants had a slightly faster onset of remission, and slightly greater side effect burden, but they did not differ overall in response or remission rates.

CONCLUSIONS

A family history of depression was associated with several clinical characteristics, although its usefulness as a predictor of treatment outcome is questionable. The slightly faster remission with an SSRI despite the slightly greater side effect burden indicates the effectiveness of using an SSRI in treating depressed patients both with and without a family history of depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00021528.

Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome

BACKGROUND

Depressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor).

METHODS

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups.

RESULTS

Participants with non-psychotic MDD and comorbid anxiety and/or substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed outcomes generally intermediate between those with both and those with neither.

CONCLUSIONS

Comorbid anxiety and/or substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.

Do depressed patients with diabetes experience more side effects when treated with CitalopramThan their counterparts without diabetes? a STAR*D study

OBJECTIVE

Diabetes mellitus (DM) is often comorbid with major depressive disorder, yet the impact and types of side effects experienced by patients with DM receiving antidepressant treatment have not been examined. This study examined antidepressant treatment side effects in depressed patients with and without DM to determine whether side effects differed between groups.

METHOD

From July 2001 through April 2004, the Sequenced Treatment Alternatives to Relieve Depression study enrolled 2,876 outpatients with DSM-IV major depressive disorder from primary and psychiatric care settings. The current study compared participants with and without DM regarding frequency, intensity, and burden of side effects-using the Frequency, Intensity, and Burden of Side Effects Rating (FIBSER)-and types of side effects experienced when treated with citalopram (12-14 weeks, 20-60 mg/d).

RESULTS

There was no statistically significant difference in the maximum rating of side effects during treatment between participants with and without DM. At the last clinic visit, participants with DM reported fewer and less intense side effects and less impairment from side effects than those without DM (after adjustment for confounding effects of age, race, Hispanic ethnicity, employment status, family history of depression, anxious depression, atypical depression, age at first major depressive episode, and length of illness). However, those with DM had more side effect symptoms consistent with the diagnosis of DM (eg, blurred vision and tremors).

CONCLUSIONS

Participants with DM reported experiencing side effects at lower rates than those without DM. After statistical adjustment, the groups did not differ significantly regarding types of side effects experienced.

Sex differences in depression symptoms in treatment-seeking adults: confirmatory analyses from the Sequenced Treatment Alternatives to Relieve Depression study

BACKGROUND

Although epidemiologic research consistently reports greater prevalence of major depressive disorder in women, small sample sizes in many studies do not allow for full elaboration of illness characteristics. This article examines sex differences in terms of illness attributes in a cohort of 2541 outpatients from across the United States who enrolled in the Sequenced Treatment Alternatives to Relieve Depression study.

METHODS

Confirmatory analyses were performed in 2541 outpatients comparing men and women with regard to sociodemographic features, comorbid Axis I and Axis III conditions, and illness characteristics. Results were compared with those of our previous report on the initial population of the first 1500 individuals enrolled in Sequenced Treatment Alternatives to Relieve Depression study.

RESULTS

In both samples, nearly two thirds of the sample (62.5%) were women. Women had greater symptom severity, but men had more episodes of major depression, despite no difference in the length of illness. No differences in age of onset emerged. As in the first cohort, women showed greater rates of an anxiety disorder, bulimia, and somatoform disorder, as well as more past suicide attempts, whereas men showed more alcohol and substance abuse. Women reported more appetite, weight, hypersomnia, interpersonal sensitivity, gastrointestinal and pain complaints, and less suicidal ideation. Irritability was equally common in men and women.

CONCLUSION

This large analysis confirmed most of the clinical features and comorbidities found to be more prevalent in the first cohort of women. In addition, this analysis corroborated previous research suggesting higher rates of atypical and anxious depression in women but refuted the notion of an "irritable depression" found in men. The report confirmed the 1.7:1 ratio for depression seen across sexes in the National Comorbidity Survey.

Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report

OBJECTIVE

About half of outpatients with major depressive disorder also have clinically meaningful levels of anxiety. The authors conducted a secondary data analysis to compare antidepressant treatment outcomes for patients with anxious and nonanxious major depression in Levels 1 and 2 of the STAR*D study.

METHOD

A total of 2,876 adult outpatients with major depressive disorder, enrolled from 18 primary and 23 psychiatric care sites, received citalopram in Level 1 of STAR*D. In Level 2, a total of 1,292 patients who did not remit with or tolerate citalopram were randomly assigned either to switch to sustained-release bupropion (N=239), sertraline (N=238), or extended-release venlafaxine (N=250) or to continue taking citalopram and receive augmentation with sustained-release bupropion (N=279) or buspirone (N=286). Treatment could last up to 14 weeks in each level. Patients were designated as having anxious depression if their anxiety/somatization factor score from the 17-item Hamilton Depression Rating Scale (HAM-D) was 7 or higher at baseline. Rates of remission and response as well as times to remission and response were compared between patients with anxious depression and those with nonanxious depression.

RESULTS

In Level 1 of STAR*D, 53.2% of patients had anxious depression. Remission was significantly less likely and took longer to occur in these patients than in those with nonanxious depression. Ratings of side effect frequency, intensity, and burden, as well as the number of serious adverse events, were significantly greater in the anxious depression group. Similarly, in Level 2, patients with anxious depression fared significantly worse in both the switching and augmentation options.

CONCLUSIONS

Anxious depression is associated with poorer acute outcomes than nonanxious depression following antidepressant treatment.

Electronic source materials in clinical research: acceptability and validity of symptom self-rating in major depressive disorder

OBJECTIVES

Clinical research projects gather large amounts of data. Typically, information is captured on paper source documents for later transcription to an electronic format, where responses can be checked, and errors, omissions, and inconsistencies can be resolved. These steps contribute delays, cost, and complexity to clinical research, particularly in large-scale multi-site investigations. To address these issues, we used a mobile computing device with a touch-screen display ("tablet PC") to capture clinical data from depressed patients directly into electronic format. We then examined ease of use, the equivalence of responses between paper and electronic methods, and the acceptability of the tablet PC for this clinical population.

SETTINGS

Outpatient clinics at four medical centers.

METHODS

80 adults with major depressive disorder (MDD) completed the 16-item Quick Inventory of Depressive Symptomatology--Self-Rated (QIDS-SR(16)), using both traditional paper forms and an electronic representation of the same questions; participants also completed a survey to evaluate their experience.

RESULTS

QIDS-SR(16) responses from paper and electronic versions were highly correlated (mean total: 15.3 (SD=5.2) electronic vs. 15.1 (SD=5.2) paper format), and showed high inter-rating reliability for overall score (intra-class correlation 0.987 (with a 95%CI [0.979,0.992])) and high degree of association for individual symptom items. Participants found both methods acceptable and overall found the electronic implementation easier to use.

CONCLUSIONS

QIDS-SR(16) values collected electronically from research participants were equivalent to those collected using traditional paper self-assessment forms. Participants with MDD found the tablet PC version to be acceptable and easier to use than the paper forms.

Effect of age at onset on the course of major depressive disorder

OBJECTIVE

This report assesses whether age at onset defines a specific subgroup of major depressive disorder in 4,041 participants who entered the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.

METHOD

The study enrolled outpatients 18-75 years of age with nonpsychotic major depressive disorder from both primary care and psychiatric care practices. At study entry, participants estimated the age at which they experienced the onset of their first major depressive episode. This report divides the population into five age-at-onset groups: childhood onset (ages <12), adolescent onset (ages 12-17), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late adult onset (ages > or =60).

RESULTS

No group clearly stood out as distinct from the others. Rather, the authors observed an apparent gradient, with earlier ages at onset associated with never being married, more impaired social and occupational function, poorer quality of life, greater medical and psychiatric comorbidity, a more negative view of life and the self, more lifetime depressive episodes and suicide attempts, and greater symptom severity and suicidal ideation in the index episode compared to those with later ages at onset of major depressive disorder.

CONCLUSIONS

Although age at onset does not define distinct depressive subgroups, earlier onset is associated with multiple indicators of greater illness burden across a wide range of indicators. Age of onset was not associated with a difference in treatment response to the initial trial of citalopram.

Diurnal mood variation in outpatients with major depressive disorder: implications for DSM-V from an analysis of the Sequenced Treatment Alternatives to Relieve Depression Study data

OBJECTIVE

Diurnal mood variation (DMV) with early morning worsening is considered a classic symptom of melancholic features in The Diagnostic and Statistical Manual of Mental Disorders (DSM) as well as The International Classification of Diseases (ICD) criteria for somatic major depressive disorder (MDD). Using the unique opportunity afforded by the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study data, we examined whether DMV with afternoon or evening worsening, in addition to classic early morning worsening, was related to other symptom constructs to determine whether the exclusive reliance on morning worsening is justified in defining melancholic features.

METHOD

Baseline demographic and clinical characteristics, as well as depressive symptoms, including DMV, were evaluated in 3744 outpatients with nonpsychotic MDD enrolled in the STAR*D study.

RESULTS

DMV in at least one of the time periods was reported by 22.4% (N = 837) of the sample. Only 3.3% (N = 28) of these 837 patients with DMV attributed it to environmental factors. Of the 809 participants (96.7%) with DMV unrelated to environmental events, only 31.9% (N = 258) reported morning worsening, while 19.5% (N = 158) and 48.6% (N = 393) reported afternoon and evening worsening, respectively. Minimal distinctions in demographic characteristics, clinical features, and depressive symptoms were found between participants with morning worsening and those with either afternoon or evening worsening. More importantly, other melancholic symptom features were associated with DMV regardless of time of worsening.

CONCLUSION

DMV was meaningfully related to other melancholia criteria regardless of when the DMV occurred. If replicated, these findings suggest that DMV as a component of melancholic features might be expanded to include any DMV, not simply early morning worsening.

Predictors of attrition during initial (citalopram) treatment for depression: a STAR*D report

OBJECTIVE

Premature attrition from treatment may lead to worse outcomes and compromise the integrity of clinical trials in major depressive disorder. The purpose of this study was to identify the pretreatment predictors of attrition during acute treatment with citalopram in a large, "real world" clinical trial.

METHOD

A total of 4,041 adult outpatients with nonpsychotic major depressive disorder were enrolled in treatment with citalopram for up to 14 weeks. Attrition was defined as "immediate" (patients who attended a baseline visit only) or "later" (patients who attended at least one postbaseline visit but who dropped out before the 12-week visit).

RESULTS

Overall, 26% of enrolled patients dropped out of the acute phase treatment for nonmedical reasons. Of these, 34% dropped out immediately, 59% dropped out by week 12, and 7% dropped out after 12 weeks. Immediate attrition was associated with younger age, less education, and higher perceived mental health functioning. Attrition later in treatment was associated with younger age, less education, and African American race. Experience with more than one episode of depression was associated with less attrition.

CONCLUSIONS

In clinical trials and clinical practice, several time points in treatment may provide opportunities to engage and encourage populations at higher risk for attrition and populations with high-risk presentation of illness. Additionally, more aggressive forms of treatment implemented earlier in the treatment process in order to increase the likelihood of more rapid efficacy may reduce dropout rates.

Substance use disorder comorbidity in major depressive disorder: a confirmatory analysis of the STAR*D cohort

The demographics and clinical features were compared between those with (29.4%) and without concurrent substance use disorder (SUD) in 2541 outpatients with major depression (MDD) enrolled in the Sequenced Treatment Alternatives to Relieve Depression study. Compared to those without SUD, MDD patients with concurrent SUD were more likely to be younger, male, divorced or never married, and at greater current suicide risk, and have an earlier age of onset of depression, greater depressive symptomatology, more previous suicide attempts, more frequent concurrent anxiety disorders, and greater functional impairment (p = 0.048 to <0.0001). They were also less likely to be Hispanic and endorse general medical comorbidities (p = 0.006 and 0.002, respectively).

Family history of mood disorder and characteristics of major depressive disorder: a STAR*D (sequenced treatment alternatives to relieve depression) study

INTRODUCTION

Clinicians routinely ask patients with major depressive disorder (MDD) about their family history. It is unknown, however, if patients who report a positive family history differ from those who do not. This study compared the demographic and clinical features of a large cohort of treatment-seeking outpatients with non-psychotic MDD who reported that they did or did not have at least one first-degree relative who had either MDD or bipolar disorder.

METHODS

Subjects were recruited for the STAR( *)D multicenter trial. Differences in demographic and clinical features for patients with and without a family history of mood disorders were assessed after correcting for age, sex, race, and ethnicity.

RESULTS

Patients with a family history of mood disorder (n=2265; 56.5%) were more frequently women and had an earlier age of onset of depression, as compared to those without such a history (n=1740; 43.5%). No meaningful differences were found in depressive symptoms, severity, recurrence, depressive subtype, or daily function.

CONCLUSIONS

Women were twice as likely as men to report a positive family history of mood disorder, and a positive family history was associated with younger age of onset of MDD in the proband. Consistent with prior research, early age of onset appears to define a familial and, by extension, genetic subtype of major depressive disorder.

Insured and non-insured depressed outpatients: how do they compare?

BACKGROUND

The purpose of this study was to examine associations between clinical and demographic characteristics of depressed patients and source of payment for care. We attempted to confirm and extend findings from a previous study regarding the first 1500 participants enrolled in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study with 2541 participants enrolled in later stages of the trial.

METHODS

Demographic, clinical, and presenting symptom features were compared among participants with public, private or no insurance.

RESULTS

Compared to those having private or no insurance, participants with public insurance were older; more likely to be women, Hispanic, widowed or divorced, unemployed, and less educated; were more frequently seen in primary care; had greater medical comorbidity and functional impairment, and a later age of depression onset. The publicly insured also had a longer current episode, but fewer episodes over their lifetime. Both the publicly insured and the uninsured had poorer life satisfaction compared to those with private insurance. Participants without insurance were intermediate between those with public and private insurance regarding several demographic characteristics and measures of severity.

CONCLUSIONS

Depressed outpatients with public insurance demonstrated greater functional impairment, though they did not have a more severe depression per se. Participants without insurance seemed to be a heterogeneous group with a presentation intermediate between those with public and private insurance. Those with public insurance were overrepresented in primary care clinics; therefore, clinicians in these settings need to be particularly vigilant in recognizing depression and offering appropriate treatments.

Major depression symptoms in primary care and psychiatric care settings: a cross-sectional analysis

PURPOSE

We undertook a study to confirm and extend preliminary findings that participants with major depressive disorder (MDD) in primary care and specialty care settings have with equivalent degrees of depression severity and an indistinguishable constellation of symptoms.

METHODS

Baseline data were collected for a distinct validation cohort of 2,541 participants (42% primary care) from 14 US regional centers comprised of 41 clinic sites (18 primary care, 23 specialty care). Participants met broadly inclusive eligibility criteria requiring a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of MDD and a minimum depressive symptom score on the 17-item Hamilton Rating Scale for Depression. The main outcome measures were the 30-item Inventory of Depressive Symptomatology--Clinician Rated and the Psychiatric Diagnostic Screening Questionnaire.

RESULTS

Primary care and specialty care participants had identical levels of moderately severe depression and identical distributions of depressive severity scores. Both primary care and specialty care participants showed considerable suicide risk, with specialty care participants even more likely to report prior suicide attempts. Core depressive symptoms or concurrent psychiatric disorders were not substantially different between settings. One half of participants in each setting had an anxiety disorder (48.6% primary care vs 51.6% specialty care, P = .143), with social phobia being the most common (25.3% primary care vs 32.1% specialty care, P = .002).

CONCLUSIONS

For outpatients with nonpsychotic MDD, depressive symptoms and severity vary little between primary care and specialty care settings. In this large, broadly inclusive US sample, the risk factors for chronic and recurrent depressive illness were frequently present, highlighting a clear risk for treatment resistance and the need for aggressive management strategies in both settings.