Multimethod assessment of baseline depression and relationship to hepatitis C treatment discontinuation

Objective The primary study objective is to determine which measures of depression are associated with early discontinuation of hepatitis C virus infection treatment and to determine which measure best characterizes the depression that develops during treatment. Methods Seventy-eight treatment-naïve subjects who initiated pegylated interferon/ribavirin treatment for hepatitis C virus infection were included. Baseline depression was assessed with the Structured Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the Hamilton Depression Rating Scale, and the Beck Depression Inventory-II. The latter two measures were repeated at treatment weeks 12 and 24. Results Depression scores, as measured by the three instruments, lacked adequate consistency. Baseline depression as measured by the Beck Depression Inventory-II, but not by the other scales, was associated with early treatment discontinuation at weeks 12 and 24. Changes in depression during treatment were restricted to somatic symptoms. Of those who completed treatment, those who were not depressed at baseline tended to demonstrate significant depression increases during treatment. Conclusion The Beck Depression Inventory-II is recommended to assess depression prior to hepatitis C virus infection treatment. Somatic symptoms of depression should be monitored during treatment. Baseline depression as measured by the Beck Depression Inventory-II was associated with early treatment discontinuation. The Beck Depression Inventory-II, Structured Interview for DSM-IV, and Hamilton Depression Rating Scale yielded results that were not consistent with each other in this sample. Future research should focus on standardizing depression assessment in medically ill populations to identify measures that predict treatment discontinuation.

Use of Peer Staff in a Critical Time Intervention for Frequent Users of a Psychiatric Emergency Room

Project Connect, a clinical demonstration program developed in consultation with the New York State Office of Mental Health, adapted critical time intervention for frequent users of a large urban psychiatric emergency room (ER). Peer staff provided frequent users with time-limited care coordination. Participants increased their use of outpatient services over 12 months, compared with a similar group not enrolled in the program. For persons with significant general medical, psychiatric, and social needs, provision of this intervention alone is unlikely to reduce reliance on ERs, especially among homeless individuals.

Multiple Family Groups for Children with Disruptive Behavior Disorders: Child Outcomes at 6-Month Follow-Up

This paper reports on the 6-month follow-up outcomes of an effectiveness study testing a multiple family group (MFG) intervention for clinic-referred youth (aged 7-11) with disruptive behavior disorders (DBDs) and their families in socioeconomically disadvantaged families compared to services-as-usual (SAU) using a block comparison design. The settings were urban community-based outpatient mental health agencies. Clinic-based providers and family partner advocates facilitated the MFG intervention. Parent-report measures targeting child behavior, social skills, and impairment across functional domains (i.e., relationships with peers, parents, siblings, and academic progress) were assessed across four timepoints (baseline, mid-test, post-test, and 6-month follow-up) using mixed effects regression modeling. Compared to SAU participants, MFG participants reported significant improvement at 6-month follow-up in child behavior, impact of behavior on relationship with peers, and overall impairment/need for services. Findings indicate that MFG may provide longer-term benefits for youth with DBDs and their families in community-based settings. Implications within the context of a transforming healthcare system are discussed.

Using claims data to generate clinical flags predicting short-term risk of continued psychiatric hospitalizations

OBJECTIVE

As health information technology advances, efforts to use administrative data to inform real-time treatment planning for individuals are increasing, despite few empirical studies demonstrating that such administrative data predict subsequent clinical events. Medicaid claims for individuals with frequent psychiatric hospitalizations were examined to test how well patterns of service use predict subsequent high short-term risk of continued psychiatric hospitalizations.

METHODS

Medicaid claims files from New York and Pennsylvania were used to identify Medicaid recipients ages 18-64 with two or more inpatient psychiatric admissions during a target year ending March 31, 2009. Definitions from a quality-improvement initiative were used to identify patterns of inpatient and outpatient service use and prescription fills suggestive of clinical concerns. Generalized estimating equations and Markov models were applied to examine claims through March 2011, to see what patterns of service use were sufficiently predictive of additional hospitalizations to be clinically useful.

RESULTS

A total of 11,801 individuals in New York and 1,859 in Pennsylvania identified met the cohort definition. In both Pennsylvania and New York, multiple recent hospitalizations, but not failure to use outpatient services or failure to fill medication prescriptions, were significant predictors of high risk of continued frequent hospitalizations, with odds ratios greater than 4.0.

CONCLUSIONS

Administrative data can be used to identify individuals at high risk of continued frequent hospitalizations. Payers and system administrators could use such information to authorize special services (such as mobile outreach) for such individuals to promote service engagement and prevent rapid rehospitalizations.

Bias due to sample selection in propensity score matching for a supportive housing program evaluation in New York City

Objectives

Little is known about influences of sample selection on estimation in propensity score matching. The purpose of the study was to assess potential selection bias using one-to-one greedy matching versus optimal full matching as part of an evaluation of supportive housing in New York City (NYC).

Study Design and Settings

Data came from administrative data for 2 groups of applicants who were eligible for an NYC supportive housing program in 2007–09, including chronically homeless adults with a substance use disorder and young adults aging out of foster care. We evaluated the 2 matching methods in their ability to balance covariates and represent the original population, and in how those methods affected outcomes related to Medicaid expenditures.

Results

In the population with a substance use disorder, only optimal full matching performed well in balancing covariates, whereas both methods created representative populations. In the young adult population, both methods balanced covariates effectively, but only optimal full matching created representative populations. In the young adult population, the impact of the program on Medicaid expenditures was attenuated when one-to-one greedy matching was used, compared with optimal full matching.

Conclusion

Given covariate balancing with both methods, attenuated program impacts in the young adult population indicated that one-to-one greedy matching introduced selection bias.

Donepezil treatment of older adults with cognitive impairment and depression (DOTCODE study): clinical rationale and design

Treatment strategies for patients with depression and cognitive impairment (DEP-CI), who are at high risk to develop a clinical diagnosis of dementia, are not established. This issue is addressed in the donepezil treatment of cognitive impairment and depression (DOTCODE) pilot clinical trial. The DOTCODE study is the first long-term treatment trial that assesses differences in conversion to dementia and cognitive change in DEP-CI patients using a study design of open antidepressant medication plus add-on randomized, double-blind, placebo-controlled treatment with the acetylcholinesterase inhibitor donepezil. In Phase 1, DEP-CI patients receive optimized antidepressant treatment for 16 weeks. In Phase 2, antidepressant treatment is continued with the addition of randomized, double-blind treatment with donepezil or placebo. The total study duration for each patient is 78 weeks (18 months). Eighty DEP-CI outpatients (age 55 to 95 years) are recruited: 40 at New York State Psychiatric Institute/Columbia University and 40 at Duke University Medical Center. The primary outcome is conversion to a clinical diagnosis of dementia. The secondary outcomes are cognitive change scores in Selective Reminding Test (SRT) total recall and the modified Alzheimer's Disease Assessment Scale (ADAS-cog). Other key assessments include the 24-item Hamilton Depression Rating Scale and antidepressant response; Clinical Global Impression (CGI) for depression, cognition, and global status; neuropsychological test battery for diagnosis; informant report of functional abilities (Pfeffer FAQ); and Treatment Emergent Symptom Scale (TESS) for somatic side effects. Apolipoprotein E ε4 status, odor identification deficits, and MRI entorhinal/hippocampal cortex atrophy at baseline are evaluated as neurobiological moderators of donepezil treatment effects.

Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial

IMPORTANCE

Obsessive-compulsive disorder (OCD) is one of the world's most disabling illnesses according to the World Health Organization. Serotonin reuptake inhibitors (SRIs) are the only medications approved by the Food and Drug Administration to treat OCD, but few patients achieve minimal symptoms from an SRI alone. In such cases, practice guidelines recommend adding antipsychotics or cognitive-behavioral therapy consisting of exposure and ritual prevention (EX/RP).

OBJECTIVE

To compare the effects of these 2 SRI augmentation strategies vs pill placebo for the first time, to our knowledge, in adults with OCD.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial (conducted January 2007-August 2012) at 2 academic outpatient research clinics that specialize in OCD and anxiety disorders. Patients (aged 18-70 years) were eligible if they had OCD of at least moderate severity despite a therapeutic SRI dose for at least 12 weeks prior to entry. Of 163 who were eligible, 100 were randomized (risperidone, n = 40; EX/RP, n = 40; and placebo, n = 20), and 86 completed the trial.

INTERVENTIONS

While continuing their SRI at the same dose, patients were randomized to the addition of 8 weeks of risperidone (up to 4 mg/d), EX/RP (17 sessions delivered twice weekly), or pill placebo. Independent assessments were conducted every 4 weeks.

MAIN OUTCOME AND MEASURE

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to measure OCD severity.

RESULTS

Patients randomized to EX/RP had significantly greater reduction in week 8 Y-BOCS scores based on mixed-effects models (vs risperidone: mean [SE], -9.72 [1.38]; P < .001 vs placebo: mean [SE], -10.10 [1.68]; P < .001). Patients receiving risperidone did not significantly differ from those receiving placebo (mean [SE], -0.38 [1.72]; P = .83). More patients receiving EX/RP responded (Y-BOCS score decrease ≥25%: 80% for EX/RP, 23% for risperidone, and 15% for placebo; P < .001). More patients receiving EX/RP achieved minimal symptoms (Y-BOCS score ≤12: 43% for EX/RP, 13% for risperidone, and 5% for placebo; P = .001). Adding EX/RP was also superior to risperidone and placebo in improving insight, functioning, and quality of life.

CONCLUSIONS AND RELEVANCE

Adding EX/RP to SRIs was superior to both risperidone and pill placebo. Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered EX/RP before antipsychotics given its superior efficacy and less negative adverse effect profile.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00389493.

Impact of hepatitis C treatment initiation on adherence to concomitant medications

Our study investigated whether initiating hepatitis C virus (HCV) treatment affected adherence to concomitant medications. Mixed-effects linear regression was used to analyze data from 57 patients (29 co-infected with HIV) in a prospective study of HCV treatment-naïve patients initiating HCV treatment. Adherence was assessed using structured self-report at the time of treatment initiation, and at 12 weeks and 24 weeks into treatment. There was no change in adherence to concomitant medications over the first 24 weeks of HCV treatment. There was a significant interaction effect such that the change in adherence to concomitant medications between baseline and 12 weeks differed between the HIV-infected and HIV-uninfected patients. Adherence to concomitant medications in the HIV-infected patients was found to decrease, whereas adherence in the HIV-uninfected patients was found to increase. HIV-infected patients may be more at risk for adherence problems in the first 12 weeks of HCV treatment as compared to HIV-uninfected patients.

Generalizability in the family-to-family education program randomized waitlist-control trial

OBJECTIVE

Randomized controlled trials (RCTs) may have limited generalizability for the community when a high proportion of individuals refuse randomization or otherwise do not participate-a not uncommon phenomenon. A randomized waitlist-control trial of the Family-to-Family (FTF) education program, a 12-week course offered by the National Alliance on Mental Illness for family members of adults with mental illness, was previously reported. This study assessed whether the RCT-derived estimates of effectiveness of FTF were generalizable to individuals who participated in FTF but declined participation in the RCT.

METHODS

Propensity score matching was used to create five quintiles, each containing scores for individuals in FTF or waitlist conditions and for decliners; scores were matched on multiple baseline characteristics (N=442) within each quintile. Effectiveness estimates, with standard errors, were derived for the decliner population on the basis of effectiveness estimates derived from participants in the RCT; estimates were weighted to the baseline distribution of quintiles for the decliners.

RESULTS

For each outcome, estimates of the effect sizes observed in the RCT were very similar to the effect sizes observed for the decliner population; confidence intervals also had a high degree of overlap.

CONCLUSIONS

This study suggests that the benefits of FTF observed in the RCT are generalizable to the group of individuals who declined RCT participation, providing further evidence of FTF's effectiveness. Propensity score matching was a useful statistical tool for addressing selection bias resulting from high rates of nonconsent in randomized waitlist-control trials.

A randomized, prospective pilot study of patient expectancy and antidepressant outcome

BACKGROUND

This study is a randomized, prospective, investigation of the relationships between clinical trial design, patient expectancy and the outcome of treatment with antidepressant medication. Method Adult out-patients with major depressive disorder (MDD) were randomized to either placebo-controlled (PC, 50% probability of receiving active medication) or comparator (COMP, 100% probability of receiving active medication) administration of antidepressant medication. Independent-samples t tests and analysis of covariance (ANCOVA) were used to determine whether the probability of receiving active medication influenced patient expectancy and to compare medication response in the PC v. COMP conditions. We also tested the correlations between baseline expectancy score and final improvement in depressive symptoms across study groups.

RESULTS

Subjects randomized to the COMP condition reported greater expectancy of improvement compared to subjects in the PC condition (t = 2.60, df = 27, p = 0.015). There were no statistically significant differences in the analyses comparing antidepressant outcomes between subjects receiving medication in the COMP condition and those receiving medication in the PC condition. Higher baseline expectancy of improvement was correlated with lower final depression severity scores (r = 0.53, p = 0.021) and greater improvement in depressive symptoms over the course of the study (r = 0.44, p = 0.058).

CONCLUSIONS

The methods described represent a promising way of subjecting patient expectancy to scientific study. Expectancy of improvement is affected by the probability of receiving active antidepressant medication and seems to influence antidepressant response.

Engagement in Trauma-Specific CBT for Youth Post-9/11

Treatment participation was examined among youth enrolled in an evaluation of cognitive behavioral therapy (CBT) for trauma following the 9/11 World Trade Center disaster. Staff at nine agencies serving a predominantly low-income ethnically diverse population were trained to deliver CBT and structured engagement strategies. Four hundred and forty-five youth ages 5-19 were eligible for CBT, and 417 (94%) received at least one treatment session. Pretreatment and treatment show rates and overall dose were examined. Treatment participation rates were higher than those typically reported in community studies of children's mental health services. Regression analyses indicated variability across sites in treatment show rates with the highest rates at where services were delivered in schools. However, sites, demographic factors and trauma symptoms accounted for a small amount of variance in treatment participation overall. The study suggests structured engagement strategies, linked to evidence-based treatments may improve treatment participation for youth.

Estimating the causal effect of randomization versus treatment preference in a doubly randomized preference trial

Although randomized studies have high internal validity, generalizability of the estimated causal effect from randomized clinical trials to real-world clinical or educational practice may be limited. We consider the implication of randomized assignment to treatment, as compared with choice of preferred treatment as it occurs in real-world conditions. Compliance, engagement, or motivation may be better with a preferred treatment, and this can complicate the generalizability of results from randomized trials. The doubly randomized preference trial (DRPT) is a hybrid randomized and nonrandomized design that allows for estimation of the causal effect of randomization versus treatment preference. In the DRPT, individuals are first randomized to either randomized assignment or choice assignment. Those in the randomized assignment group are then randomized to treatment or control, and those in the choice group receive their preference of treatment versus control. Using the potential outcomes framework, we apply the algebra of conditional independence to show how the DRPT can be used to derive an unbiased estimate of the causal effect of randomization versus preference for each of the treatment and comparison conditions. Also, we show how these results can be implemented using full matching on the propensity score. The methodology is illustrated with a DRPT of introductory psychology students who were randomized to randomized assignment or preference of mathematics versus vocabulary training. We found a small to moderate benefit of preference versus randomization with respect to the mathematics outcome for those who received mathematics training.

Adolescent-adult discrepancies on the eating disorder examination: a function of developmental stage or severity of illness?

OBJECTIVE

Across studies, adolescents score lower on measures of eating disorder pathology than adults, but it is unclear whether such findings reflect discrepancies inherent to site/study or true developmental differences. The aim of this study was to determine whether age predicts subscale and diagnostic scores of the Eating Disorder Examination (EDE) in adolescents and adults with anorexia nervosa (AN) admitted to a single research center within the same period of time.

METHOD

The sample consisted of 16 adolescent and 20 adult consecutive admissions to parallel, age-specific, research-based AN treatment programs. Participants completed a baseline evaluation at admission that included the EDE, depression measures, and global assessment of functioning scales.

RESULTS

Age significantly predicted EDE scores in univariate regression analyses. However, in multivariate models that included severity indices of general and specific psychopathology as covariates, age was no longer a significant predictor of severity of eating disorder symptoms.

DISCUSSION

This study adds to the growing body of data showing lower scores on the EDE for adolescents with AN relative to their adult counterparts, while eliminating potential site confounds. Results indicate that the higher adult scores may be carried in part by a more overall severe and chronic general clinical profile.

Minocycline augmentation of pharmacotherapy in obsessive-compulsive disorder: an open-label trial

not applicable, since submission is “letter to the editor.”

Post-approval drug safety surveillance

Following the drug-approval process, concerns remain regarding the safety of new drugs that are introduced into the marketplace. In the case of rare adverse events, the number of subjects that are treated in randomized controlled trials is invariably inadequate to determine the safety of the new pharmaceutical. Identifying safety signals for new and/or existing drugs is a major priority in the protection of public health. Unfortunately, design, analysis, and available data are often quite limited for detecting in a timely fashion any potentially harmful effects of drugs. In this review, we examine a variety of approaches for determining the possibility of adverse drug reactions. Our review includes spontaneous reports, meta-analysis of randomized controlled clinical trials, ecological studies, and analysis of medical claims data. We consider both experimental design and analytic problems as well as potential solutions. Many of these methodologies are then illustrated through application to data on the possible relationship between taking antidepressants and increased risk of suicidality.

Prevalence and patient awareness of medical comorbidities in an urban AIDS clinic

Mortality in HIV-positive persons is increasingly due to non-HIV-related medical comorbidities. There are limited data on the prevalence and patient awareness of these comorbid conditions. Two hundred subjects at an urban HIV clinic were interviewed in 2005 to assess their awareness of 15 non-HIV-related medical comorbidities, defined as medical problems that are neither AIDS-defining by standard definitions, nor a direct effect of immune deficiency. Medical charts were subsequently reviewed to establish prevalence and concordance between self-report and chart documentation. Eighty-four percent of subjects self-reported at least 1 of 15 medical comorbidities and 92% had at least 1 condition chart-documented. The top 5 chart-documented conditions were hepatitis C (51.5%), pulmonary disease (28.5%), high blood pressure (27%), high cholesterol (24.5%), and obesity (22.5%). In multivariate analysis, higher number of non-HIV-related medical comorbidities was associated with older age, female gender, and intravenous drug use as route of HIV transmission. Across self-reported non-HIV-related medical comorbidities, the absolute concordance rate ranged from 67% to 96%, the sensitivity ranged from 0% to 79%; the positive predictive value ranged from 0% to 100%. While the vast majority of largely urban minority HIV-positive subjects were diagnosed with non-HIV-related medical comorbidities, there is significant room for improvement in patient awareness. In order to help patients optimally access and adhere to medication and medical care for these non-HIV-related medical comorbidities, interventions and educational campaigns to improve patient awareness that take cultural background, literacy, and educational level into account should be developed, implemented, and evaluated.

Adverse reactions to over-the-counter cough and cold products among children: the cases managed out of hospitals

BACKGROUND AND OBJECTIVE

Prompted by continuing concerns about the safety of over-the-counter (OTC) cough and cold medications, we examined the frequency and severity of pediatric adverse drug reactions (ADRs) to OTC cough and cold products reported to a major poison control center. The goal was to focus on cases that are usually managed out of hospitals and may not be recognized by the traditional adverse events surveillance and reporting programs.

METHODS

We conducted a retrospective review of electronic records on ADRs reported to the New Jersey Poison Information and Education System (NJPIES) through the National Poison Data System. Analyses included ADRs involving a single OTC cough and cold product. The number and proportion of reported ADRs to OTC cough and cold medicines were examined and compared by severity level between children <2 years of age, and children from 2 through 11 years of age.

RESULTS

A total of 91 pediatric ADRs to OTC cough and cold products were reported to the NJPIES from 2000 through 2007. Of these, 61 cases (67%) were of minor severity. A larger proportion of the children 2-11 years of age (21.2%), compared with children <2 years of age (8.0%), experienced a reaction of moderate to major severity.

CONCLUSIONS

While we found fewer ADR cases of moderate to major severity in younger children, our results call for a further review of the safety of OTC cough and cold medicines in children 2 years of age and older.

Using Non-experimental Data to Estimate Treatment Effects

While much psychiatric research is based on randomized controlled trials (RCTs), where patients are randomly assigned to treatments, sometimes RCTs are not feasible. This paper describes propensity score approaches, which are increasingly used for estimating treatment effects in non-experimental settings. The primary goal of propensity score methods is to create sets of treated and comparison subjects who look as similar as possible, in essence replicating a randomized experiment, at least with respect to observed patient characteristics. A study to estimate the metabolic effects of antipsychotic medication in a sample of Florida Medicaid beneficiaries with schizophrenia illustrates methods.

Balancing Treatment Comparisons in Longitudinal Studies

<p>Evaluation of treatment efficacy in psychiatric trials involves a comparison of outcomes for those who receive a treatment versus those who receive a control or comparison treatment. However, if the treatment and comparison groups are not comparable or “balanced,” observed differences in outcomes between treated and comparison groups may be due, in part, to these imbalances. In such settings, estimates of treatment efficacy may be biased unless some adjustments are made to make the groups more comparable. </p> <h4>ABOUT THE AUTHORS</h4> <p>Sue M. Marcus, PhD, is with the Department of Psychiatry, Mount Sinai School of Medicine, New York. Juned Siddique, DrPH, is with the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago. Thomas R. Ten Have, PhD, is with the Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia. Robert D. Gibbons, PhD, is Professor of Biostatistics and Psychiatry, and is Director of the Center for Health Statistics, University of Illinois at Chicago. Elizabeth Stuart, PhD, is with the Johns Hopkins Bloomberg School of Public Health, Baltimore. Sharon-Lise T. Normand, PhD, is with the Department of Health Care Policy, Harvard Medical School, and the Department of Biostatistics, Harvard School of Public Health, Boston.</p> <p>Address correspondence to Sue Marcus, PhD, Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, NY 10029; fax 212-860-4630; or e-mail <a href="mailto:sue.marcus@mssm.edu">sue.marcus@mssm.edu</a>.</p> <p>Dr. Marcus, Dr. Siddique, Dr. Ten Have, Dr. Gibbons, Dr. Stuart, and Dr. Normand, have disclosed no relevant financial relationships.</p>

Increased serotonin 2C receptor mRNA editing: a possible risk factor for suicide

Suicide is a major public health problem with approximately 1 million victims each year worldwide. Up to 90% of adults who commit suicide have at least one psychiatric diagnosis such as major depression, bipolar disorder (BPD), schizophrenia (SZ), substance abuse or dependence. A question that has remained unanswered is whether the biological substrates of suicide are distinct from those of the psychiatric disorders in which it occurs. The serotonin 2C receptor (5-HT 2C R) has been implicated in depression and suicide. We, therefore, compared the frequencies of its mRNA editing variants in postmortem prefrontal cortical specimens from subjects who committed suicide or who died from other causes. All suicides occurred in the context of either SZ or BPD. The non-suicide cases included subjects with either SZ or BPD as well as subjects with no psychiatric diagnosis. We identified 5-HT 2CR mRNA editing variations that were associated with suicide but not with the comorbid psychiatric diagnoses, and were not influenced by demographic characteristics (age and sex) and alcohol or drug use. These variations consisted of a significant increase in the pool of mRNA variants (ACD and ABCD) that encode one of the most prevalent and highly edited isoforms of 5-HT 2C R, that is, VSV (Val156-Ser158-Val160). Because the VSV isoform of 5-HT 2C R exhibits low functional activity, an increase in its expression frequency may significantly influence the serotonergic regulation of the brain. Thus, at least in patients with SZ or BPD, overexpression of the VSV isoform in the prefrontal cortex may represent an additional risk factor for suicidal behavior.

Mixed-effects Poisson regression analysis of adverse event reports: the relationship between antidepressants and suicide

A new statistical methodology is developed for the analysis of spontaneous adverse event (AE) reports from post-marketing drug surveillance data. The method involves both empirical Bayes (EB) and fully Bayes estimation of rate multipliers for each drug within a class of drugs, for a particular AE, based on a mixed-effects Poisson regression model. Both parametric and semiparametric models for the random-effect distribution are examined. The method is applied to data from Food and Drug Administration (FDA)'s Adverse Event Reporting System (AERS) on the relationship between antidepressants and suicide. We obtain point estimates and 95 per cent confidence (posterior) intervals for the rate multiplier for each drug (e.g. antidepressants), which can be used to determine whether a particular drug has an increased risk of association with a particular AE (e.g. suicide). Confidence (posterior) intervals that do not include 1.0 provide evidence for either significant protective or harmful associations of the drug and the adverse effect. We also examine EB, parametric Bayes, and semiparametric Bayes estimators of the rate multipliers and associated confidence (posterior) intervals. Results of our analysis of the FDA AERS data revealed that newer antidepressants are associated with lower rates of suicide adverse event reports compared with older antidepressants. We recommend improvements to the existing AERS system, which are likely to improve its public health value as an early warning system.

Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings

The purpose of the study was to examine the rates and inter-relationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care. While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (TWEAK and quantity and frequency of alcohol use in past year), and depression (Center for Epidemiological Studies Depression Scale - CESD and prior history of depression). Over 30% of women reported either violence receipt, alcohol use problems or depression risk. Significant inter-relationships among all measured risk variables were found. Although violence receipt was significantly related to alcohol misuse, cigarette use, less education, and scoring above the cutoff on the CESD (>/= 16) was most strongly associated with violence. Practitioners should be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.

Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents

OBJECTIVE

In 2003 and 2004, U.S. and European regulators issued public health warnings about a possible association between antidepressants and suicidal thinking and behavior. The authors assessed whether these warnings discouraged use of antidepressants in children and adolescents and whether they led to increases in suicide rates as a result of untreated depression.

METHOD

The authors examined U.S. and Dutch data on prescription rates for selective serotonin reuptake inhibitors (SSRIs) from 2003 to 2005 in children and adolescents (patients up to age 19), as well as suicide rates for children and adolescents, using available data (through 2004 in the United States and through 2005 in the Netherlands). They used Poisson regression analyses to determine the overall association between antidepressant prescription rates and suicide rates, adjusted for sex and age, during the periods preceding and immediately following the public health warnings.

RESULTS

SSRI prescriptions for youths decreased by approximately 22% in both the United States and the Netherlands after the warnings were issued. In the Netherlands, the youth suicide rate increased by 49% between 2003 and 2005 and shows a significant inverse association with SSRI prescriptions. In the United States, youth suicide rates increased by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the Centers for Disease Control and Prevention began systematically collecting suicide data in 1979.

CONCLUSIONS

In both the United States and the Netherlands, SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents.

Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets

OBJECTIVE

In late 2006, a U.S. Food and Drug Administration advisory committee recommended that the 2004 black box warning regarding suicidality in pediatric patients receiving antidepressants be extended to include young adults. This study examined the relationship between antidepressant treatment and suicide attempts in adult patients in the Veterans Administration health care system.

METHOD

The authors analyzed data on 226,866 veterans who received a diagnosis of depression in 2003 or 2004, had at least 6 months of follow-up, and had no history of depression from 2000 to 2002. Suicide attempt rates overall as well as before and after initiation of antidepressant therapy were compared for patients who received selective serotonin reuptake inhibitors (SSRIs), new-generation non-serotonergic-specific (non-SSRI) antidepressants (bupropion, mirtazapine, nefazodone, and venlafaxine), tricyclic antidepressants, or no antidepressant. Age group analyses were also performed.

RESULTS

Suicide attempt rates were lower among patients who were treated with antidepressants than among those who were not, with a statistically significant odds ratio for SSRIs and tricyclics. For SSRIs versus no antidepressant, this effect was significant in all adult age groups. Suicide attempt rates were also higher prior to treatment than after the start of treatment, with a significant relative risk for SSRIs and for non-SSRIs. For SSRIs, this effect was seen in all adult age groups and was significant in all but the 18-25 group.

CONCLUSIONS

These findings suggest that SSRI treatment has a protective effect in all adult age groups. They do not support the hypothesis that SSRI treatment places patients at greater risk of suicide.

A comparison of medication side effect reports by panic disorder patients with and without concomitant cognitive behavior therapy

OBJECTIVE

The authors assessed whether adding cognitive behavior therapy (CBT) to imipramine for patients with panic disorder decreased the severity of side effects and dropouts from side effects.

METHOD

Data were analyzed for 172 panic disorder patients who were randomly assigned to receive imipramine alone, imipramine plus CBT, or placebo. Mixed-effects models were used to assess longitudinal differences among the treatment groups with respect to side effect burden and dropout rates during the acute, maintenance, and follow-up phases of treatment.

RESULTS

Patients treated with imipramine plus CBT experienced less severe fatigue/weakness, dry mouth, and sweating and had a lower rate of dropout due to side effects compared with those treated with imipramine only.

CONCLUSIONS

The addition of CBT to medication treatment with imipramine was associated with less severe side effects and fewer dropouts due to perceived side effects than treatment with imipramine alone.

Rater bias in a blinded randomized placebo-controlled psychiatry trial

Rater bias occurs when rater knowledge of treatment assignment modifies the outcome assessment. Raters may be unconsciously influenced by inclinations for or against a particular treatment and consequently may give a more or less generous assessment depending upon these biases. Blinding of raters by keeping raters unaware of treatment assignment is one way to limit bias influencing assessment due to knowledge of treatment assignment. Unblinding may be particularly problematic in efficacy studies comparing placebo to drugs and/or non-drug psychotherapy treatments where subjects may reveal drug side-effects or mention their therapist by name, thus unblinding their treatment assignment. We present a new instrumental variable statistical approach for assessing the association between success in blinding and its impact on efficacy estimates of active drug and/or cognitive behavioural psychotherapy versus placebo in the multicentre comparative treatment study of panic disorder. Despite the uncertainty involved in assessing bias that may be unobserved and unconscious, we will show how to derive a bound for the impact of rater bias.

Simulation of the Syst-Eur randomized control trial using a primary care electronic medical record was feasible

OBJECTIVE

To determine the validity of outcome research using a primary care practice database by comparing a randomized controlled trial (RCT) with a simulated one.

STUDY DESIGN AND SETTING

A cohort from the United Kingdom General Practice Research Database (GPRD) was used to simulate the Systolic Hypertension in Europe (Syst-Eur) trial, a study of antihypertensive therapy of isolated systolic hypertension, by replicating all aspects of that RCT (selection criteria, study time frame, treatment, and outcomes) except randomization.

RESULTS

The exposed and unexposed groups in the GPRD study exhibited similar baseline characteristics. Stroke, the primary RCT outcome, decreased significantly in both the RCT (incidence rate ratio IRR = 0.58) and the GPRD study (IRR = 0.68). Myocardial infarction decreased nonsignificantly but similarly in both studies (RCT IRR = 0.70; GPRD IRR = 0.74). With the GPRD study extended for 3 years more, myocardial infarction decreased significantly, comparable to findings from the Systolic Hypertension in the Elderly Program (SHEP), another RCT similar to Syst-Eur.

CONCLUSIONS

The findings support the potential value of clinical databases to investigate treatment effectiveness. RCT simulation using the GPRD may be the most feasible way to assess observational study validity in comparison to RCTs. The extended GPRD study shows the feasibility of using a simulated study to supplement the results of an RCT of limited duration.

Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy

CONTEXT

Reduced cortisol levels have been linked with vulnerability to posttraumatic stress disorder (PTSD) and the risk factor of parental PTSD in adult offspring of Holocaust survivors.

OBJECTIVE

The purpose of this study was to report on the relationship between maternal PTSD symptoms and salivary cortisol levels in infants of mothers directly exposed to the World Trade Center collapse on September 11, 2001 during pregnancy.

DESIGN

Mothers (n = 38) collected salivary cortisol samples from themselves and their 1-yr-old babies at awakening and at bedtime.

RESULTS

Lower cortisol levels were observed in both mothers (F = 5.15, df = 1, 34; P = 0.030) and babies of mothers (F = 8.0, df = 1, 29; P = 0.008) who developed PTSD in response to September 11 compared with mothers who did not develop PTSD and their babies. Lower cortisol levels were most apparent in babies born to mothers with PTSD exposed in their third trimesters.

CONCLUSIONS

The data suggest that effects of maternal PTSD related to cortisol can be observed very early in the life of the offspring and underscore the relevance of in utero contributors to putative biological risk for PTSD.

A screening study of antidepressant treatment rates and mood symptoms in pregnancy

STUDY DESIGN

As part of a large screening study of perinatal depression, pregnant women were screened for demographic, depression and treatment variables in obstetrics clinics. Women taking antidepressant medication prior to conception were included in the sample as the study aimed to document rates of antidepressant medication use, and relationship to depressive symptomatology.

RESULTS

Among women who reported using antidepressant medications within 2 years prior to screening (n = 390, or 11% of all women), 22% reported current use of these medications. Women who reported using antidepressant medications (52%) and those who discontinued them (49%) evidenced elevated depressive symptoms during pregnancy.

CONCLUSIONS

Both women who discontinue and some who continue antidepressants during pregnancy demonstrate depressive symptoms, suggesting sub-optimal management of both groups. Future studies should carefully assess the adequacy of treatments prescribed as well as the monitoring and adherence of recommended treatments. Full symptom remission should be the goal for antenatal and postnatal depression in order to minimize risk to mother and baby.

Independent evaluator knowledge of treatment in a multicenter comparative treatment study of panic disorder

The purpose of this study was to examine independent evaluators' (IEs) blindness to treatment condition during a Multicenter Comparative Treatment Study of Panic Disorder. IEs were 15 doctoral- and masters-level clinicians in psychology, social work, and medicine. They conducted three post-treatment assessments with each patient. Immediately after each assessment interview, IEs completed a form indicating which of the five possible treatments they believed the patient had received and any specific information that provided IEs with information about a patient's treatment condition. These forms were completed for 170 patients. Analyses were conducted to determine the accuracy of guesses about treatment condition by IEs during post-treatment assessments, the relationship between accuracy of IE guessing and actual treatment assignment, the relationship between accurate guessing and outcome ratings, and contributors to the breaking of the blind. A significant relationship was found between IE guesses and actual treatment at all three assessment points, across individual IEs, treatment sites, and IE professional affiliations. IEs were no more accurate in their guessing about patients taking medication than those receiving behavior therapy. Patients and project staff inadvertently provided information to IEs that enhanced the rates of accurate guessing. Implications of these findings on interpretation of the treatment study are discussed, and recommendations are made for improving blindness procedures.

RNA editing and alternative splicing of human serotonin 2C receptor in schizophrenia

Serotonin 2C receptor (5-HT2CR) heterogeneity in the brain occurs mostly from two different sources: (i) 5-HT2CR mRNA undergoes adenosine-to-inosine editing events at five positions, which leads to amino acid substitutions that produce receptor variants with different pharmacological properties; (ii) 5-HT2CR mRNA is alternatively spliced, resulting in a truncated mRNA isoform (5-HT2CR-tr) which encodes a non-functional serotonin receptor. 5-HT2CR mRNA editing efficiencies and the expression of the full-length and the truncated 5-HT2CR mRNA splice isoforms were analyzed in the prefrontal cortex of elderly subjects with schizophrenia vs. matched controls (ns = 15). No significant differences were found, indicating that there are no alterations in editing or alternative splicing of 5-HT2CRs that are associated with schizophrenia in persons treated with antipsychotic medications. Quantitation of 5-HT2CR and 5-HT2CR-tr mRNA variants revealed that the expression of 5-HT2CR-tr was approximately 50% of that observed for the full-length isoform.

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.

Factors associated with home environmental problems among community-living older people

PURPOSE

This paper describes the types of difficulties older people have with their home environments and the factors associated with having such difficulties.

METHOD

Data were used from 296 study participants of the University at Buffalo's Consumer Assessments Study that examines the home modification needs and environmental difficulties of older people. A combination of socio-demographic variables, health and functional status indicators and measures of psychosocial well-being were used to predict environmental problems.

RESULTS

An average of 13 problems with the environment that posed as a barrier to safe and independent performance was observed in homes. It was found that most difficulties occurred in bathrooms, kitchens, bedrooms and access to entryways and rooms. Hierarchical multiple regression analysis showed that having home environmental problems was most strongly associated with younger age, being female, being of minority status, having pain, and greater physical disability.

CONCLUSION

The findings show that a combination of conditions that include demographic and functional conditions place older people at risk for problems with the home environment that impede performance of daily living activities.

Risk of venous thromboembolism from oral contraceptives containing gestodene and desogestrel versus levonorgestrel: a meta-analysis and formal sensitivity analysis

Controversy exists regarding whether oral contraceptives (OCs) containing desogestrel and gestodene are associated with an increased risk of venous thromboembolism (VTE) versus OCs containing levonorgestrel. We were interested in synthesizing the available data, exploring explanations for mixed results, and characterizing the degree of uncontrolled confounding that could have produced a spurious association. We performed a meta-analysis and formal sensitivity analysis of studies that examined the relative risk of VTE for desogestrel and gestodene versus levonorgestrel. Twelve studies, all observational, were included. The summary relative risk (95% CI) was 1.7 (1.3-2.1; heterogeneity p = 0.09). If real, the incremental risk of VTE would be about 11 per 100,000 women per year. An association was present when accounting for duration of use and when restricted to the first year of use in new users. However, in the sensitivity analysis, the association abated in many, but not all, scenarios in which an unmeasured confounding factor increased the risk of VTE three to fivefold and in nearly all examined scenarios in which the factor increased the risk 10-fold. The summary relative risk of 1.7 does not appear to be caused by depletion of susceptibles, but is sensitive to a modest degree of unmeasured confounding. Whether such confounding occurred is unknown. However, given this sensitivity, this issue probably cannot be settled unequivocally with observational data. In the absence of a definitive answer, this apparent increased risk, together with its uncertainty and small magnitude and its important consequences, should be considered when selecting an OC for a given woman.

A sensitivity analysis for subverting randomization in controlled trials

In some randomized controlled trials, subjects with a better prognosis may be diverted into the treatment group. This subverting of randomization results in an unobserved non-compliance with the originally intended treatment assignment. Consequently, the estimate of treatment effect from these trials may be biased. This paper clarifies the determinants of the magnitude of the bias and gives a sensitivity analysis that associates the amount that randomization is subverted and the resulting bias in treatment effect estimation. The methods are illustrated with a randomized controlled trial that evaluates the efficacy of a culturally sensitive AIDS education video.

Treatment guidelines for depression in pregnancy

Depression is a ubiquitous disorder in childbearing women with up to 10% of women experiencing depression in pregnancy. Postpartum depression occurs in 12-16% of pregnancies making it a common complication. Moreover, these illnesses are frequently underdiagnosed in obstetric settings, and a recent report of the Surgeon General's Office confirms that many women do not access services, or receive treatment of inadequate intensity or duration. This paper provides current treatment guidelines to aid in appropriate diagnosis and treatment of depression in pregnancy and postpartum. Review of current literature on psychotropic medication use in pregnancy is also provided.

Strictureplasty for Crohn's disease: meta-analysis

PURPOSE

The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohn's disease based on differences in surgical procedures.

METHODS

A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohn's disease. Meta-analysis of multiple variables for outcome was performed using random-effects models.

RESULTS

Five hundred six patients underwent 1,825 strictureplasties for Crohn's disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke-Mikulicz technique and 13 percent used Finney strictureplasty. Forty-four percent of procedures included concurrent bowel resection. Recurrence rate of Crohn's disease after strictureplasty was increased in patients with longer study duration after surgery (P = 0.04), who showed symptoms of active disease (P = 0.02), who experienced preoperative weight loss (P = 0.02), or who received the Heineke-Mikulicz procedure (P = 0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P = 0.006), with preoperative weight loss (P = 0.001), or with the Heineke-Mikulicz procedure (P = 0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P = 0.008) as compared with those treated by the Heineke-Mikulicz procedure.

CONCLUSION

Although the Heineke-Mikulicz technique is most often used for Crohn's strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

Adherence by African American men to prostate cancer education and early detection

BACKGROUND

This study was designed to identify factors that predict adherence by African American men to prostate cancer education and early detection.

METHODS

In the spring of 1995, the authors identified 548 African American men who were patients at the University Health Services of the University of Chicago, were ages 40-70 years, and did not have a personal history of prostate cancer. Baseline telephone survey data were collected from 413 men (75%). Participants were randomly assigned to either a minimal or an enhanced intervention group. Men in the former group were mailed a letter and a reminder that invited them to a urology clinic for prostate cancer education and early detection. Men in the enhanced intervention group were sent the same correspondence and were also given print material and telephone contacts, which were tailored to each recipient.

RESULTS

Adherence was significantly higher (OR = 2.6, CI: 1.7-3.9) in the enhanced intervention group than in the minimal intervention group (51% and 29%, respectively). Men who were age 50 years or older (OR = 1.7, CI: 1.1-2.8), were married (OR = 1.8, CI: 1.2-2.9), believed that prostate cancer early detection examination should be performed in the absence of symptoms (OR = 2.3, CI: 1.3-4.0), and self-reported an intention to have an early detection examination (OR = 1.9, CI: 1.2-2.9) were also more likely to adhere.

CONCLUSIONS

A tailored behavioral intervention can influence adherence to prostate cancer early detection among African American men. Individual background and cognitive and psychosocial characteristics may also affect behavior. Future studies should assess the impact of this type of intervention on cognitive and psychologic correlates of decision-making and behavior along the continuum of prostate cancer care. [See editorial on pages 1-2, this issue.]

Treatment of superficial basal cell carcinoma and squamous cell carcinoma in situ with a high-energy pulsed carbon dioxide laser

BACKGROUND

High-energy pulsed carbon dioxide (CO2) lasers have been used extensively to resurface wrinkled and photodamaged skin with a low risk of scarring. Results of histological studies demonstrate precise ablation depths in treated skin with minimal thermal damage to underlying tissue. Our objective was to determine if a pulsed CO2 laser could effectively ablate superficial malignant cutaneous neoplasms (superficial multifocal basal cell carcinoma [BCC] and squamous cell carcinoma [SCC] in situ).

OBSERVATIONS

Thirty superficial neoplasms (17 BCCs and 13 SCCs) and their surrounding 3-mm margins were treated with either 2 or 3 passes of a pulsed CO2 laser (500 mJ, 2-4 W) using a 3-mm collimated handpiece. The treated areas were subsequently excised and evaluated histologically by serial sectioning at 5-micron intervals for residual tumor at the deep and lateral margins. Average patient age was greater for those with SCCs than for those with BCCs (76.5 vs 56.7 years; P = .001). The average tumor thickness of SCC in situ was significantly greater than that of superficial BCC (0.57 vs 0.34 mm; P = .01). All (9 of 9 patients) BCCs were completely ablated with 3 passes, and residual tumor in the deep margins was seen in 5 of 8 patients treated with 2 passes of the pulsed CO2 laser (P = .005). Incomplete vaporization of the SCC depth was seen in 3 of 7 patients treated with 3 passes and in 2 of 6 patients treated with 2 passes. Those SCCs incompletely treated were significantly thicker than those completely ablated (0.65 vs 0.41 mm; P = .01). Positive lateral margins were seen in 1 BCC and 3 SCC specimens.

CONCLUSIONS

Pulsed CO2 laser treatment can be effective in ablating superficial BCC. Treatment of the neoplasm and a minimum of 4-mm margins with 3 passes (500 mJ, 2-4 W) is recommended for complete vaporization using this laser system. Because 3 passes did not completely ablate all SCC in situ, use of this modality alone is not recommended for treatment of thick or keratotic lesions. No direct comparison of efficacy can be made with other destructive modalities that have not been evaluated with comparably sensitive histological techniques. Further study is needed to establish any cosmetic advantage of pulsed CO2 lasers over other destructive modalities for treatment of superficial malignant neoplasms and long-term cure rates.

Does surgical approach affect the incidence of inflatable penile prosthesis infection?

OBJECTIVES

To review retrospectively the rate of infection in 380 consecutive organically impotent men implanted with a Mentor Alpha I inflatable penile prosthesis, stratified by surgical approach (scrotal or infrapubic).

METHODS

Data were obtained from review of medical records. One hundred percent of cases were available for a minimum postoperative follow-up of 6 months.

RESULTS

Twenty patients had a prior penile prosthetic operation and were excluded, leaving 360 primary implants for review. Overall, 6 patients (1.7%) developed periprosthetic infection. Four of these 6 patients were diabetic. Four of 139 infrapubic cases (2.9%) and 2 of 221 scrotal cases (0.9%) developed periprosthetic infection. This difference was not statistically significant (P = 0.15). Equal proportions of the infrapubic (39.6%) and scrotal cases (40.3%) were diabetic patients. The infection rate in patients with and without diabetes was 4 of 144 (2.8%) and 2 of 216 (0.9%), respectively. This difference was not statistically significant (P = 0.18).

CONCLUSIONS

This study indicates that there is no statistically significant difference in the infection rate when the scrotal and infrapubic approaches to inflatable penile prosthesis insertion are compared.