Adriana Feder

Depression and Glycemic Control in Hispanic Primary Care Patients with Diabetes

CONTEXT: Maintaining optimal glycemic control is an important goal of therapy in patients with diabetes mellitus. Patients of Hispanic ancestry have been shown to have high rates of diabetes and poor glycemic control (PGC). Although depression is common in adults with diabetes, its relationship to glycemic control remains unclear, especially among Hispanics.OBJECTIVE: To assess the association of depression with PGC in Hispanics.DESIGN: Data from a cross-sectional mental health survey in primary care were crosslinked to the hospital’s computerized laboratory database.SETTING: Urban general medicine practice at a teaching hospital.PATIENTS: Two hundred and nine patients (mean [standard deviation] age, 57.1 [10.3] years; 68% females) with recent International Classification of Diseases, Ninth Revision (ICD-9) codes for diabetes mellitus, and 1 or more hemoglobin A1c (HbA1c) tests.MAIN OUTCOME MEASURE: Probability of PGC (HbA1c ≥8%).RESULTS: Probability for PGC steadily increased with severity of depression. Thirty-nine (55.7%) of the 70 patients with major depression had HbA1c ≥80%, compared with 39/92 (42.4%) in the minimal to mild depression group, and 15/47 (31.9%) in the no depression group (Ptrend=.01; adjusted odds ratio, 3.27; 95% confidence interval, 1.23 to 8.64, for moderate or severe depression vs no depression). Only 29 (41.4%) of the patients with major depression received mental health treatment in the previous year.CONCLUSIONS: In this primary care sample of Hispanic patients with diabetes, we found a significant association between increasing depression severity and PGC. Yet, less than one half of the patients with moderate or severe depression received mental health treatment in the previous year. Improving identification and treatment of depression in this high-risk population might have favorable effects on diabetic outcomes.

Depressed mothers coming to primary care: maternal reports of problems with their children

BACKGROUNDnStudies of depressed mothers have generally been conducted in psychiatric settings with non-minority, middle-class women. Primary care has an increasing role in early detection and treatment, especially for the poor who have less access to specialized mental health services. Data on the relationship between maternal depression and problems in the offspring in a primary care context could help physicians to more effectively identify children in need of psychiatric help.nnnMETHODSnAll mothers aged 25 to 55 from a systematic sample of consecutive adults (response rate, 80%) in an urban general medicine practice were screened using the PRIME-MD Patient Health Questionnaire (PHQ). Mothers who screened positive for major depression (n=85); other psychiatric disorders, but not major depression (n=67); or no psychiatric disorders (n=191) were compared on their childrens history of emotional problems, unmet need for mental health treatment, parent-child discord, maternal functional status and mental health treatment.nnnRESULTSnCompared to non-psychiatric controls, depressed mothers reported a three-times greater risk of serious emotional problems in their children (95% confidence interval [CI], 1.7-6.1); a four-times greater risk of having their childrens problems left untreated (95% CI, 2.3-8.2), and a 10-times greater risk of having poor mother-child relations within the past month (95% CI, 3.9-29.4). Depressed mothers reported more functional disability, more psychiatric treatment and more problems in their offspring than mothers with non-depressive psychiatric disorders. Although a majority of mothers (regardless of psychiatric status) believed that counseling (96%) or medication (84%) should be offered to those with serious emotional problems, only about half (49%) of the depressed mothers had received mental health treatment in the past month.nnnLIMITATIONSnChildren were not assessed directly.nnnCONCLUSIONSnThe children of low-income depressed women at a general medicine practice were reported to have a greatly increased risk for emotional problems. Many mothers had not received treatment for their own emotional problems. By enquiring about the emotional health of children of adult primary care patients, primary care providers have an opportunity to promote early detection and to facilitate appropriate treatment for both the mothers and their children.

Twenty-four-hour cortisol secretion patterns in prepubertal children with anxiety or depressive disorders.

BACKGROUNDnPrevious studies found few abnormalities in hypothalamic-pituitary-adrenal (HPA) axis function in prepubertal children with anxiety or depressive disorders. In this study, we combined data from two independent, consecutive studies to achieve a larger sample size. Our goal was to identify potential alterations in the circadian pattern of cortisol secretion in anxious or depressed children.nnnMETHODSnA total of 124 prepubertal subjects from two independent samples (76 with major depressive disorder, 31 with anxiety disorders, and 17 healthy control subjects) were studied. Blood samples collected for cortisol at hourly intervals over a 24-hour period were examined. Analyses were performed aligning cortisol samples by clock-time. Additional analyses aligning samples by sleep-onset time were performed with a subsample of subjects.nnnRESULTSnIn the combined sample, significant findings emerged that were previously undetected. Anxious children exhibited significantly lower nighttime cortisol levels and an initially sluggish rise in cortisol during the nighttime when compared with depressed and healthy control children. In contrast, depressed children did not show a clear-cut pattern of differences compared with healthy control children.nnnCONCLUSIONSnAnxious children seem to exhibit an altered pattern of nighttime cortisol secretion, with an initially sluggish or delayed nocturnal rise before reaching similar peak levels of cortisol near the time of awakening. These findings suggest subtle alterations in HPA axis function in prepubertal children with anxiety disorders.

Gender differences in posttraumatic stress disorder among primary care patients after the World Trade Center attack of September 11, 2001.

BACKGROUNDnDebate surrounds the nature of gender differences in rates of posttraumatic stress disorder (PTSD).nnnOBJECTIVEnThe goal of this study was to quantify and explore the reasons for gender differences in rates of PTSD in low income, primary care patients after the World Trade Center (WTC) attack of September 11, 2001.nnnMETHODSnA survey was conducted at a large primary care practice in New York City 7 to 16 months after the WTC attack. The study involved a systematic sample of primary care patients aged 18 to 70 years. The main outcome measures were the Life Events Checklist, the Posttraumatic Stress Disorder Checklist-Civilian Version, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, all administered by a bilingual research staff.nnnRESULTSnA total of 3807 patients were approached at the primary care clinic. Of the 1347 who met eligibility criteria, 1157 (85.9%) consented to participate. After the addition of the WTC/PTSD supplement to the study, the total number of patients was 992, of whom 982 (99.0%) completed the survey. Both sexes had high rates of direct exposure to the WTC attack and high rates of lifetime exposure to stressful life events. Overall, females had lower rates of exposure to the attack compared with males (P < 0.05). Hispanic females had the highest rate of PTSD in the full sample. Gender differences in rates of PTSD were largely accounted for by differences in marital status and education. The rate of current major depressive disorder (MDD) was higher in females than in males (P < 0.001), and the reverse was true for substance abuse (P < 0.001). Gender differences for MDD and substance abuse persisted even after adjustments for demographic differences between the sexes.nnnCONCLUSIONSnThe increased rate of PTSD in women attending a primary care clinic was mediated by their social and economic circumstances, such as living alone without a permanent relationship and with little education or income. The increased rate of MDD in women appeared to be less dependent on these circumstances. These findings have implications for the treatment of women with PTSD in primary care and for research on gender differences in rates of psychiatric disorders.

Differentiating Depressed Adolescent 24 h Cortisol Secretion in Light of Their Adult Clinical Outcome

A clinical follow-up study was performed of adolescent major depressives and normal control subjects approximately 10 years after the subjects had undergone serial cortisol measurements over a 24-h period. In light of their young adulthood clinical status, our objective was to ascertain whether there were any premorbid cortisol abnormalities associated with depressive course of illness. In all, 77 young adults who had received a diagnosis of adolescent major depressive disorder, or were determined to be normal volunteers free of psychiatric diagnosis at index period and during follow-up, were studied. When subjects were adolescents, blood samples were collected for cortisol at 20-min intervals during the 24-h period coinciding with the third consecutive night of sleep EEG. The subjects, in young adulthood at the time of follow-up, were reinterviewed regarding longitudinal course of illness, and the original adolescent cortisol data were analyzed in the light of information obtained. Of the subjects who had experienced at least one lifetime major depressive episode during the follow-up period, the subgroup who would go on to make suicide attempts during the follow-up period secreted significantly greater levels of cortisol in the 4, 6, and 12u2009h prior to sleep onset. Conversely, this same subgroup exhibited reduced cortisol levels 2–4u2009h following sleep onset. Adolescents who are at risk to make suicide attempts appear to display significant elevations of cortisol prior to sleep onset, a time when the hypothalamic–pituitary–adrenal (HPA) axis is normally most quiescent. Dysregulation of the HPA axis, combined with dysfunction of sleep-onset mechanisms previously reported in this same cohort, might serve as premorbid biological substrates that predict suicide attempts during follow-up.

The Effect of a Single Dose of Intravenous Ketamine on Suicidal Ideation: A Systematic Review and Individual Participant Data Meta-Analysis

OBJECTIVEnSuicide is a public health crisis with limited treatment options. The authors conducted a systematic review and individual participant data meta-analysis examining the effects of a single dose of ketamine on suicidal ideation.nnnMETHODnIndividual participant data were obtained from 10 of 11 identified comparison intervention studies that used either saline or midazolam as a control treatment. The analysis included only participants who had suicidal ideation at baseline (N=167). A one-stage, individual participant data, meta-analytic procedure was employed using a mixed-effects, multilevel, general linear model. The primary outcome measures were the suicide items from clinician-administered (the Montgomery-Åsberg Depression Rating Scale [MADRS] or the Hamilton Depression Rating Scale [HAM-D]) and self-report scales (the Quick Inventory of Depressive Symptomatology-Self Report [QIDS-SR] or the Beck Depression Inventory [BDI]), obtained for up to 1 week after ketamine administration.nnnRESULTSnKetamine rapidly (within 1 day) reduced suicidal ideation significantly on both the clinician-administered and self-report outcome measures. Effect sizes were moderate to large (Cohens d=0.48-0.85) at all time points after dosing. A sensitivity analysis demonstrated that compared with control treatments, ketamine had significant benefits on the individual suicide items of the MADRS, the HAM-D, and the QIDS-SR but not the BDI. Ketamines effect on suicidal ideation remained significant after adjusting for concurrent changes in severity of depressive symptoms.nnnCONCLUSIONSnKetamine rapidly reduced suicidal thoughts, within 1 day and for up to 1 week in depressed patients with suicidal ideation. Ketamines effects on suicidal ideation were partially independent of its effects on mood, although subsequent trials in transdiagnostic samples are required to confirm that ketamine exerts a specific effect on suicidal ideation. Additional research on ketamines long-term safety and its efficacy in reducing suicide risk is needed before clinical implementation.