Alyna Turner

Depression Screening in Stroke A Comparison of Alternative Measures With the Structured Diagnostic Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Major Depressive Episode) as Criterion Standard

Background and Purpose— Screening tools for depression and psychological distress commonly used in medical settings have not been well validated in stroke populations. We aimed to determine the accuracy of common screening tools for depression or distress in detecting caseness for a major depressive episode compared with a clinician-administered structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition as the gold standard. Methods— Seventy-two participants ≥3 weeks poststroke underwent a diagnostic interview for major depressive episode and completed the Patient Health Questionnaire-2 and -9, Hospital Anxiety and Depression Scale, Beck Depression Inventory-II, Distress Thermometer, and Kessler-10. Internal consistency, sensitivity, specificity, likelihood ratios, and posttest probabilities were calculated. Each measure was validated against the gold standard using receiver operating characteristic curves with comparison of the area under the curve for all measures. Results— Internal consistency ranged from acceptable to excellent for all measures (Cronbach &agr;=0.78–0.94). Areas under the curve (95% CI) for the Patient Health Questionnaire-2, Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale depression and total score, Beck Depression Inventory-II, and Kessler-10 ranged from 0.80 (0.69–0.89) for the Kessler-10 to 0.89 (0.79–0.95) for the Beck Depression Inventory-II with no significant differences between measures. The Distress Thermometer had an area under the curve (95% CI) of 0.73 (0.61–0.83), significantly smaller than the Beck Depression Inventory-II (P<0.05). Conclusions— Apart from the Distress Thermometer, selected scales performed adequately in a stroke population with no significant difference between measures. The Patient Health Questionnaire-2 would be the most useful single screen given free availability and the shortest number of items.

The long and the short of treatments for alcohol or cannabis misuse among people with severe mental disorders.

Substance misuse among people with severe mental disorders is very common and has been associated with a number of adverse outcomes. Most trials among people with severe mental disorders have reported general substance misuse outcomes and have argued that longer treatments are likely to be more effective. Such studies have not specifically compared intervention effectiveness for alcohol vs. cannabis misuse. The present paper reports findings from a synthesis of datasets from three randomized controlled trials (N=248) comparing brief (1-session advice or motivational interviewing, MI) and extended (10 sessions MI/cognitive-behaviour therapy; CBT) interventions for substance misuse among people with psychosis or major depression and outcomes are reported separately for alcohol and cannabis use. Whilst there were comparable rates of reduction in alcohol consumption for the BI and intensive MI/CBT, BI tended to be associated with less reduction in cannabis use. A stepped care approach for substance misuse in people with severe mental disorders may help to improve cannabis outcomes, including monitoring of both mental health and substance misuse domains, with interventions stepped up or down according to treatment response. Future studies should evaluate the effectiveness of stepped care approaches.

Design and rationale of a 16-week adjunctive randomized placebo-controlled trial of mitochondrial agents for the treatment of bipolar depression

OBJECTIVE Bipolar disorder places a significant burden on individuals, caregivers and family, and the broader community. Current treatments are believed to be more effective against manic symptoms, leaving a shortfall in recovery during the depressive phase of the illness. The current study draws on recent evidence suggesting that, in addition to increased oxidative load, alterations in mitochondrial function occur in bipolar disorder. METHODS This 16-week study aims to explore the potential benefits of N-acetylcysteine (NAC) alone or in combination (CT) with selected nutraceuticals believed to enhance mitochondrial function. The study includes adults diagnosed with bipolar disorder currently experiencing an episode of depression. Participants are asked to take NAC, CT, or placebo in addition to any usual treatments. A post-discontinuation visit is conducted 4 weeks following the treatment phase. RESULTS The primary outcome of the study will be mean change on the Montgomery-Asberg Depression Rating Scale. Secondary outcomes include functioning, substance use, mania ratings, and quality of life. Blood samples will be collected at baseline and week 16 to explore biochemical alterations following treatment. CONCLUSION This study may provide a novel adjunctive treatment for bipolar depression. Analysis of biological samples may assist in understanding the therapeutic benefits and the underlying etiology of bipolar depression. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry ACTRN12612000830897.

Clinical outcomes associated with depression, anxiety and social support among cardiac rehabilitation attendees

Objective: To utilize existing medical record information in order to examine the relationship between depression, anxiety, levels of social support and clinical outcomes in cardiac rehabilitation attendees. Method: In a tertiary care centre 389 records for cardiac rehabilitation outpatients were analysed. Hospital Anxiety and Depression Scales scores collected at week 4 of their cardiac rehabilitation programme were linked with medical record information on demographic, lifestyle, medical and other coronary heart disease risk factors, as well as follow-up cardiovascular events and readmissions for an average of 2.6 years. Variables of interest were anxiety and depression scores and proxy measures of social support. Clinical outcome measures were number of hospital admissions, length of stay and mortality. Results: Multiple variable analysis revealed higher anxiety scores were associated with more hospital admissions and higher depression scores were associated with longer length of stay after controlling for other established prognostic risk factors. Depression, anxiety and social support were not associated with mortality, however there was a low mortality rate in the present study. Conclusion: A comprehensive summary of the characteristics of cardiac rehabilitation patients was gathered through the linkage and examination of existing clinical databases. The results of this study provide some support for a prognostic role of depressive and anxiety symptoms and highlight the need for screening for psychological distress and provision of appropriate interventions when indicated.

'Better Health Choices' by telephone: A feasibility trial of improving diet and physical activity in people diagnosed with psychotic disorders

The study objective was to evaluate the feasibility of a telephone delivered intervention consisting of motivational interviewing and cognitive behavioural strategies aimed at improving diet and physical activity in people diagnosed with psychotic disorders. Twenty participants diagnosed with a non-acute psychotic disorder were recruited. The intervention consisted of eight telephone delivered sessions targeting fruit and vegetable (F&V) consumption and leisure screen time, as well as smoking and alcohol use (as appropriate). F&V frequency and variety, and overall diet quality (measured by the Australian Recommended Food Score, ARFS), leisure screen time, overall sitting and walking time, smoking, alcohol consumption, mood, quality of life, and global functioning were examined before and 4-weeks post-treatment. Nineteen participants (95%) completed all intervention sessions, and 17 (85%) completed follow-up assessments. Significant increases from baseline to post-treatment were seen in ARFS fruit, vegetable and overall diet quality scores, quality of life and global functioning. Significant reductions in leisure screen time and overall sitting time were also seen. Results indicated that a telephone delivered intervention targeting key cardiovascular disease risk behaviours appears to be feasible and relatively effective in the short-term for people diagnosed with psychosis. A randomized controlled trial is warranted to replicate and extend these findings.

Oxidative Stress and Post-Stroke Depression: Possible Therapeutic Role of Polyphenols?

Post-stroke depression is a common neuropsychiatric affective disorder that may develop after a stroke event. In addition to abnormalities in the biogenic amine neurotransmitters and cytokine expression induced by stroke we will focus on the role of oxidative stress and hypothesize that polyphenols may be useful as therapeutics targets for the treatment of post-stroke depression. In this paper, we discuss the hypothesis that increased oxidative stress in cerebral tissues during ischemia is implicated in the pathogenesis of depressive-like symptoms following stroke. There is substantive evidence regarding the role of oxidative stress in the pathogenesis of both stroke and depression, which provides support to this hypothesis. Reactive oxygen species, generated during stroke, cause oxidative stress, lipid peroxidation, protein oxidation, and DNA damage in neural tissues. The resultant pathophysiological processes in the neural tissues could be considered a leading mechanism in the induction of post-stroke depression. Antioxidants including polyphenols therefore, may play an important role in the outcomes of ischemia and stroke, due to their ability to protect neurons against oxidative stress, to mitigate ischemic damage via inhibition of lipid peroxidation and ability to interact with the generation of nitric oxide from the vascular endothelium, and also to decrease inflammation. These data suggest that polyphenols may therefore be a useful new therapeutic target for the treatment of post-stroke depression.

A brief review of exercise, bipolar disorder, and mechanistic pathways

Despite evidence that exercise has been found to be effective in the treatment of depression, it is unclear whether these data can be extrapolated to bipolar disorder. Available evidence for bipolar disorder is scant, with no existing randomized controlled trials having tested the impact of exercise on depressive, manic or hypomanic symptomatology. Although exercise is often recommended in bipolar disorder, this is based on extrapolation from the unipolar literature, theory and clinical expertise and not empirical evidence. In addition, there are currently no available empirical data on program variables, with practical implications on frequency, intensity and type of exercise derived from unipolar depression studies. The aim of the current paper is to explore the relationship between exercise and bipolar disorder and potential mechanistic pathways. Given the high rate of medical co-morbidities experienced by people with bipolar disorder, it is possible that exercise is a potentially useful and important intervention with regard to general health benefits; however, further research is required to elucidate the impact of exercise on mood symptomology.

Resumption of Work After Acute Coronary Syndrome or Coronary Artery Bypass Graft Surgery

BACKGROUND Return to work is an important indicator of recovery after acute cardiac events. This study aimed to determine rates of work resumption and identify predictors of non-return to work and delayed resumption of work. METHODS 401 currently employed patients consecutively admitted after acute coronary syndrome or to undergo coronary artery bypass graft surgery were recruited. Patient characteristics, perceptions and occupational outcomes were investigated via interviews and self-report questionnaires. RESULTS Twenty-three patients were lost to follow-up. Of the 378 completers, 343 (90.7%) patients resumed work, while 35 (9.3%) did not. By four months, 309 (91.1%) patients had returned to work. At 12 months, 302 (79.9%) of the 378 patients were employed, 32 (8.5%) unemployed and 20 (5.3%) retired. The employment status of 24 (6.3%) patients was unknown. Non-return to work was significantly more likely if patients were not intending to return to work or were uncertain, had a negative perception of health, had a comorbidity other than diabetes and reported financial stress. Significant predictors of delayed return to work were cardiac rehabilitation attendance, longer hospital stay, past angina, having a manual job, physically active work, job dissatisfaction, no confidante and depression. CONCLUSIONS Patients at risk of poor occupational outcomes can be identified early. Strategies to improve vocational rehabilitation require further investigation.

Are poor health behaviours in anxious and depressed cardiac patients explained by sociodemographic factors

Introduction: While there is evidence of poor health behaviours in anxious and depressed cardiac patients, it is possible that sociodemographic factors explain these associations. Few previous studies have adequately controlled for confounders. The present study investigated health behaviours in anxious and depressed cardiac patients, while accounting for sociodemographic confounders. Method: A consecutive sample of 275 patients admitted to hospital after acute myocardial infarction (32%) or for coronary bypass surgery (40%) or percutaneous coronary intervention (28%) was interviewed six weeks after hospital discharge. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Smoking, physical activity, alcohol intake and dietary fat intake were assessed by self-report. Backward stepwise logistic regression was used to identify the factors independently associated with anxiety and depression. Results: In total, 41 patients (15.2%) were ‘depressed’ (HADS-D ≥8) while 68 (25.2%) were ‘anxious’ (HADS-A ≥8). Depressed patients reported higher rates of smoking (χ2 = 4.47, p = 0.034), lower physical activity (F = 8.63, p < 0.004) and higher dietary fat intake (F = 7.22, p = 0.008) than non-depressed patients. Anxious patients reported higher smoking rates (χ2 = 5.70, p = 0.024) and dietary fat intake (F = 7.71, p = 0.006) than non-anxious patients. In multivariate analyses, an association with depression was retained for both diet and physical activity, and an association with anxiety was retained for diet. Low social support and younger age were significant confounders with depression and anxiety respectively. Conclusions: While the high smoking rates evidenced in anxious and depressed patients were explained by sociodemographic factors, their poor diet and low physical activity (depressed patients only) were independent of these factors. Given the impact of lifestyle modification on survival after a cardiac event, anxious and depressed patients should be a priority for cardiac rehabilitation and other secondary prevention programmes.

BraveHeart Begins: Pilot Results of Group Cognitive Behaviour Therapy for Depression and Anxiety in Cardiac Patients

Objective: In a general medical hospital with limited mental health resources, a clinical need arose for an effective treatment for depression and anxiety symptoms in cardiac rehabilitation patients. Method: A total of 628 cardiac rehabilitation outpatients at a tertiary care centre were screened with the Hospital Anxiety and Depression Scale at week 4 of their programme, and 182 of 558 responders (33%) scored ≥8 on the Depression and/or Anxiety subscales. A 6 week group cognitive behaviour therapy programme was developed to assist these identified patients. The resulting programme, BraveHeart, was piloted on 39 patients still experiencing significant symptoms of depression or anxiety at the end of rehabilitation. Patients were assessed at baseline, after treatment, 1 and 6 months after treatment using the Hospital Anxiety and Depression Scale and the Beck Depression Inventory-II. Results: Significant improvement in levels of depression and anxiety symptoms occurred from baseline to post-treatment assessment, and this change was maintained at 6 months, with moderate–strong effect sizes. Feedback from the group members was positive. Conclusions: A specialized group treatment programme for cardiac patients with existing depression and anxiety was created that resulted in significant reductions in symptoms.