Carla Boutin-Foster

A Randomized Controlled Trial of Positive-Affect Intervention and Medication Adherence in Hypertensive African Americans

BACKGROUND Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes. METHODS This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months. RESULTS The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant. CONCLUSIONS A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

Sleep Duration and the Risk of Diabetes Mellitus: Epidemiologic Evidence and Pathophysiologic Insights

Evidence from well-defined cohort studies has shown that short sleep, through sleep fragmentation caused by obstructive sleep apnea (OSA) or behavioral sleep curtailment because of lifestyle choices, is associated with increased incidence of diabetes. In this report, we review epidemiologic and clinical data suggesting that OSA is involved in the pathogenesis of altered glucose metabolism. Evidence suggesting increased risk of developing diabetes resulting from curtailed sleep duration is also considered. Proposed mechanisms explaining associations between short sleep and diabetes are examined and clinical management of OSA among patients with diabetes is discussed.

INCIDENCE OF POSTTRAUMATIC STRESS DISORDER (PTSD) AFTER MYOCARDIAL INFARCTION (MI) AND PREDICTORS OF PTSD SYMPTOMS POST-MI— A BRIEF REPORT*

Objectives: The objectives of this pilot study were to determine the incidence of Posttraumatic Stress Disorder (PTSD) one to two months after Myocardial Infarction (MI), and to evaluate potential predictors of PTSD symptoms post-MI. Methods: A convenience sample of 31 patients hospitalized for treatment of acute MI was interviewed during hospitalization and one to two months later. The assessments included socio-demographic questions, questions related to clinical history and hospitalization, assessment of depressive symptoms using the Center for Epidemiologic Studies— Depression (CES-D) scale, medical comorbidity using the Charlson Comorbidity Index (CCI), and perceived social support using the Medical Outcomes Study (MOS) scale. Medical records were reviewed for collection of clinical data. Symptoms of PTSD were evaluated using the Structured Clinical Interview for DSM-IV (SCID) and the Impact of Events Scale-Revised (IES-R). Results: While one patient (4.0%) met DSM IV criteria for PTSD; additional 16% of the patients had significant symptoms of PTSD as measured by the IES-R (scoring above 24). Higher scores of PTSD symptoms were significantly associated (p < 0.05) with younger age, black race, depressive symptoms in baseline, and self-reported anxiety during the MI. Conclusions: The incidence of PTSD following MI was low, but 16% of MI patients developed subsyndromal PTSD. The emotional status of the patients at the time of the MI and their subjective reaction to the event were important factors in the development of PTSD symptoms. Black and younger patients were in increased risk of developing PTSD symptoms post-MI.

Barriers to Lifestyle Behavioral Change in Migrant South Asian Populations

The purpose of this literature review is to describe and assess the cultural barriers to behavior change in migrant South Asians, given the high morbidity and mortality associated with cardiovascular disease in this population. We reviewed studies that explored the relationship between South Asian culture in the Diaspora and lifestyle behaviors. Our review produced 91 studies, of which 25 discussed the relationship between various aspects of South Asians’ belief system and their approach to modifying lifestyle habits. We identify 6 specific categories of beliefs which play the largest role in the difficulties South Asians describe with behavior change: gender roles, body image, physical activity misconceptions, cultural priorities, cultural identity, and explanatory model of disease. Future research and interventions should account for these cultural factors to successfully improve dietary habits and physical activity levels in migrant South Asian populations.

Translating Basic Behavioral and Social Science Research to Clinical Application: The EVOLVE Mixed Methods Approach

OBJECTIVE To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations. METHOD We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events. RESULTS Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age. CONCLUSIONS The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.

Cardiovascular disease risk reduction with sleep apnea treatment

Cardiovascular diseases are the leading cause of death among adults in developed countries. An increase in prevalent cardiovascular risk factors (e.g., obesity, hypertension and diabetes) has led to a concerted effort to raise awareness of the need to use evidence-based strategies to help patients at risk of developing cardiovascular disease and to reduce their likelihood of suffering a stroke. Sleep apnea has emerged as an important risk factor for the development of cardiovascular disease. Epidemiologic and clinical evidence has prompted the American Heart Association to issue a scientific statement describing the need to recognize sleep apnea as an important target for therapy in reducing cardiovascular disease risks. This article examines evidence supporting associations of sleep apnea with cardiovascular disease and considers evidence suggesting cardiovascular risk reductions through sleep apnea treatment. Perspectives on emerging therapeutic approaches and promising areas of clinical and experimental research are also discussed.

Problematic Resident-patient Relationships: The Patient's Perspective

OBJECTIVES: The objectives of the study were to identify the characteristics of a problematic doctor-patient relationship from the perspective of primary care patients who are cared for by medical residents and to determine whether patients’ perception of the relationship is a function of their demographic, clinical, or social attributes.DESIGN: Cross-sectional survey.SETTING: An adult primary care practice in an academic medical center.PATIENTS: One hundred fifty-one patients whose primary care physicians were senior internal medicine residents.MEASUREMENTS AND MAIN RESULTS: Patients completed a questionnaire addressing several aspects of their doctor-patient relationship, the general health perception item on the SF-12, and items on social support from the Duke Social Support and Stress Scale. By design of the study, approximately half of the patients had been identified by their physicians as being in problematic relationship (n=74) and half as being in satisfying relationships (n=77). Among patients in relationships described as satisfying by their resident, 10% viewed the relationship as problematic. Of the patients involved in relationships described as problematic by the resident, 23% viewed their relationship as problematic (P=.03). Patients who rated the relationship as problematic were much more likely to also report low social support compared to patients involved in relationships described as satisfying (76% vs 16%; P<.001). Compared to residents involved in relationships described as satisfying by their patients, residents in problematic relationships were more likely to be described as being less accessible and less capable of handling medical complaints (P<.001).CONCLUSIONS: Patients were more likely to describe the doctor-patient relationship as problematic if they felt that the resident was less accessible or less capable of handling medical complaints, or if they had low self-perceived social support.

An item-level analysis of the Center for Epidemiologic Studies Depression Scale (CES-D) by race and ethnicity in patients with coronary artery disease

The Center for Epidemiologic Studies Depression Scale (CES‐D) is a measure of depressive symptoms that is commonly used in clinical studies. Studies employing this measure often describe variations in aggregate scores. However, few studies have examined variations in response to specific items by race and ethnicity.

Associations between posttraumatic stress disorder and hemoglobin A1C in low-income minority patients with diabetes

OBJECTIVE Posttraumatic Stress Disorder (PTSD) is prevalent among low-income minorities and is associated with poorer health. However, the association between PTSD and hemoglobin A1(C) (A1(C)) among patients with diabetes has not been fully described. The objective of this cross-sectional study was to evaluate associations between PTSD and A1(C) among low-income minorities with diabetes. METHOD Adults with diabetes were recruited from a network of primary care clinics. Data were obtained from surveys and electronic medical records. Lifetime PTSD symptoms were assessed using the Structured Clinical Interview-DSM-IV and depressive symptoms with the Patient Health Questionnaire-9. A1(C) was obtained from chart review. RESULTS Of 103 adults analyzed, 12% had lifetime full PTSD and 12% had subthreshold PTSD. On backward stepwise logistic regression, patients with any PTSD symptoms were significantly more likely to have an A1(C) >7% compared to patients without symptoms (OR(adj) 2.98, 95% CI 1.04-8.52, P=.04). An A1(C) >7% also was associated with an interaction between PTSD symptoms and longer diabetes duration (P<.05). CONCLUSION In this cohort of low-income minorities with diabetes, lifetime PTSD symptoms were significantly associated with an A1(C) >7%.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

We suggest that clinicians consider models of shared decision‐making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.