Carmela Alcántara

Racial/Ethnic Differences in Sleep Disturbances: The Multi-Ethnic Study of Atherosclerosis (MESA).

OBJECTIVES There is limited research on racial/ethnic variation in sleep disturbances. This study aimed to quantify the distributions of objectively measured sleep disordered breathing (SDB), short sleep duration, poor sleep quality, and self-reported sleep disturbances (e.g., insomnia) across racial/ethnic groups. DESIGN Cross-sectional study. SETTING Six US communities. PARTICIPANTS Racially/ethnically diverse men and women aged 54-93 y in the Multi-Ethnic Study of Atherosclerosis Sleep Cohort (n = 2,230). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Information from polysomnography-measured SDB, actigraphy-measured sleep duration and quality, and self-reported daytime sleepiness were obtained between 2010 and 2013. Overall, 15.0% of individuals had severe SDB (apnea-hypopnea index [AHI] ≥ 30); 30.9% short sleep duration (< 6 h); 6.5% poor sleep quality (sleep efficiency < 85%); and 13.9% had daytime sleepiness. Compared with Whites, Blacks had higher odds of sleep apnea syndrome (AHI ≥ 5 plus sleepiness) (sex-, age-, and study site-adjusted odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.20, 2.63), short sleep (OR = 4.95, 95% CI: 3.56, 6.90), poor sleep quality (OR = 1.57, 95% CI: 1.00, 2.48), and daytime sleepiness (OR = 1.89, 95% CI: 1.38, 2.60). Hispanics and Chinese had higher odds of SDB and short sleep than Whites. Among non-obese individuals, Chinese had the highest odds of SDB compared to Whites. Only 7.4% to 16.2% of individuals with an AHI ≥ 15 reported a prior diagnosis of sleep apnea. CONCLUSIONS Sleep disturbances are prevalent among middle-aged and older adults, and vary by race/ethnicity, sex, and obesity status. The high prevalence of sleep disturbances and undiagnosed sleep apnea among racial/ethnic minorities may contribute to health disparities.

Effectiveness of the Engagement and Counseling for Latinos (ECLA) Intervention in Low-income Latinos

Background:Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments. Objective:Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6–8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression. Design:Multisite randomized controlled trial. Setting:Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico. Participants:257 Latino patients recruited from primary care between May 2011 and September 2012. Main Outcome Measures:The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0). Results:Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03). Conclusions and Relevance:The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.

Sleep Disturbances and Depression in the Multi-Ethnic Study of Atherosclerosis.

STUDY OBJECTIVES We examined the association of objectively and subjectively measured sleep disturbances with depression, and explored if race/ethnicity, socioeconomic status, and sex modified these associations. METHODS We used data from the cross-sectional Multi-Ethnic Study of Atherosclerosis Sleep Study. Participants included 1,784 adults (ages 54-93 y), 36.8% non-Hispanic Whites, 28.0% African Americans, 23.7% Hispanics, 11.5% Chinese, and 46.0% males. Sleep was assessed with actigraphy, polysomnography, and self-report. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. We used relative risk regression to evaluate the association of sleep measures and depression (CES-D score ≥ 16) adjusting for site, sociodemographics, and behavioral and medical risk factors. RESULTS Overall, 14.5% had depression, 29.3% had insomnia symptoms, 14.1% had excessive daytime sleepiness (EDS), 15.1% had apnea-hypopnea index (AHI) ≥ 30, and 30.4% experienced short sleep (< 6 h). Depression was associated with short sleep duration (adjusted prevalence ratio [PR] = 1.47, 95% confidence interval [CI] = 1.11, 1.94), < 10% rapid eye movement [REM] sleep (PR = 1.57, 95% CI = 1.08, 2.27), ≥ 25% REM sleep (PR = 1.42, 95% CI = 1.03, 1.95), insomnia (PR = 1.83, 95% CI = 1.39, 2.40), excessive daytime sleepiness (EDS) (PR = 1.61, 95% CI = 1.19, 2.18), and AHI > 15 + EDS (PR = 1.55, 95% CI = 1.01, 2.39). Short sleep duration was associated with depression among those with high school education or beyond, but not among those with less education. Insomnia was more strongly associated with depression among men than women. CONCLUSIONS Sleep disturbances are associated with depression among middle-aged and older adults; these associations may be modified by education and sex. Future research should further test these hypotheses, evaluate whether early detection or treatment of sleep disturbances ameliorate depression, and explore subpopulation differences.

Self-Esteem and the Acute Effect of Anxiety on Ambulatory Blood Pressure.

Objectives Recent research suggests that self-esteem may be associated with improved parasympathetic nervous system functioning. This study tested whether high self-esteem is associated with decreased ambulatory systolic blood pressure (ASBP) reactivity to anxiety in healthy adults during the waking hours of a normal day. Methods Each of 858 participants completed a short version of the Rosenberg Self-Esteem Scale and then wore an ABP monitor that took two blood pressure readings per hour for 24 hours. Immediately after each blood pressure reading, participants completed an electronic diary report that included an anxiety rating on a 100-point visual analog scale. Using multilevel models, we assessed the association of momentary anxiety, high trait self-esteem, and their interaction on momentary ASBP, with adjustment for age, sex, race, ethnicity, and body mass index. Sensitivity analyses were conducted examining psychological factors associated with self-esteem: sense of mastery, optimism, social support, and depressive symptoms. Results On average, a 1-point increase in cube root–transformed anxiety was associated with a 0.80-mm Hg (standard error = 0.09, p < .001) increase in ASBP, and the interaction of high self-esteem and momentary anxiety was significant, such that this effect was 0.48 (standard error = 0.20, p = .015) less in individuals with high self-esteem compared with all others. Results for self-esteem remained significant when adjusting for sex and psychological factors. Conclusions Momentary increases in anxiety are associated with acute increases in ASBP, and high self-esteem buffers the effect of momentary anxiety on blood pressure. Thus, high self-esteem may confer cardiovascular benefit by reducing the acute effects of anxiety on systolic blood pressure.

Perfect Storm Concurrent Stress and Depressive Symptoms Increase Risk of Myocardial Infarction or Death

Background—Depression and stress have each been found to be associated with poor prognosis in patients with coronary heart disease. A recently offered psychosocial perfect storm conceptual model hypothesizes amplified risk will occur in those with concurrent stress and depressive symptoms. We tested this hypothesis in a large sample of US adults with coronary heart disease. Methods and Results—Participants included 4487 adults with coronary heart disease from the REasons for Geographic and Racial Differences in Stroke study, a prospective cohort study of 30 239 black and white adults. We conducted Cox proportional hazards regression with the composite outcome of myocardial infarction or death and adjustment for demographic, clinical, and behavioral factors. Overall, 6.1% reported concurrent high stress and high depressive symptoms at baseline. During a median 5.95 years of follow-up, 1337 events occurred. In the first 2.5 years of follow-up, participants with concurrent high stress and high depressive symptoms had increased risk for myocardial infarction or death (adjusted hazard ratio, 1.48 [95% confidence interval, 1.08–2.02]) relative to those with low stress and low depressive symptoms. Those with low stress and high depressive symptoms (hazard ratio, 0.92 [95% confidence interval, 0.66–1.28]) or high stress and low depressive symptoms (hazard ratio, 0.86 [95% confidence interval, 0.57–1.29]) were not at increased risk. The association on myocardial infarction or death was not significant after the initial 2.5 years of follow-up (hazard ratio, 0.89 [95% confidence interval, 0.65–1.22]). Conclusions—Our results provide initial support for a psychosocial perfect storm conceptual model; the confluence of depressive symptoms and stress on medical prognosis in adults with coronary heart disease may be particularly destructive in the shorter term.

Neighborhood factors as predictors of poor sleep in the sueno ancillary study of the hispanic community health study/study of latinos

Study Objectives To evaluate whether an adverse neighborhood environment has higher prevalence of poor sleep in a US Hispanic/Latino population. Methods A cross-sectional analysis was performed in 2156 US Hispanic/Latino participants aged 18-64 years from the Sueño ancillary study of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Participants completed surveys of neighborhood environment including perceived safety, violence and noise, the Insomnia Severity Index (ISI), and 7 days of wrist actigraphy. Results In age and sex-adjusted analyses, short sleep, low sleep efficiency, and late sleep midpoint were all more prevalent among those living in an unsafe neighborhood. After adjustment for background, site, nativity, income, employment, depressive symptoms, and sleep apnea, the absolute risk of sleeping <6 hours was 7.7 (95% CI [0.9, 14.6]) percentage points greater in those living in an unsafe compared to a safe neighborhood. There were no differences in the prevalence of insomnia by level of safety or violence. Insomnia was more prevalent among those living in a noisy neighborhood. In adjusted analysis, the absolute risk of insomnia was 4.4 (95% CI [0.4, 8.4]) percentage points greater in those living in noisy compared to non-noisy neighborhoods. Conclusion Using validated measures of sleep duration and insomnia, we have demonstrated the existence of a higher prevalence of short sleep and insomnia by adverse neighborhood factors. An adverse neighborhood environment is an established risk factor for a variety of poor health outcomes. Our findings suggest negative effects on sleep may represent one pathway by which neighborhood environment influences health.

Enduring somatic threat perceptions and post-traumatic stress disorder symptoms in survivors of cardiac events

Post-traumatic stress disorder due to acute cardiovascular events may be uniquely defined by enduring perceptions of somatic threat. We tested whether post-traumatic stress disorder at 1 month post–acute coronary syndrome indeed required both high peritraumatic threat during the acute coronary syndrome and ongoing cardiac threat perceptions. We assessed peritraumatic threat during emergency department enrollment of 284 patients with a provisional acute coronary syndrome diagnosis and cardiac threat perceptions and post-traumatic stress disorder symptoms 1 month post-discharge. In a multiple regression model with adjustment for important covariates, emergency department threat perceptions were associated with higher 1 month post-traumatic stress disorder symptoms only among those with high levels of ongoing cardiac threat.

Depressive symptoms and decision-making preferences in patients with comorbid illnesses

OBJECTIVE Shared decision-making (SDM) is increasingly promoted in the primary care setting, but depressive symptoms, which are associated with cognitive changes, may influence decision-making preferences. We sought to assess whether elevated depressive symptoms are associated with decision-making preference in patients with comorbid chronic illness. METHODS We enrolled 195 patients ≥18years old with uncontrolled hypertension from two urban, academic primary care clinics. Depressive symptoms were assessed using the 8-item Patient Health Questionnaire. Clinician-directed decision-making preference was assessed according to the Control Preference Scale. The impact of depressive symptoms on decision-making preference was assessed using generalized linear mixed models adjusted for age, gender, race, ethnicity, education, Medicaid status, Charlson Comorbidity Index, partner status, and clustering within clinicians. RESULTS The mean age was 64.2years; 72% were women, 77% Hispanic, 38% Black, and 33% had elevated depressive symptoms. Overall, 35% of patients preferred clinician-directed decision-making, 19% mostly clinician-directed, 39% shared, and 7% some or little clinician-input. Patients with (vs. without) elevated depressive symptoms were more likely to prefer clinician-directed decision-making (46% versus 29%; p=0.02; AOR 2.51, 95% CI 1.30-4.85, p=0.005). Remitted depressive symptoms (vs. never depressed) were not associated with preference. CONCLUSIONS Elevated depressive symptoms are associated with preference for clinician-directed decision-making. We suggest that clinicians should be aware of this effect when incorporating preference into their communication styles and take an active role in eliciting patient values and exchanging information about treatment choice, all important components of shared decision-making, particularly when patients are depressed.

Anxiety sensitivity and racial differences in sleep duration: Results from a national survey of adults with cardiovascular disease

Although Blacks sleep between 37 and 75min less per night than non-Hispanic Whites, research into what drives racial differences in sleep duration is limited. We examined the association of anxiety sensitivity, a cognitive vulnerability, and race (Blacks vs. White) with short sleep duration (<7h of sleep/night), and whether anxiety sensitivity mediated race differences in sleep duration in a nationally representative sample of adults with cardiovascular disease. Overall, 1289 adults (115 Black, 1174 White) with a self-reported physician/health professional diagnosis of ≥1 myocardial infarction completed an online survey. Weighted multivariable logistic regressions and mediation analyses with bootstrapping and case resampling were conducted. Anxiety sensitivity and Black vs. White race were associated with 4%-84% increased odds, respectively, of short sleep duration. Anxiety sensitivity mediated Black-White differences in sleep duration. Each anxiety sensitivity subscale was also a significant mediator. Implications for future intervention science to address sleep disparities are discussed.

Racial/ethnic differences in the associations between obesity measures and severity of sleep-disordered breathing: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVES The objective of this study was to evaluate associations between obesity measures and sleep-disordered breathing severity among White, Black, Hispanic, and Chinese Americans. METHODS The method used in this study was a community-based cross-sectional study of 2053 racially/ethnically diverse adults in the Multi-Ethnic Study of Atherosclerosis. Anthropometry and polysomnography were used to measure obesity and apnea-hypopnea index (AHI). Linear regression models were fitted to investigate associations of body mass index (BMI) and waist circumference with AHI (log transformed) with adjustment for sociodemographics, lifestyle factors, and comorbidities. RESULTS The mean participant age was 68.4 (range: 54-93) years; 53.6% of participants were women. The median AHI was 9.1 events/h. There were significant associations of BMI and waist circumference with AHI in the overall cohort and within each racial/ethnic group. A significant interaction was observed between race/ethnicity and BMI (Pinteraction = 0.017). Models predicted that for each unit increase in BMI (kg/m2), the mean AHI increased by 19.7% for Chinese, 11.6% for Whites and Blacks, and 10.5% for Hispanics. Similarly, incremental changes in waist circumference were associated with larger increases in AHI among Chinese than among other groups. CONCLUSIONS Associations of BMI and waist circumference with AHI were stronger among Chinese than among other racial/ethnic groups. These findings highlight a potential emergence of elevated sleep-disordered breathing prevalence occurring in association with increasing obesity in Asian populations.