Gregory Moullec

Smoking Cessation, Depression, and Exercise: Empirical Evidence, Clinical Needs, and Mechanisms

INTRODUCTIONnSmoking is significantly more common among persons with major depressive disorders (MDDs). Furthermore, smokers with MDD report more difficulties when they quit smoking (greater withdrawal symptoms, higher probability of relapse). The aim of this narrative review is to describe research on exercise and depression and exercise and smoking cessation.nnnMETHODSnWe have critically reviewed various smoking cessation intervention programs for depressive smokers examining (a) the protective effect of exercise against relapse for smokers with MDD and (b) the benefits of exercise for treating withdrawal symptoms. We have also reviewed the current literature investigating the mechanisms between exercise-depression and exercise-smoking.nnnRESULTSnThis review suggests that exercise may reduce depressive symptoms following cessation and provide a useful strategy for managing withdrawal symptoms in smokers with MDD. Various psychological, biological, and genetic hypotheses have been tested (e.g., distraction hypothesis, expectations hypothesis, cortisol hypothesis) and few have obtained significant results.nnnCONCLUSIONSnIt might be beneficial for health professionals to recommend physical activity and promote supervised exercise sessions for smokers with MDD during smoking cessation. Future research needs to examine relationships between exercise, smoking, and depression with transdisciplinary and ecological momentary assessment.

Efficacy of interventions to improve adherence to inhaled corticosteroids in adult asthmatics: impact of using components of the chronic care model

BACKGROUNDnAdherence to inhaled corticosteroids (ICS) remains poor among asthmatics, yet little is known about the efficacy of interventions to improve adherence. Implementing the Chronic Care Model (CCM) components among patients with respiratory disorders has been associated with an improvement in outcomes, yet little is known about its effects on ICS adherence in asthmatics.nnnOBJECTIVEnWe conducted a systematic review to assess the efficacy of interventions to improve ICS adherence among adult-asthmatics, and whether the use of CCM components (i.e., teaching self-management skills, providing decision support, delivery system design, and clinical information systems) resulted in greater ICS adherence.nnnMETHODSnAll English language articles testing the efficacy of an intervention including ICS medication on outcome from MEDLINE and PsychINFO databases through Aug-2010 were reviewed. Interventions were categorized based on the inclusion of CCM components. We standardized treatment effects to obtain effect-sizes (ESs) and we combined the ESs of studies according to the number of CCM components included in their interventions.nnnRESULTSnEighteen studies met inclusion criteria. Inclusion of a greater number of CCM components within interventions was associated with stronger effects on ICS adherence outcomes, with interventions featuring one, two, and four CCM components having medium (ES = 0.29; 95%CI, 0.16-0.42), large (0.53; 0.40-0.66), and very-large (0.83; 0.69-0.98) effects respectively.nnnCONCLUSIONSnFindings provide support for using the CCM as a framework for the design and implementation of interventions to improve adherence among adult-asthmatics.

Can a self-management education program for patients with chronic obstructive pulmonary disease improve quality of life ?

OBJECTIVEnTo assess the effects of a self-management program on health-related quality of life (HRQoL) and morbidity commonly associated with chronic obstructive pulmonary disease (COPD).nnnMETHODSnA total of 57 outpatients with stable COPD received four weeks of self-management education, while 45 patients received usual care. Patients were evaluated at baseline, at three months and one year following the educational intervention. The primary outcome variable was HRQoL measured by the St Georges Respiratory Questionnaire (SGRQ). The secondary outcome variables were number of emergency room visits and hospitalizations for exacerbation.nnnRESULTSnThe intervention groups HRQoL improved significantly at three months (total score A = -5.0 [P = 0.006]) and 12 months (total score A = -6.7 [P < 0.001]), as evidenced by decreased scores on the SGRQ. In contrast, the SGRQ scores increased significantly in the control group at three months (total score A = +3.7 [P = 0.022]) and 12 months (total score A = +3.4 [P = 0.032]). Global impact appeared to be responsible for the change in the intervention group. Moreover, in the intervention group, the number of hospitalizations dropped from 0.7⁄person⁄year to 0.3⁄person⁄year (P = 0.017), and emergency room visits dropped from 1.1 person⁄year to 0.2⁄person⁄year (P = 0.002), while subjects in the control group did not experience any significant decreases in these parameters.nnnCONCLUSIONSnA planned education program improved HRQoL while decreasing the number of emergency room visits and hospitalizations in patients with stable COPD; this improvement persisted at 12 months.

The impact of psychological distress on exacerbation rates in COPD.

Background: Exacerbations are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to COPD morbidity and mortality. COPD is also associated with high levels of psychological distress, which has been shown to be associated with higher exacerbation rates. However, the existing literature on the association between psychological distress and exacerbation risk remains largely misunderstood. Objectives: To critically review the current literature on the association between psychological distress (defined as anxiety and depressive symptoms or anxiety and depressive disorders) and COPD exacerbations in COPD patients, to highlight the limitations of the existing literature, and to provide recommendations for future research. Methods: A critical review of English-language peer-reviewed longitudinal and retrospective studies was conducted. The Ovid portal to Medline, EMBASE, and PsycINFO databases were accessed. Results: Some acceptable evidence suggested that psychological distress confers greater risk for exacerbations, more specifically symptom-based exacerbations or those treated in the patient’s own environment. However, most studies showed an absence of a positive association, especially with exacerbations leading to hospitalization. Conclusions: Methodological weaknesses and the use of a wide range of psychological tools mean that there is an inconsistent association between psychological distress and exacerbations in the current literature. However, psychological distress may confer greater risk for symptom-based rather than event-based defined exacerbations. Further studies are needed to more comprehensively assess the question, particularly in light of the high levels of both anxiety and depression in COPD patients.

The evolution of a Canadian Hypertension Education Program recommendation: the impact of resistance training on resting blood pressure in adults as an example.

Ever since the first set of hypertension recommendations which were generated from the Canadian Hypertension Education Program, lifestyle and health behaviour have been a key focus. An initial recommendation focused on the benefits of aerobic exercise to reduce resting blood pressure (BP). However, until the 2013 edition, resistance exercise (RT) was not included. The current article describes a meta-analysis that was conducted which helped inform the creation of the newly introduced recommendation. Literature searches were conducted in 4 electronic databases. Inclusion criteria included: (1) randomized controlled trials with 4-week minimum, RT-alone intervention arms; (2) BP-lowering as the primary outcome; (3) human, adult participants; and (4) reporting control data, baseline, and postintervention resting systolic BP and diastolic BP. Nine studies (11 intervention groups, 452 participants) were identified. The analyses indicated that diastolic BP was significantly reduced (-2.2 mm Hg; 95% confidence interval,xa0-3.9 toxa0-0.5) in those randomized to RT compared with control participants. In contrast, no statistically significant change in systolic BP (-1.0 mm Hg; 95% confidence interval,xa0-3.4 to 1.4) was observed. None of the studies found RT to increase BP and no adverse effects of RT were explicitly reported. Results suggest that participation in RT is not harmful and does not increase BP. However, more evidence is needed before recommending RT as a specific BP-lowering therapy.

Screening for occupational asthma by using a self-administered questionnaire in a clinical setting.

Objective: Because of its high prevalence, early screening for occupational asthma (OA) is crucial. We aimed to evaluate the screening performance of the Occupational Asthma Screening Questionnaire–11 items (OASQ-11) in a clinical setting. Methods: Between January 2009 and December 2011, 169 workers referred for potential OA to our hospital completed the OASQ-11 and underwent workups to determine the final diagnosis. The discriminative abilities of the OASQ-11 as a whole and in relation to demographic and exposure parameters were determined by the area under the receiving operator characteristic curve (AUC). Results: Model 1, consisting of the OASQs items, showed fair discrimination (AUC, 0.69; 95% confidence interval, 0.58 to 0.80). Addition of age and exposure duration to model 1 improved discrimination (AUC, 0.80; confidence interval, 0.72 to 0.88). Conclusion: A simple model consisting of the OASQ-11s items, age, and exposure duration could well discriminate subjects with OA in a clinical setting.

Type-D Personality and Heart Disease: It Might Be ‘One Small Step’, but It Is Still Moving Forward: A Comment on Grande et al.

Since the landmark studies of the late 60s and early 70s, we as a field have tried to find the key psychosocial predictors of poorer cardiovascular outcomes. In the mid-90s, a new construct, type-D personality, was found to have significant predictive ability for mortality in patients with coronary heart disease [1]. This has led to a constant stream of original studies and reviews exploring the potential role of type-D personality in the progression of heart disease. Of particular note, there has been a recent spate of systematic reviews [2–4] on the topic. In spite of this, the review by Grande et al. [5] truly provides an extension, not only through the inclusion of new studies, but also in its conceptualisation. Grande and colleagues have taken a rigorous and refined approach to assessing the impact of type-D personality on cardiac outcomes, which has created a number of interesting talking points. One particularly interesting point rightly highlighted by the authors is the contrasting data on patients with coronary artery disease vs. those with congestive heart failure (CHF). They raise the issue of whether this difference is driven by a true lack of prognostic effects in CHF patients or if this just reflects the increased sample size in the newer larger CHF studies and tend, with good reason, to lean more on the side of an actual prognostic difference. There is, however, an alternative possibility which revolves around the appropriate cut point for different populations. The type-D scale, which was used in 11 out of the 12 studies, was developed in a specific population, a Flemish/Dutch coronary artery disease population [6], and whilst there has been some good work to establish the factor structure invariance of the scale across different languages and populations [7], the same cannot be said for the cut point of 10. One of the main underpinnings of good psychometrics is that all aspects of a scale or questionnaire are validated when used in new populations, i.e. any population that differs substantially from the original cohort the scale/ questionnaire was developed in. Following this, it could be that type-D personality may be predictive of outcomes in CHF populations, but not with a cut point of 10. Further complicating this issue is the way in which the original cut point was generated. The figure of 10 is derived from a median split of negative affect and social inhibition in the original validation study. We think all of us would argue that this is not the optimal way of defining a diagnostic level, though, as highlighted by Grande and colleagues, what is the comparator or ‘reference standard’ [8] needed to determine the classification accuracy of the type-D cut point? Suffice to say, there needs to bemore work around the optimisation of a type-D cut point, or if no valid measure can be reliably generated, then only continuous data should be used in the future. Another interesting finding from this meta-analysis was that no matter what way the data were analysed, the pooled odds ratio or hazard ratio (HR) ranged from 1.5 to 2.3, though for those sub-analyses with less studies, the increased confidence intervals suggested non-significance. At this point in time, it S. L. Bacon :G. Moullec Montreal Behavioural Medicine Centre, Montreal, Quebec H4J 1C5, Canada

Individual and Combined Impact of Cigarette Smoking, Anxiety, and Mood Disorders on Asthma Control

INTRODUCTIONnDespite the availability of effective therapies, research indicates that more than 50% of asthmatics are poorly controlled. Poor asthma control has been linked to behavioral (i.e., cigarette smoking) and psychological factors (i.e., anxiety and depression). However, little is known about the individual versus combined impact of cigarette smoking and anxiety or mood disorders in adult asthmatics on asthma control.nnnMETHODSnA total of 796 confirmed adult asthma patients completed a sociodemographic and medical history interview and underwent a psychiatric interview using the Primary Care Evaluation of Mental Disorders. Asthma control was evaluated using the Asthma Control Questionnaire.nnnRESULTSnAfter adjusting for age, sex, and dose of inhaled corticosteroids, general linear model analyses indicated a significant main effect of current smoking on asthma control (B [SE] = 0.156 [0.059], p = .008) and main effects of anxiety disorders (B [SE] = 0.408 [0.095], p = < .001) and mood disorders (B [SE] = 0.448 [0.098], p = < .001) on asthma control. Pack-years were not associated with asthma control, and there were no interaction effects of current smoking or pack-years with either anxiety or mood disorders on asthma control.nnnCONCLUSIONSnFindings suggest that current smoking, having an anxiety disorder, and having a mood disorder are independently associated with poorer asthma control but that cumulative smoking history (i.e., pack-years) was not associated with worse asthma control. These results indicate that smoking cessation may have a positive impact on asthma control levels in spite of past smoking intensity and highlight the importance of interventions that target anxiety and mood disorders in adult asthmatics.

Resistance Training, Blood Pressure, and Meta-Analyses

To the Editor:nnWe read with great interest the recent meta-analysis by Cornelissen et al1 evaluating the impact of resistance training on blood pressure. This is an area that certainly needs a great deal of clarification, and the finding that dynamic and isometric resistance training results in a decrease of 3.9/3.9 mm Hg in normotensive/prehypertensive participants and a 4.1/1.5-mm Hg decrease in hypertensives provides a useful synthesis of the existent literature. However, we feel there are some methodological issues that need to be considered when interpreting these data.nnFirst, the authors have included articles for which blood pressure was not the primary outcome of interest. Although the inclusion of such secondary data certainly helps to provide as full a picture as possible, it does have the possibility to influence the effect estimates …

Beck Depression Inventory II: determination and comparison of its diagnostic accuracy in cardiac outpatients.

Objectives To evaluate the impact of covariates on performance accuracy of the Beck Depression Inventory II (BDI-II) and to determine the optimal cut-off score for the BDI-II in cardiac outpatients. Differences of optimal cut-off scores were also verified across covariate subgroups. Design and setting Prospective cross-sectional study at the Department of Nuclear Medicine of the Montreal Heart Institute (Quebec, Canada). Methods A total of 750 adult cardiac outpatients (meanu2009±u2009SD age 58u2009±u200910 years, 31% women) completed the BDI-II and the Primary Care Evaluation of Mental Disorders (PRIME-MD; a psychiatric interview used as the reference standard for determining diagnosis of major depressive disorder). The receiver operating characteristics (ROC) curve of the BDI-II was adjusted for age, sex, level of education, smoking status, obesity, anxiety disorder, psychotropic medication, and history of coronary artery disease. The ROC analyses were conducted to determine optimal cut-off scores. Results Forty-two (6%) patients met criteria for current major depressive disorder according to the PRIME-MD. After adjusted for covariates, the area under the ROC curve was significantly smaller than the unadjusted curve (0.76, 95% CI 0.66 to 0.85 vs. 0.84, 95% CI 0.77 to 0.89; ΔAUCu2009=u2009−0.07, 95% CI −0.13 to −0.02). While the optimal cut-off score was 10 for the total sample (sensitivity 83%, specificity 73%), the analyses indicated different cut-off scores across covariate subgroups: e.g. sex (women 13; men 10), and anxiety disorders (yes 15; no 10). Conclusions BDI-II is a good screening instrument for depression in cardiac outpatients. However, the present results suggest that covariates can affect the classification accuracy of the BDI-II’s original recommended cut-off score. Scholars and clinicians should be aware of the principle that a screening score established in one population may not be relevant to another.