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Featured researches published by Judith A. Skala.


Psychosomatic Medicine | 2003

Prevalence of Depression in Hospitalized Patients With Congestive Heart Failure

Kenneth E. Freedland; Michael W. Rich; Judith A. Skala; Robert M. Carney; Victor G. Dávila-Román; Allan S. Jaffe

Objective Prevalence estimates of depression in hospitalized patients with congestive heart failure (CHF) differ considerably across studies. This article reports the prevalence of depression in a larger sample of hospitalized patients with CHF and identifies demographic, medical, psychosocial, and methodological factors that may affect prevalence estimates. Methods A modified version of the Diagnostic Interview Schedule was administered to a series of 682 hospitalized patients with CHF to determine the prevalence of DSM-IV major and minor depression; 613 patients also completed the Beck Depression Inventory. Medical, demographic, and social data were obtained from hospital chart review, echocardiography, and patient interview. Results In the sample as a whole, 20% of the patients met the DSM-IV criteria for a current major depressive episode, 16% for a minor depressive episode, and 51% scored above the cutoff for depression on the Beck Depression Inventory (≥10). However, the prevalence of major depression differed significantly between strata defined by the functional severity of heart failure, age, gender, employment status, dependence in activities of daily living, and past history of major depression. For example, the prevalence ranged from as low as 8% among patients in New York Heart Association class I failure to as high as 40% among patients in class IV. Conclusions The prevalence of depression in hospitalized patients with CHF is similar to rates found in post-myocardial infarction patients. However, it is considerably higher in certain subgroups, such as patients with class III or IV heart failure. Further research is needed on the prognostic importance and treatment of comorbid depression in CHF.


Psychosomatic Medicine | 2000

Change in heart rate and heart rate variability during treatment for depression in patients with coronary heart disease

Robert M. Carney; Kenneth E. Freedland; Phyllis K. Stein; Judith A. Skala; Patricia M. Hoffman; Allan S. Jaffe

Objective Major depression is a common problem in patients with coronary heart disease (CHD) and is associated with an increased risk for cardiac morbidity and mortality. It is not known whether treating depression will improve medical prognosis in patients with CHD. Depression is also associated with elevated heart rate and reduced heart rate variability (HRV), which are known risk factors for cardiac morbidity and mortality that may explain the increased risk associated with depression. The purpose of this study was to determine whether treatment for depression with cognitive behavior therapy (CBT) is associated with decreased heart rate or increased HRV. Methods Thirty depressed patients with stable CHD, classified as either mildly or moderately to severely depressed, received up to 16 sessions of CBT. The 24-hour heart rate and HRV were measured in these patients and in 22 medically comparable nondepressed controls before and after treatment of the depressed patients. Results Average heart rate and daytime rMSSD (reflecting mostly parasympathetic activity) improved significantly in the severely depressed patients, but remained unchanged in the mildly depressed and the control patients. However, only rMSSD improved to a level comparable to the control patients. None of the remaining indices of HRV showed improvement. Conclusions The results suggest that treating depression with CBT may reduce heart rate and increase short-term HRV. Thus, CBT may have a beneficial effect on a risk factor for mortality in depressed patients with coronary heart disease. A randomized, controlled study is needed to confirm these findings.


Journal of Psychosomatic Research | 2000

Severe depression is associated with markedly reduced heart rate variability in patients with stable coronary heart disease

Phyllis K. Stein; Robert M. Carney; Kenneth E. Freedland; Judith A. Skala; Allan S. Jaffe; Robert E. Kleiger; Jeffrey N. Rottman

OBJECTIVE The purpose of this study was to investigate the relationship between depression and heart rate variability in cardiac patients. METHODS Heart rate variability was measured during 24-hour ambulatory electrocardiographic (ECG) monitoring in 40 medically stable out-patients with documented coronary heart disease meeting current diagnostic criteria for major depression, and 32 nondepressed, but otherwise comparable, patients. Patients discontinued beta-blockers and antidepressant medications at the time of study. Depressed patients were classified as mildly (n = 21) or moderately-to-severely depressed (n = 19) on the basis of Beck Depression Inventory scores. RESULTS There were no significant differences among the groups in age, gender, blood pressure, history of myocardial infarction, diabetes, or smoking. Heart rates were higher and nearly all indices of heart rate variability were significantly reduced in the moderately-to-severely versus the nondepressed group. Heart rates were also higher and mean values for heart rate variability lower in the mildly depressed group compared with the nondepressed group, but these differences did not attain statistical significance. CONCLUSION The association of moderate to severe depression with reduced heart rate variability in patients with stable coronary heart disease may reflect altered cardiac autonomic modulation and may explain their increased risk for mortality.


General Hospital Psychiatry | 1996

Depression in patients with coronary heart disease ☆: A 12-month follow-up

Melissa Hance; Robert M. Carney; Kenneth E. Freedland; Judith A. Skala

Little is known about the course and outcome of depression in patients with coronary heart disease, despite its prevalence and effect on medical prognosis. A series of 200 patients undergoing diagnostic cardiac catheterization and coronary angiography were administered a psychiatric diagnostic interview. Seventeen percent were diagnosed with a current major depressive episode, and another 17% with a current minor depressive episode. Ninety percent of those patients who consented to follow-up completed the study. Half of the patients with major depression either remained depressed or relapsed within 12 months. Nearly half of the patients with minor depression remitted, but 42% subsequently developed major depression. These results suggest that major depression, if left untreated, is persistent in patients with coronary heart disease. Furthermore, minor depression is nearly as likely to progress to major depression as to remit over the course of the 12 months following diagnostic angiography.


Archives of General Psychiatry | 2009

Treatment of Depression After Coronary Artery Bypass Surgery: A Randomized Controlled Trial

Kenneth E. Freedland; Judith A. Skala; Robert M. Carney; Eugene H. Rubin; Patrick J. Lustman; Victor G. Dávila-Román; Brian C. Steinmeyer; Charles W. Hogue

CONTEXT There has been little research on the treatment of depression after coronary artery bypass surgery. OBJECTIVE To test the efficacy of 2 nonpharmacological interventions for depression after coronary artery bypass surgery compared with usual care. DESIGN A 12-week, randomized, single-blind clinical trial with outcome evaluations at 3, 6, and 9 months. SETTING Outpatient research clinic at Washington University School of Medicine, St Louis, Missouri. PATIENTS One hundred twenty-three patients who met the DSM-IV criteria for major or minor depression within 1 year after surgery. INTERVENTION Twelve weeks of cognitive behavior therapy or supportive stress management. Approximately half of the participants were taking nonstudy antidepressant medications. MAIN OUTCOME MEASURE Remission of depression, defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression. RESULTS Remission of depression occurred by 3 months in a higher proportion of patients in the cognitive behavior therapy (71%) and supportive stress-management (57%) arms than in the usual care group (33%) (chi(2)(2) = 12.22, P = .002). Covariate-adjusted Hamilton scores were lower in the cognitive behavior therapy (mean [standard error], 5.5 [1.0]) and the supportive stress-management (7.8 [1.0]) arms than in the usual care arm (10.7 [1.0]) at 3 months. The differences narrowed at 6 months, but the remission rates differed again at 9 months (73%, 57%, and 35%, respectively; chi(2)(2) = 12.02, P = .003). Cognitive behavior therapy was superior to usual care at most points on secondary measures of depression, anxiety, hopelessness, stress, and quality of life. Supportive stress management was superior to usual care only on some of the measures. CONCLUSIONS Both cognitive behavior therapy and supportive stress management are efficacious for treating depression after coronary artery bypass surgery, relative to usual care. Cognitive behavior therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00042198.


Psychosomatic Medicine | 2002

The Depression Interview and Structured Hamilton (DISH): Rationale, development, characteristics, and clinical validity

Kenneth E. Freedland; Judith A. Skala; Robert M. Carney; James M. Raczynski; C. Barr Taylor; Carlos F. Mendes de Leon; Gail Ironson; James D. Hosking; Marston E. Youngblood; K. Ranga Rama Krishnan; Richard C. Veith

Objective The Depression Interview and Structured Hamilton (DISH) is a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter clinical trial of treatment for depression and low perceived social support after acute myocardial infarction. The DISH is designed to diagnose depression in medically ill patients and to assess its severity on an embedded version of Williams’ Structured Interview Guide for the Hamilton Depression scale (SIGH-D). This article describes the development and characteristics of the DISH and presents a validity study and data on its use in ENRICHD. Methods In the validity study, the DISH and the Structured Clinical Interview for DSM-IV (SCID) were administered in randomized order to 57 patients. Trained interviewers administered the DISH, and clinicians administered the SCID. In ENRICHD, trained research nurses administered the DISH and recorded a diagnosis. Clinicians reviewed 42% of the interviews and recorded their own diagnosis. The Beck Depression Inventory (BDI) was administered in both studies. Results In the validity study, the SCID diagnosis agreed with the DISH on 88% of the interviews (weighted &kgr; = 0.86). In ENRICHD, the clinicians agreed with 93% of the research nurses’ diagnoses. The BDI and the Hamilton depression scores derived from the DISH in the two studies correlated 0.76 (p < .0001) in the validity study and 0.64 (p < .0001) in ENRICHD. Conclusions These findings support the validity of the DISH as a semistructured interview to assess depression in medically ill patients. The DISH is efficient in yielding both a DSM-IV depression diagnosis and a 17-item Hamilton depression score.


Biological Psychiatry | 1999

Major depression, heart rate, and plasma norepinephrine in patients with coronary heart disease

Robert M. Carney; Kenneth E. Freedland; Richard C. Veith; Philip E. Cryer; Judith A. Skala; Tiffany Lynch; Allan S. Jaffe

BACKGROUND Although it is now well established that psychiatric depression is associated with adverse outcomes in patients with coronary heart disease (CHD), the mechanism underlying this association is unclear. Elevated heart rate (HR) and plasma norepinephrine (NE), possibly reflecting altered autonomic nervous system activity, have been documented in medically well depressed psychiatric patients, and this pattern is associated with increased risk for cardiac events in patients with CHD. The purpose of this study was to determine whether autonomic nervous system activity is altered in depressed CHD patients. METHODS HR, plasma NE, and blood pressure (BP) were measured in 50 depressed and 39 medically comparable nondepressed CHD patients at rest and during orthostatic challenge. RESULTS Resting HR (p = .005), and the change from resting HR at 2, 5, and 10 min after standing (p = .02, .004, and .02, respectively), were significantly higher in the depressed than in the nondepressed patients. There were no differences between the groups in NE or in BP at rest, or in standing minus resting change scores at any time during orthostatic challenge (p < .05). CONCLUSIONS Depression is associated with altered autonomic activity in patients with CHD, as reflected by elevated resting HR and an exaggerated HR response to orthostatic challenge. Previously reported differences in NE levels between depressed and nondepressed patients were not replicated.


The Canadian Journal of Psychiatry | 2006

Coronary Heart Disease and Depression: A Review of Recent Mechanistic Research

Judith A. Skala; Kenneth E. Freedland; Robert M. Carney

Objective: Both behavioural and physiological factors have been proposed as mechanisms that may explain the negative effect of depression on coronary heart disease (CHD). Our aim is to review some of the most important findings since our prior review. Method: We searched MEDLINE, PsycINFO, and other sources for recent studies of candidate mechanisms, with an emphasis on publications since 2002. Results: Physiological pathways have received far greater attention than behavioural ones in the emerging literature. Recent studies have identified shared genetic determinants, inflammation, blood clotting, and vascular mechanisms as plausible explanatory mechanisms. Conclusions: Future research should focus on relations between behavioural and physiological mechanisms and on the effects of pharmacologic and psychotherapeutic treatments for depression on candidate mechanisms.


Psychosomatic Medicine | 2005

Depression and smoking in coronary heart disease.

Kenneth E. Freedland; Robert M. Carney; Judith A. Skala

Objective: This review examines the relationship between depression and smoking in coronary heart disease (CHD). It summarizes relevant findings from general population and smoking cessation studies and discusses the few studies that have investigated whether smoking confounds, mediates, or moderates the effect of depression on cardiac morbidity and mortality. Methods: Qualitative review of research literature. Results: Although many studies of the prognostic importance of depression in CHD have adjusted for smoking, there is no convincing evidence that smoking actually confounds the relationship between depression and CHD. There is also no evidence that smoking moderates this relationship. There is, however, limited evidence that smoking may partially mediate the effect of depression on morbidity and mortality in CHD. Conclusion: We need more research on the relationship between depression and smoking in CHD to develop a more complete model of the mechanisms linking depression to cardiac morbidity and mortality. CHD = coronary heart disease; MI = myocardial infarction.


Behavioral Medicine | 1998

Adherence to a prophylactic medication regimen in patients with symptomatic versus asymptomatic ischemic heart disease

Robert M. Carney; Kenneth E. Freedland; Seth A. Eisen; Michael W. Rich; Judith A. Skala; Allan S. Jaffe

Although angina pectoris is the most common symptom of coronary artery disease, some patients do not experience angina during ischemic episodes. The effects of asymptomatic (silent) heart disease on patient self-management have rarely been studied. Studies of other patient populations with asymptomatic illnesses indicate that patients with silent myocardial ischemia might adhere less well to a prophylactic medication regimen than would those with symptomatic ischemia. Depression, a state associated with poor adherence to medical regimens is more common among patients with symptomatic ischemia. For prevention of thromboembolic events, 37 patients with documented ischemic heart disease who denied having anginal symptoms and 28 patients who reported almost daily symptoms were given a 3-week supply of low-dose aspirin packaged in an unobtrusive electronic adherence monitor. All other medications were provided in standard pill bottles. The symptomatic patients removed their prescribed aspirin on 62.4% of the days; the patients with silent ischemia took their medication on 77.3% of the days. Possible explanations for these results, their clinical implications, and directions for future research are discussed.

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Kenneth E. Freedland

Washington University in St. Louis

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Robert M. Carney

Washington University in St. Louis

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Michael W. Rich

Washington University in St. Louis

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Phyllis K. Stein

Washington University in St. Louis

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Victor G. Dávila-Román

Washington University in St. Louis

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Brian C. Steinmeyer

Washington University in St. Louis

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Eugene H. Rubin

Washington University in St. Louis

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Patrick J. Lustman

Washington University in St. Louis

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