Kara Zivin Bambauer

The effect of a telephone counseling intervention on self-rated health of cardiac patients

Objective: The objective of this study was to evaluate the effectiveness of a telephone-based intervention on psychological distress among patients with cardiac illness. Methods: We recruited hospitalized patients surviving an acute coronary syndrome with scores on the Hospital and Anxiety Depression Scale (HADS) indicating mild to severe depression and/or anxiety at 1 month postdischarge. Recruited patients were randomized into either an intervention or control group. Intervention patients received up to six 30-minute telephone-counseling sessions focused on identifying cardiac-related fears. Control patients received usual care. For both groups, we collected patients’ responses to the HADS and to the Global Improvement (CGI-I) subscale of the Clinical Global Impressions (CGI) Scale at baseline and at 2, 3, and 6 months postbaseline using Interactive Voice Recognition (IVR) technologies. We used mixed-effects analysis to estimate patients’ changes in CGI-I measures over the three time points of data collection postbaseline. Results: We enrolled 100 patients, and complete CGI-I measures were collected for 79 study patients. The mean age was 60 years (standard deviation = 10), and 67% of the patients were male. A mixed-effects analysis confirmed that patients in the intervention group had significantly greater improvements in self-rated health (SRH) between baseline and month 3 than the control group (p = .01). Between month 3 and month 6, no significant differences in SRH improvements were observed between the control and intervention groups. Conclusions: Study patients reported greater SRH improvement resulting from the telephone-based intervention compared with control subjects. Future research should include additional outcome measures to determine the effect of changes in SRH on patients with comorbid physical and emotional disorders. ACS = acute coronary syndrome; ADL = activities of daily living; CAD = coronary artery disease; CGI = Clinical Global Impressions Scale; CGI-I = Global Improvement subscale of the Clinical Global Impressions (CGI) Scale; ENRICHD = Enhancing Recovery in Heart Disease Patients trial; HADS = Hospital and Anxiety Depression Scale; HTS = Healthcare Technology Systems; ICD-9 = International Classification of Diseases, Ninth Edition; IRB = Institutional Review Boards; IVR = interactive voice recognition; MI = myocardial infarction; SADHART = the Sertraline Antidepressant Heart Attack Randomized Trial; SRH = self-rated health.

Improving psychologic adjustment to chronic illness in cardiac patients. The role of depression and anxiety

AbstractBACKGROUND: Poor mood adjustment to chronic medical illness is often accompanied by decrements in function. OBJECTIVE: To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness. DESIGN: Randomized, controlled trial. METHODS: We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale (HADS) with scores indicative of mood disturbances at 1-month postdischarge. Recruited patients were randomized to experimental or control status. Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns. Control patients received usual care. Patients’ responses to the HADS and the Workplace Social Adjustment Scale (WSAS) were collected at baseline, 2, 3, and 6 months using interactive voice recognition technology. At baseline, the PRIME-MD was used to establish diagnosis of depression. We used mixed effects regression to study changes in outcomes. RESULTS: We enrolled 100 patients. Mean age was 60; 67% of the patients were male. Findings confirmed that the intervention group had a 27% improvement in depression symptoms (P=.05), 27% in anxiety (P=.02), and a 38% improvement in home limitations (P=.04) compared with controls. Symptom improvement tracked those for WSAS measures of home function (P=.04) but not workplace function. CONCLUSIONS: The intervention had a moderate effect on patient’s emotional and functional outcomes that were observed during a critical period in patients’ lives. Patient convenience, ease of delivery, and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness.

Does Antidepressant Adherence Have an Effect on Glycemic Control among Diabetic Antidepressant Users

Objective: To examine the relationship between adherence to antidepressant medications and HbA1c levels among patients with diabetes in a managed care setting. Method: The analysis included measures of HbA1c levels before, during, and after initial antidepressant use among 568 patients with diabetes enrolled in the Harvard Pilgrim Health Care insurance plan from 1991–1995. Adherence was defined as four refills in a six-month period after the first antidepressant prescription. General linear models using SAS PROC MIXED were used to estimate the effects of covariates including antidepressant adherence on HbA1c levels over time, comparing patients who were adherent to antidepressant medications to those patients who were non-adherent to antidepressant medications. Results: Adherence to antidepressant treatment was not significantly associated with HbA1c levels among diabetic patients who are antidepressant users. Younger age, use of insulin and oral medications, and female gender were all significantly associated with HbA1c levels over time. Conclusions: Although we did not observe any association between level of adherence to antidepressant therapy among diabetic patients and levels of glucose control, our results confirm previously established associations between patient characteristics and glycemic control. Further research is needed to disentangle the complex relationship among antidepressant treatment adherence and diabetes outcomes.

The effect of underlying health status on patient or surrogate preferences for end-of-life care: a pilot study.

This study explored the role of health status, as measured by the Palliative Performance Score, in shaping patient preferences for end-of-life care. Scores were correlated with 3 potential goals of care: prolonging life, maintaining function, and maximizing comfort among patients seen in palliative care consultation. Eighty-six patients expressed treatment preferences: 16 (19%) preferred prolonging life, 23 (27%) preferred maintaining function, and 47 (54%) preferred maximizing comfort (P < .0001); their average scores ± standard deviation were, respectively, 51.9 ± 19.4, 56.5 ± 16.7, and 45.3 ± 14.1 (P = .0459). There was a significant relationship between patient preferences and Palliative Performance Score, with lower scores indicating preferences for comfort and higher scores indicating a preference for maintaining function and life expectancy. Further research is needed to test the sensitivity of health status, as measured by the Palliative Performance Score, in affecting patient preferences.