Karen Downing

Exploratory data mining analysis identifying subgroups of patients with depression who are at high risk for suicide

OBJECTIVE Although prior research has identified a number of separate risk factors for suicide among patients with depression, little is known about how these factors may interact to modify suicide risk. Using an empirically based decision tree analysis for a large national sample of Veterans Affairs (VA) health system patients treated for depression, we identified subgroups with particularly high or low rates of suicide. METHOD We identified 887,859 VA patients treated for depression between April 1, 1999, and September 30, 2004. Randomly splitting the data into 2 samples (primary and replication samples), we developed a decision tree for the primary sample using recursive partitioning. We then tested whether the groups developed within the primary sample were associated with increased suicide risk in the replication sample. RESULTS The exploratory data analysis produced a decision tree with subgroups of patients at differing levels of risk for suicide. These were identified by a combination of factors including a co-occurring substance use disorder diagnosis, male sex, African American race, and psychiatric hospitalization in the past year. The groups developed as part of the decision tree accurately discriminated between those with and without suicide in the replication sample. The patients at highest risk for suicide were those with a substance use disorder who were non-African American and had an inpatient psychiatric stay within the past 12 months. CONCLUSIONS Study findings suggest that the identification of depressed patients at increased risk for suicide is improved through the examination of higher order interactions between potential risk factors.

Antidepressant Agents and Suicide Death Among US Department of Veterans Affairs Patients in Depression Treatment

Background Studies report mixed findings regarding antidepressant agents and suicide risks, and few examine suicide deaths. Studies using observational data can accrue the large sample sizes needed to examine suicide death, but selection biases must be addressed. We assessed associations between suicide death and treatment with the 7 most commonly used antidepressants in a national sample of Department of Veterans Affairs patients in depression treatment. Multiple analytic strategies were used to address potential selection biases. Methods We identified Department of Veterans Affairs patients with depression diagnoses and new antidepressant starts between April 1, 1999, and September 30, 2004 (N = 502,179). Conventional Cox regression models, Cox models with inverse probability of treatment weighting, propensity-stratified Cox models, marginal structural models (MSM), and instrumental variable analyses were used to examine relationships between suicide and exposure to bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine. Results Crude suicide rates varied from 88 to 247 per 100,000 person-years across antidepressant agents. In multiple Cox models and MSMs, sertraline and fluoxetine had lower risks for suicide death than paroxetine. Bupropion had lower risks than several antidepressants in Cox models but not MSMs. Instrumental variable analyses did not find significant differences across antidepressants. Discussion Most antidepressants did not differ in their risk for suicide death. However, across several analytic approaches, although not instrumental variable analyses, fluoxetine and sertraline had lower risks of suicide death than paroxetine. These findings are congruent with the Food and Drug Administration meta-analysis of randomized controlled trials reporting lower risks for “suicidality” for sertraline and a trend toward lower risks with fluoxetine than for other antidepressants. Nevertheless, divergence in findings by analytic approach suggests caution when interpreting results.

Predictors of alternative antidepressant agent initiation among U. S. veterans diagnosed with depression.

Naturalistic studies comparing differences in risks across antidepressant agents must take into account factors which influence selection of specific agents and may be associated with outcomes. We examined predictors of antidepressant choice among VA patients treated for depression.

Emergent anxiety after antidepressant initiation: a retrospective cohort study of Veterans Affairs Health System patients with depression.

BACKGROUND Initiation of antidepressant treatment for depression may be associated with new onset (emergent) anxiety. OBJECTIVE The purpose of this study was to assess demographic and clinical factors associated with emergent anxiety following a new antidepressant start among Department of Veterans Affairs (VA) Health System patients with depression. METHODS Using a retrospective cohort design, we obtained data from 328,888 VA patients with depression who were newly prescribed 1 of the 7 most commonly used antidepressant drugs between April 1999 and September 2004 from the VA National Depression Registry. We examined the prevalence of emergent anxiety, defined as either a new anxiety diagnoses or by new antianxiety medication starts, during the 12 weeks following new antidepressant start. In multivariate analyses, we assessed the hazard ratios for emerging anxiety associated with patient characteristics and specific antidepressant agents. RESULTS Approximately 3% of patients developed clinically significant anxiety within 12 weeks of starting an antidepressant drug regimen. Younger age (age <45 years and 45-64 years) was associated with higher risks for emergent anxiety than older age (≥65 years) (hazard ratio [HR] = 1.72 and 1.55; 95% CI, 1.59-1.85, and 1.38-1.72, respectively). Female gender was associated with higher risks than male gender (HR = 1.17; 95% CI, 1.10-1.26), and white and other races compared with black race were associated with higher risks of emergent anxiety (HR = 1.49 and 1.13; 95% CI, 1.30-1.59 and 1.04-1.23, respectively). Finally, filling antidepressant drug prescriptions in years subsequent to 1999 was associated with lower risks of emergent anxiety. CONCLUSIONS Only a small proportion of patients developed emergent anxiety following a new antidepressant start, resulting in a new diagnosis or antianxiety medication use. Anxiety occurred more often in young adults, whites, and women.

Mlibrary: Concepts for Redefining Reference

ABSTRACT Readily available reference services have been a key component of the University of Michigan Librarys (MLibrary) success in supporting and advancing campus research, teaching, and learning. An examination of the evolution of our reference services over the past 10 years suggests strategies and innovative approaches that may well inform future service directions. The purpose of this article is to capture the University of Michigan experience as a way to better understand this evolution and, in doing so, to offer critical concepts to consider when thinking about the development of current and future reference services.

Race as Multidimensional: The Personal Shaping the Professional in the Library and Information Field

Abstract Purpose This chapter argues that, though the field of library and information science has made some progress in advancing diversity and inclusion, race still needs to be acknowledged as a barrier and its collateral damage needs to be spoken in order to ensure equity in our practice, research, and/or service. Core to the argument is that race as a univariate measure, equated with phenotype, is problematic and simplistic. This chapter instead makes a case for race as multidimensional. Although race figures in how one is perceived, this lens diminishes the agency of people of color to define themselves through their own worldview, experiences, and actions. Methodology/approach The chapter is a collection of interwoven first-person essays that reveal what people see, perceive, and mask, with the intention to continue to push an authentic conversation on race in the field. Contributors include librarians, educators, and scholars, who represent distinct dimensions of the race spectrum, question such categorization, and do not necessarily neatly fit into a racial category. They explore how they view race in the library and information field, the extent to which they feel included or not, and how they have attempted and continue to shape the field through their practice, research, and/or service. Findings As individuals, each contributor speaks in their own voice, and as a collective, the authors move the race dialogue forward by speaking about dimensions of race from their own experiences, representing individual stories, and allowing their intersections to be revealed.