Lakshminarayana Chekuri

Demographic, economic, and clinical correlates of depression treatment response in an underserved primary care population

Objective To examine demographic, economic, and clinical correlates of depression treatment outcomes in a rural low-income population served by federally qualified health centers (FQHCs). Method The current study utilized data collected during a pragmatic comparative effectiveness trial (N = 364) that was conducted at 9 FQHC clinics between November 2007 and June 2009. Participants were randomly assigned to either telemedicine-based collaborative care or practice-based collaborative care. Depression severity was measured at baseline and at 12-month follow-up using the Hopkins Symptom Checklist (SCL-20) and used to categorize outcomes as nonresponse, partial response, full response, and remission. The associations between demographic, economic, and clinical variables and outcomes were estimated using bivariate analyses and multinomial logistic regression. Results 287 participants (78.8%) completed the 12-month follow-up assessment. Among these, 127 participants (44.25%) did not respond to treatment, 53 (18.47%) experienced partial response, 47 (16.38%) experienced full response, and 60 (20.91%) experienced remission. Of the 7 demographic characteristics examined, only gender had a significant (P < .05) effect on outcomes. Of the 2 economic variables examined, income was not associated with outcomes, while individuals without health insurance reported higher response rates than those with public health insurance (P < .05). Among the 13 clinical variables examined, baseline depression severity, physical and mental health status, number of prior depression episodes, and comorbid generalized anxiety had a significant (P < .05) effect on outcomes. Conclusions Low treatment response rates and treatment response heterogeneity continue to be significant challenges to clinicians treating depression in low-income underserved populations facing multiple barriers to care. Baseline depression severity and chronicity, health status, and comorbid anxiety appear to have a consistent effect on treatment outcomes in depression.

A comparison of provider attitudes toward serious mental illness across different health care disciplines.

Persons experiencing serious mental illness (SMI) report feeling marginalized by health care providers, receive health care services at alarmingly lower rates, receive poorer quality of services, and experience higher mortality rates when compared to non-SMI populations. Providers’ negative attitudes may be 1 contributing factor, as they have been found to affect providers’ clinical intentions. This study compared provider attitudes toward individuals with schizophrenia across 5 different Veterans Affairs (VA) health care provider groups to identify targets for antistigma interventions. Two clinical vignettes (schizophrenia vs. no schizophrenia) that varied only in history of schizophrenia were distributed to 5 provider groups (primary care physicians, psychiatrists, psychologists, and primary care and mental health nurses) employed by VA hospitals in the south-central United States. Each provider read 1 of the 2 vignettes before completing short surveys assessing attitudes (stereotype, social distance, and attribution of mental illness) toward the vignette patient. Responses of 351 providers were compared on these 3 attitudes. Primary care physicians, primary care nurses, and psychiatrists exhibited more negative attitudes toward persons with schizophrenia when compared to mental health nurses and psychologists. In addition, primary care physicians, primary care nurses, and psychiatrists held more negative beliefs about persons with schizophrenia when compared to those without schizophrenia. These findings identify how various provider groups may differ in their stigmatizing attitudes and can inform future antistigma programs focused on changing provider attitudes toward individuals with SMI, thereby improving the quality of health care provided.

Vitamin D Levels and Sociodemographic and Clinical Correlates in Individuals With Serious Mental Illness Admitted to an Acute Psychiatry Unit

OBJECTIVE To describe the prevalence of vitamin D deficiency in psychiatric inpatients with serious mental illness. Associated clinical and sociodemographic factors are also explored. METHOD Data were collected using a retrospective review of medical records. Eligible subjects were individuals aged ≥ 18 years who were consecutively newly admitted to an adult inpatient teaching unit of a state psychiatric hospital from July 2012 through August 2013. The main outcome measure was prevalence rate of vitamin D deficiency in the target population. Vitamin D deficiency was defined as a level < 20 ng/mL. Psychiatric diagnoses were established using DSM-IV-TR criteria. RESULTS Of 85 subjects, approximately two-thirds (67%) had a vitamin D level < 20 ng/mL. The mean vitamin D level was 18.4 ng/mL. Among the sociodemographic and clinical factors analyzed, only total serum protein (odds ratio = 0.33; CI, 0.12-0.88; P < .05) was associated with vitamin D deficiency. CONCLUSIONS The high prevalence of vitamin D deficiency with all the attendant physical and mental health burdens in vulnerable populations such as individuals with serious mental illness requires further large research studies. In the meantime, it seems prudent to institute routine screening for vitamin D deficiency in individuals with mental illness, especially those who are hospitalized.

Lithium-Induced Transient Euthyroid Hyperthyroxinemia: A Case Report

To the Editor: Sixty years after its introduction, lithium remains a first-line medication in the treatment of bipolar disorder.1 While lithium treatment has been associated with a wide range of adverse effects,2,3 thyroid-related abnormalities, especially hypothyroidism, are the most commonly reported ones.4,5 Lithium-associated hyperthyroidism, however, is quite rare, and only a few sporadic case reports of thyrotoxicosis that developed after several years of lithium therapy or after stopping lithium3,6 are described in the literature. Lithium-induced euthyroid hyperthyroxinemia, described as an elevation in serum thyroid hormone levels without clinical manifestations of thyrotoxicosis,7 has not been reported to our knowledge. Stratakis and Chrousos8 described a case of transient euthyroid hyperthyroxinemia associated with discontinuation of chronic lithium treatment. We report a patient who developed transient euthyroid hyperthyroxinemia within a few weeks of initiation of lithium therapy. Case report. Ms A, a 24-year-old African American woman with a 4-year history of schizoaffective disorder, bipolar type (DSM-IV-TR), was admitted to our hospital in December 2011 with signs and symptoms consistent with mania with psychosis. At admission, she presented with a labile mood with aggressive and violent behavior, insomnia, poor concentration, pressured speech with racing thoughts, and increased psychomotor activity. She was also very paranoid, reported auditory hallucinations, and was often found responding to internal stimuli. She had no acute medical findings, except for past history of gastroesophageal reflux/dyspepsia symptoms and urinary urgency. She had never been pregnant, and her family history was negative for thyroid abnormalities. Her admission laboratory workup, including thyroid function, was unremarkable except for elevated serum total creatine kinase level of 574 U/L (normal range, 26–140 U/L), which subsequently normalized. She was started on lithium carbonate titrated to 900 mg daily, risperidone, and clonazepam. Under this regimen, her mood and psychotic symptoms started to improve. Serum lithium, free T4, and thyroid-stimulating hormone (TSH) levels were serially monitored over the course of her hospitalization (Figure 1). Figure 1. Serial Serum Levels of Lithium, TSH, and Free T4 in a Patient Treated With Lithium About 2.5 months after treatment initiation, we noticed an elevation in her free T4 levels with a slight decrease in TSH levels. During this period, she remained clinically euthyroid with no evidence of thyrotoxicosis. A full hyperthyroidism workup revealed the following: an elevated serum total thyroglobulin level over 180 ng/mL (normal range, 1.2–35 ng/mL), thyroid antibody levels within normal limits, no evidence of a thyroid nodule on ultrasonogram, a 0.9% I123 uptake at 4 hours (normal, 5%–15%) and a 0.3% uptake at 24 hours (normal, 5%–15%) on a thyroid uptake scan, and no evidence suggestive of an ectopic thyroid tissue. Lithium therapy was continued with careful monitoring for evidence of thyrotoxicosis. Elevation of free T4 and associated drop in TSH levels persisted for the next 2 months (Figure 1). During the fourth month of treatment, free T4 levels returned to within normal limits. The incidence of transient euthyroid hyperthyroxinemia in acute psychiatric inpatients at admission has been reported to be at 9%–18%.7 The subject in the present report had normal TSH and T4 levels at admission. To our knowledge, this is the first reported case of lithium-induced transient euthyroid hyperthyroxinemia. Although the role of lithium in thyroid hormone synthesis and release has been extensively investigated and reviewed,9 how it may induce euthyroid hyperthyroxinemia is unclear. From a clinical perspective, if a clinician finds elevated thyroxine levels in the absence of overt thyrotoxicosis in a patient started on lithium therapy, it would seem prudent to carefully monitor clinically for development of thyrotoxic symptoms without immediately resorting to an extensive and expensive diagnostic workup.

Attitudes Regarding Seeking Help for Mental Health Problems and Beliefs About Treatment Effectiveness: A Comparison Between Providers and the General Public.

Providers are not immune from experiencing mental health problems and the attitudes and beliefs of providers in regards to seeking mental health treatment and their perceptions regarding the effectiveness of that treatment may have important implications for the patients they serve. However, little is known about these attitudes and beliefs. We compared the attitudes and beliefs of a sample of United States Department of Veterans Affairs health care providers regarding their own mental health problems and treatment to a representative sample of U.S. residents. The majority of the participants in both samples reported willingness to seek professional help for mental health problems and approximately one-third reported feeling embarrassed if their friends were to know about their help seeking; no significant differences were found between the groups. The majority in both samples also felt comfortable talking about mental health problems, with providers significantly more comfortable than the general public. The majority of both groups believed that at least half of those people who saw professionals for mental health problems are helped and that for those people who did not see professionals for mental health problems, less than half tended to get better without treatment; providers’ beliefs were significantly more positive regarding treatment effectiveness. The findings suggest the need for interventions to address perceived public stigma and label avoidance. Additionally, providers should be aware that their views about treatment effectiveness, the natural course of mental health problems, and level of comfort are not necessarily shared by the general public.