Lydia Chwastiak

Chronic pain in a large community sample of persons with multiple sclerosis.

Introduction: This study examined the prevalence, intensity, interference, and biopsychosocial correlates of pain in a large community-based sample of persons with multiple sclerosis (MS). Methods: Mail surveys were returned by 442 members of the King C ounty (WA) MS Association. Average pain intensity, pain-related activity interference, depressive symptoms and severity of MS were assessed. Results: Forty-four percent reported persistent, bothersome pain in the three months prior to completing the survey. Participants with pain reported an average pain intensity rating of 5.2 (SD =2.3) on the 0 (no pain) to 10 (pain as bad as could be) scale. Twenty-seven percent reported severe pain (score of 7-10), while 51% of those with pain rated the interference of their pain with daily activities as none to minimal. Twenty percent reported severe interference in activities as a result of pain. In multivariate modeling, MS illness severity, marital status, and self-ratings of overall health were significantly associated with pain-related interference with activities. Conclusions: A pproximately a fourth of this sample described having a chronic pain problem characterized by severe pain intensity and significant pain-related interference with activities. Disability due to pain may be more important than previously recognized for the MS population.

Association of Psychiatric Illness and Obesity, Physical Inactivity, and Smoking among a National Sample of Veterans

BACKGROUND Increased cardiovascular morbidity and mortality have been reported across a number of chronic psychiatric illnesses. Interventions to decrease cardiovascular risk have focused on single health behaviors. OBJECTIVE To evaluate the co-occurrence of multiple poor health behaviors that increase cardiovascular risk among veterans with psychiatric diagnoses. METHODS Using data from the 1999 Large Health Survey of Veterans (n=501,161), multivariate logistic regression was used to evaluate the associations between current smoking, no regular exercise, and obesity with each of six Axis I diagnoses. RESULTS There were statistically increased odds of co-occurrence of obesity, current tobacco use, and no regular exercise among veterans with each of the psychiatric diagnoses, with the exception of drug use disorders (which was not significantly different from 1). The highest odds were among veterans with schizophrenia, PTSD, and bipolar disorder [OR (95% CI) of 1.37 (1.29, 1.45); 1.26 (1.20, 1.32); and 1.19 (1.11, 1.25), respectively]. The OR for depression was not significant after adjustment for medical comorbidity. CONCLUSIONS Veterans with psychiatric illnesses, and particularly those with schizophrenia, PTSD, and bipolar disorder, are much more likely to have multiple poor health behaviors that increase their cardiovascular risk. Interventions to decrease cardiovascular risk among veterans with serious mental illness need to target multiple health behaviors.

Efficacy of paroxetine in treating major depressive disorder in persons with multiple sclerosis

OBJECTIVE The objective of this study was to evaluate the efficacy of paroxetine in treating major depressive disorder (MDD) in persons with multiple sclerosis (MS). METHOD In this double-blind trial, 42 participants with MS and MDD were randomly assigned to one of two parallel 12-week treatment arms: paroxetine or placebo. The participants started at an initial dose of 10 mg/day paroxetine or placebo, titrated up to 40 mg daily based on symptoms response and side effects. The primary outcome measure was the Hamilton Rating Scale for Depression (HAM-D). Secondary outcomes included fatigue, anxiety and self-reported quality of life. RESULTS Intent-to-treat analyses revealed that both groups improved from pretreatment to posttreatment. Although the treatment group improved more than the control group on most measures, few differences were statistically significant. For the primary outcome, 57.1% of participants in the treatment arm had at least a 50% reduction in HAM-D score, compared with 40% in the control group (nonsignificant). Treatment effects were greater among the participants who completed the study; 78.6% of completers had a treatment response compared with 42.1% of controls (P=.073). CONCLUSION Although paroxetine may not be efficacious for all persons with MS and MDD, it appears to benefit some individuals.

Clinical management of depression and anxiety in Hiv-infected adults

HIV clinical care providers are increasingly confronted by comorbid psychiatric illness among their patients. Prevalence rates of psychiatric disorders among HIVinfected patients approach 50% [1]. These conditions commonly manifest around the time of diagnosis [2], but many patients develop symptoms later in their course of illness [1]. Axis I disorders, including anxiety and depression, are particularly likely to occur at times of stress–—including an illness episode, a psychosocial stressor such as divorce or loss of a loved one, and when facing a new disability. Anxiety and depression are among the most commonly diagnosed psychiatric conditions affecting HIV-infected patients [3,4]. These can complicate the treatment of HIV, presenting numerous diagnostic and interventional challenges for the clinician.

Cardiovascular risk in a first-episode psychosis sample: a ‘critical period’ for prevention?

OBJECTIVE Studies in first episode psychosis samples about status of cardiovascular risk factors have shown discordant results. We aimed to determine the 10-year risk of developing coronary heart disease in a sample of first episode psychosis patients referred to an early intervention clinic and compared the same with age, gender, and race matched controls from the U.S. National Health and Nutrition Examination Survey (NHANES). METHOD We conducted a cross-sectional analysis of baseline data of 56 subjects enrolled in first episode psychosis clinic from April 2006 to January 2010. This sample was compared with age, gender, and race matched 145 individuals drawn from NHANES 2005-2006 database. Sociodemographic and clinical variables were collected. Physical examination including laboratory evaluation was used to screen for common medical illnesses. The 10-year risk of developing coronary heart disease was calculated by using a tool developed by the National Cholesterol Education Program (NCEP-ATP III). RESULTS There were elevated rates of smoking (46%) and hypertension (11%) albeit statistically significant differences from the control could not be demonstrated for these measures or weight, body mass index, or total or HDL cholesterol, fasting plasma glucose, status of diabetes and impaired fasting plasma glucose, HbA1C level. The 10-year median (range) risk of developing coronary heart disease in patients and controls was 1 (0-5)% and 0 (0-9)% respectively. The difference was not statistically significant. CONCLUSIONS First episode psychosis patients do not present with significantly higher cardiovascular risk than age and race-matched controls despite clinically significant prevalence of individual risk factors. This sample presents an opportunity for early intervention for the primary prevention of cardiovascular morbidity and mortality.

The impact of obesity on health care costs among persons with schizophrenia

BACKGROUND Obesity is the second leading cause of preventable death in the United States and is twice as common among individuals with schizophrenia as the general population. METHODS Data from the Clinical Antipsychotic Trials of Intervention Effectiveness, a multisite trial of antipsychotic pharmacotherapy in 1460 patients with schizophrenia, were used to examine the relationships between body mass index (BMI) and medical costs. RESULTS ANCOVA analyses found significant increases in both psychiatric and nonpsychiatric medication costs associated with increasing BMI and a significant, but smaller, difference in costs of outpatient medical-surgical service utilization: US

The prevalence of bipolar disorder in general primary care samples: a systematic review

41 per month for morbidly obese patients compared to US

Long-term Risk of Dementia in Persons With Schizophrenia: A Danish Population-Based Cohort Study.

26 per month for patients of normal weight (F=2.4, P=.04). In multivariable logistic regression analyses, morbid obesity was associated with significantly increased odds of any outpatient medical-surgical service costs. When compared to observations of BMI>35, BMI observations within the normal range (18.5-24.9) were half as likely to be associated with any outpatient medical-surgical costs (OR=0.53; 95% CI=0.45, 0.63). CONCLUSIONS In this large sample of persons with schizophrenia, obesity was associated with increased outpatient general medical service and medication costs even after controlling for demographic characteristics and medical comorbidity, but the absolute dollar amount was small.

The Effect of Serious Mental Illness on the Risk of Rehospitalization Among Patients With Diabetes

OBJECTIVE To obtain an estimate of the prevalence of bipolar disorder in primary care. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed. RESULTS We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients. CONCLUSION In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings. Prevalence estimates from studies using screening measures that have been found to have low positive predictive value were generally higher than those found using structured interviews.

Psychiatric–Medical ComorbidityThe prevalence of bipolar disorder in general primary care samples: a systematic review☆☆☆

IMPORTANCE Although schizophrenia is associated with several age-related disorders and considerable cognitive impairment, it remains unclear whether the risk of dementia is higher among persons with schizophrenia compared with those without schizophrenia. OBJECTIVE To determine the risk of dementia among persons with schizophrenia compared with those without schizophrenia in a large nationwide cohort study with up to 18 years of follow-up, taking age and established risk factors for dementia into account. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study of more than 2.8 million persons aged 50 years or older used individual data from 6 nationwide registers in Denmark. A total of 20 683 individuals had schizophrenia. Follow-up started on January 1, 1995, and ended on January 1, 2013. Analysis was conducted from January 1, 2015, to April 30, 2015. MAIN OUTCOMES AND MEASURES Incidence rate ratios (IRRs) and cumulative incidence proportions (CIPs) of dementia for persons with schizophrenia compared with persons without schizophrenia. RESULTS During 18 years of follow-up, 136 012 individuals, including 944 individuals with a history of schizophrenia, developed dementia. Schizophrenia was associated with a more than 2-fold higher risk of all-cause dementia (IRR, 2.13; 95% CI, 2.00-2.27) after adjusting for age, sex, and calendar period. The estimates (reported as IRR; 95% CI) did not change substantially when adjusting for medical comorbidities, such as cardiovascular diseases and diabetes mellitus (2.01; 1.89-2.15) but decreased slightly when adjusting for substance abuse (1.71; 1.60-1.82). The association between schizophrenia and dementia risk was stable when evaluated in subgroups characterized by demographics and comorbidities, although the IRR was higher among individuals younger than 65 years (3.77; 3.29-4.33), men (2.38; 2.13-2.66), individuals living with a partner (3.16; 2.71-3.69), those without cerebrovascular disease (2.23; 2.08-2.39), and those without substance abuse (1.96; 1.82-2.11). The CIPs (95% CIs) of developing dementia by the age of 65 years were 1.8% (1.5%-2.2%) for persons with schizophrenia and 0.6% (0.6%-0.7%) for persons without schizophrenia. The respective CIPs for persons with and without schizophrenia were 7.4% (6.8%-8.1%) and 5.8% (5.8%-5.9%) by the age of 80 years. CONCLUSIONS AND RELEVANCE Individuals with schizophrenia, especially those younger than 65 years, had a markedly increased relative risk of dementia that could not be explained by established dementia risk factors.