Maida Sewitch

Patient nonadherence to medication in inflammatory bowel disease

OBJECTIVE:The aim of this study was to identify determinants of nonadherence to medication in outpatients with established inflammatory bowel disease (IBD).METHODS:Ten gastroenterologists and 153 of their IBD patients participated in this prospective study. Demographic, clinical, and psychosocial characteristics, as well as patient-physician discordance, were assessed at an office visit. Nonadherence to medication was assessed 2 wk later. Separate generalized estimating equations were used to identify determinants of nonadherence.RESULTS:Physicians averaged 47.9 yr in age (range 30.1–57.5 yr), and 90% were male. Patients averaged 37.0 yr (SD = 15.1), and 87 (56.9%) were female. In all, 63 patients (41.2%) were nonadherent to medication; of these, 51 (81.0%) indicated unintentional nonadherence, 23 (36.5%) intentional nonadherence, and 11 (17.5%) both. Overall nonadherence was predicted by disease activity (OR = 0.55, p = 0.0022), new patient status (OR = 2.14, p = 0.0394), disease duration (OR = 0.50, p = 0.0001), and scheduling a follow-up appointment (OR = 0.30, p = 0.0059), whereas higher discordance on well-being was predictive only in psychologically nondistressed patients (p = 0.0026 for interaction). Unintentional nonadherence was predicted by age (OR = 0.97, p = 0.0072), new patient status (OR = 2.80, p = 0239), and higher discordance on well-being in psychologically nondistressed patients (p = 0.0504). Intentional nonadherence was predicted by disease duration (OR = 0.55, p = 0032), scheduling a follow-up appointment (OR = 0.12, p = 0.0001), certainty that medication would be helpful (OR = 0.99, p = 0.0409), and total patient-physician discordance (OR = 1.59, p = .0120).CONCLUSIONS:These findings suggest that the therapeutic relationship, as well as individual clinical and psychosocial characteristics, influence adherence to medication.

Recognition of Depression by Non-psychiatric Physicians—A Systematic Literature Review and Meta-analysis

BACKGROUNDDepression, with up to 11.9% prevalence in the general population, is a common disorder strongly associated with increased morbidity. The accuracy of non-psychiatric physicians in recognizing depression may influence the outcome of the illness, as unrecognized patients are not offered treatment for depression.OBJECTIVESTo describe and quantitatively summarize the existing data on recognition of depression by non-psychiatric physicians.METHODSWe searched the following databases: MEDLINE (1966–2005), Psych INFO (1967–2005) and CINAHL (1982–2005). To summarize data presented in the papers reviewed, we calculated the Summary receiver operating characteristic (ROC) and the summary sensitivity, specificity and odds ratios (ORs) of recognition, and their 95% confidence intervals using the random effects model.MEASUREMENTS AND MAIN RESULTSThe summary sensitivity, specificity, and OR of recognition using the random effects model were: 36.4% (95% CI: 27.9–44.8), 83.7% (95% CI: 77.5–90.0), and 4.0 (95% CI: 3.2–4.9), respectively. We also calculated the Summary ROC. We performed a metaregression analysis, which showed that the method of documentation of recognition, the age of the sample, and the date of study publication have significant effect on the summary sensitivity and the odds of recognition, in the univariate model. Only the method of documentation had a significant effect on summary sensitivity, when the age of the sample and the date of publication were added to the model.CONCLUSIONThe accuracy of depression recognition by non-psychiatrist physicians is low. Further research should focus on developing standardized methods of documenting non-psychiatric physicians’ recognition of depression.

Predicting relapse in Crohn’s disease: a biopsychosocial model

Background: Crohn’s disease (CD) is a chronic relapsing inflammatory bowel disorder. Both biological and psychosocial factors may modulate the illness experience. Aim: The aim of this study was to identify clinical, biological and psychosocial parameters as predictors of clinical relapse in quiescent CD. Methods: Patients in medically induced remission were followed prospectively for 1 year, or less if they relapsed. Disease characteristics were determined at baseline. Serum cytokines, anti-Saccharomyces cerevisiae antibodies, C-reactive protein (CRP), erythrocyte sedimentation rate and intestinal permeability were measured every 3 months. Psychological distress, perceived stress, minor life stressors and coping strategies were measured monthly. A time-dependent multivariate Cox regression model determined predictors of time to relapse. Results: 101 patients (60 females, 41 males) were recruited. Fourteen withdrew and 37 relapsed. CRP (HR = 1.5 per 10 mg/l, 95% CI 1.1 to 1.9, p = 0.007), fistulising disease (HR = 3.2, 95% CI, 1.1 to 9.4, p = 0.04), colitis (HR = 3.5 95% CI 1.2 to 9.9, p = 0.02) and the interaction between perceived stress and avoidance coping (HR = 7.0 per 5 unit increase for both scales, 95% CI 2.3 to 21.8, p = 0.003) were predictors of earlier relapse. Conclusions: In quiescent CD, a higher CRP, fistulising disease behaviour and disease confined to the colon were independent predictors of relapse. Moreover, patients under conditions of low stress and who scored low on avoidance coping (ie, did not engage in social diversion or distraction) were least likely to relapse. This study supports a biopsychosocial model of CD exacerbation.

Psychological distress, social support, and disease activity in patients with inflammatory bowel disease.

OBJECTIVES:The objectives of this study were to compare the psychological status of patients in active and inactive disease states, to assess social support, and to identify correlates of psychological distress in patients with inflammatory bowel disease (IBD).METHODS:This cross-sectional study was conducted in 200 patients (mean age 36.7 yr [SD = 14.8], 119 [59.5%] female) with long-standing IBD who were seen in tertiary care. Psychosocial assessments included psychological distress (Symptom Checklist-90R), social support (Social Support Questionnaire-6), perceived stress (Perceived Stress Scale-10), and recent minor stressful events (Weekly Stress Inventory). Disease activity was assessed with the Harvey Bradshaw Index.RESULTS:Patients reported higher levels of satisfaction with social support and smaller network sizes compared with normative values. Using multiple linear regression, the independent correlates of psychological distress (p = 0.0001; adjusted R2= 0.62) were as follows: active disease (p = 0.0234), less time since diagnosis (p = 0.0012), and greater number (p = 0.0001) and impact of stressful events (p = 0.0003). A statistically significant interaction term (p = 0.0171) revealed that the relationship between psychological distress and perceived stress changes depending on the level of satisfaction with social support. For patients with low levels of perceived stress, satisfaction with social support did not affect levels of psychological distress. However, for patients who experienced moderate to high levels of perceived stress, high satisfaction with social support decreased the level of psychological distress.CONCLUSIONS:These findings suggest that strategies aimed at improving social support can have a favorable impact on psychological distress and, ultimately, can improve health outcomes in patients with IBD.

Acute tryptophan depletion blocks morphine analgesia in the cold-pressor test in humans

The effects of depletion of the serotonin precursor,l-tryptophan, on the threshold and tolerance to cold pressor pain, and the analgesic effect of morphine (10 mg intramuscularly), were tested in a double blind trial on human volunteers. Effects on mood were also assessed using the Profile of Mood States and the Addiction Research Center Inventory (ARCI) Scales. To deplete tryptophan, subjects were fed a tryptophan-deficient amino acid mixture 4.5 h before morphine was administered. Controls received the mixture with tryptophan, which is equivalent to a nutritionally balanced protein. The tryptophan-deficient meal reduced plasma tryptophan more than 70% but had no effect on threshold or tolerance to cold pressor pain. After morphine, tolerance to cold pressor pain increased in controls. Tryptophan depletion abolished this analgesic effect. Pain threshold was not altered by morphine. In subjects with normal tryptophan, the analgesic effect of morphine was predicted by the level of plasma morphine-6-glucuronide, but not by the level of morphine. Morphine increased scores on the LSD scale of the ARCI, but had no effect on other measures of mood. Tryptophan depletion also failed to alter mood in these subjects, who had unusually low depression scores before tryptophan depletion.

Adherence to colorectal cancer screening guidelines in Canada

BackgroundTo identify correlates of adherence to colorectal cancer (CRC) screening guidelines in average-risk Canadians.Methods2003 Canadian Community Health Survey Cycle 2.1 respondents who were at least 50 years old, without past or present CRC and living in Ontario, Newfoundland, Saskatchewan, and British Columbia were included. Outcomes, defined according to current CRC screening guidelines, included adherence to: i) fecal occult blood test (FOBT) (in prior 2 years), ii) endoscopy (colonoscopy/sigmoidoscopy) (prior 10 years), and iii) adherence to CRC screening guidelines, defined as either (i) or (ii). Generalized estimating equations regression was employed to identify correlates of the study outcomes.ResultsOf the 17,498 respondents, 70% were non-adherent CRC screening to guidelines. Specifically, 85% and 79% were non-adherent to FOBT and endoscopy, respectively. Correlates for all outcomes were: having a regular physician (OR = (i) 2.68; (ii) 1.91; (iii) 2.39), getting a flu shot (OR = (i) 1.59; (ii) 1.51; (iii) 1.55), and having a chronic condition (OR = (i) 1.32; (ii) 1.48; (iii) 1.43). Greater physical activity, higher consumption of fruits and vegetables and smoking cessation were each associated with at least 1 outcome. Self-perceived stress was modestly associated with increased odds of adherence to endoscopy and to CRC screening guidelines (OR = (ii) 1.07; (iii) 1.06, respectively).ConclusionHealthy lifestyle behaviors and factors that motivate people to seek health care were associated with adherence, implying that invitations for CRC screening should come from sources that are independent of physicians, such as the government, in order to reduce disparities in CRC screening.

Psychosocial correlates of patient-physician discordance in inflammatory bowel disease.

Abstract OBJECTIVE: The aim of this study was to identify the independent psychosocial correlates of patient-physician discordance in adult outpatients with inflammatory bowel disease. METHODS: This cross-sectional study was conducted in three university-affiliated tertiary care settings. Psychological distress, social support, perceived stress, and negative life events were assessed, as were demographic, lifestyle, and clinical characteristics. Patient-physician discordance was assessed with 10-item questionnaires. RESULTS: Ten gastroenterologists and 200 of their patients participated. Patients and their physicians disagreed most on discussion of personal issues. Patients with Crohn’s disease had statistically significantly higher discordance on disease activity and physical limitation, as well as higher average overall discordance scores than patients with ulcerative colitis. Mean discordance levels were similar across different physicians. Higher psychological distress and more perceived stress were independently associated with higher discordance after controlling for Crohn’s disease, active disease, being with the treating physician for less than 1 yr, and recommendation for further medical investigation. Psychological distress was the most important correlate of overall discordance. CONCLUSIONS: Increased physician awareness that psychologically distressed patients have difficulty processing of clinically relevant information may lead to improved doctor-patient communication during an office visit.

Reproducibility of histological assessments of disease activity in UC.

Objective Histopathology is potentially an important outcome measure in UC. Multiple histological disease activity (HA) indices, including the Geboes score (GS) and modified Riley score (MRS), have been developed; however, the operating properties of these instruments are not clearly defined. We assessed the reproducibility of existing measures of HA. Design Five experienced pathologists with GI pathology fellowship training and expertise in IBD evaluated, on three separate occasions at least two weeks apart, 49 UC colon biopsies and scored the GS, MRS and a global rating of histological severity using a 100 mm visual analogue scale (VAS). The reproducibility of each grading system and for individual instrument items was quantified by estimates of intraclass correlation coefficients (ICCs) based on two-way random effects models. Uncertainty of estimates was quantified by 95% two-sided CIs obtained using the non-parametric cluster bootstrap method. Biopsies responsible for the greatest disagreement based on the ICC estimates were identified. A consensus process was used to determine the most common sources of measurement disagreement. Recommendations for minimising disagreement were subsequently generated. Results Intrarater ICCs (95% CIs) for the total GS, MRS and VAS scores were 0.82 (0.73 to 0.88), 0.71 (0.63 to 0.80) and 0.79 (0.72 to 0.85), respectively. Corresponding inter-rater ICCs were substantially lower: 0.56 (0.39 to 0.67), 0.48 (0.35 to 0.66) and 0.61 (0.47 to 0.72). Correlation between the GS and VAS was 0.62 and between the MRS and VAS was 0.61. Conclusions Although ‘substantial’ to ‘almost perfect’ ICCs for intrarater agreement were found in the assessment of HA in UC, ICCs for inter-rater agreement were considerably lower. According to the consensus process results, standardisation of item definitions and modification of the existing indices is required to create an optimal UC histological instrument.

Receiving guideline-concordant pharmacotherapy for major depression: impact on ambulatory and inpatient health service use.

Objective: This study aimed to determine the associations between guideline-concordant pharmacotherapy for depression and the use of health services in the year following diagnosis. Method: This population-based, retrospective cohort study examined Quebec drug plans between 1999 and 2002. We included beneficiaries aged 18 to 64 years who were newly diagnosed with an episode of depression by primary care physicians and psychiatrists between October 1, 2000, and March 31, 2001, and who made at least one psychotropic pharmacy claim within 31 days of diagnosis. We defined guideline concordance as the receipt of recommended medication, starting dosage, and treatment duration as defined by the Canadian Network for Mood and Anxiety Treatments guidelines. We measured outcomes on use of ambulatory (number of visits to prescribing physician, other physicians, or emergency departments) and inpatient (hospitalization) services. Results: There were 2742 patients (mean age 42 years; 64% female patients) who met the study criteria. Of the 2047 (75%) patients to whom an antidepressant was dispensed, 1958 (71%) received a recommended first-line medication, 1297 (63%) received a recommended starting dosage, and 304 (15%) received a recommended duration. According to the 3 criteria, only 8% were treated appropriately; 21% received benzodiazepines rather than antidepressants. There were 2 median visits (inferquartile range [IQR] 1 to 3) to prescribing physicians, 0 visits (IQR 0 to 1) to other physicians, and 0 visits (IQR 0 to 0) to emergency departments; 497 (18%) patients were hospitalized. In separate multivariate models for repeated measures, recommended first-line medication, dosage, and duration were associated with more prescribing physician visits. Recommended first-line medication reduced the odds of hospitalization. Conclusion: Guideline concordance was associated with more visits to prescribing physicians and lower odds of hospitalization.

Epidemiology of inflammatory bowel disease in Québec: recent trends.

Background:Among 10 provinces in Canada, Québec has the second highest incidence of Crohns disease (CD), based on data collected more than a decade ago. To date, there are no reports on the occurrence of ulcerative colitis (UC) and no updates on the occurrence of CD in Québec. We sought to describe trends in the annual incidence and prevalence of inflammatory bowel disease in Québec during 2001 to 2008. Methods:A population-based retrospective cohort study was conducted using the administrative health databases of Québec. IBD cases were identified using a validated case definition requiring at least 1 hospitalization or 4 physician claims within a 2-year period. Incident cases were defined as individuals who had been free of inflammatory bowel disease for at least 2 years before the 2-year time span of the case definition. Results:We identified 24,377 CD and 15,346 UC cases. The mean age at diagnosis was 39 and 46 years for CD and UC, respectively. There was a significant decline in the annual incidence from 2001 to 2008 for both CD (P < 0.003) and UC (P < 0.001). No significant change with time was found in pediatric cases. The point prevalence in 2008 was 277 CD and 164 UC cases per 100,000 population. The average incidence was 17.4 CD cases per 100,000 person-years and 10.1 UC cases per 100,000 person-years. There was no predominance of urban or rural cases for either CD or UC. Conclusions:During 2001 to 2008, annual incidence for both CD and UC declined in Québec. There was no significant change with time in incidence for pediatric cases.