Maren Nyer

Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions.

BACKGROUND Intervention research at the intersection of psychiatry and cardiology has primarily focused on the relationship between negative psychological syndromes (e.g., depression) and cardiac outcomes, with less emphasis on positive psychological attributes, such as optimism, gratitude, and well-being, as they relate to cardiac disease. METHODS Literature is reviewed in three specific areas regarding positive attributes and cardiac disease: (1) associations between positive attributes and cardiac outcomes, (2) potential mechanisms-both behavioral and physiologic-by which positive psychological states may impact cardiovascular health, and (3) interventions aimed at cultivating positive psychological attributes in healthy and medically ill persons. RESULTS There is significant evidence that positive psychological attributes--especially optimism--may be independently associated with superior cardiac outcomes. Positive attributes appear to be associated with increased participation in cardiac health behaviors (e.g., healthy eating, physical activity) linked to beneficial outcomes; data linking positive psychological states and biomarkers of cardiac health (e.g., inflammatory markers) is mixed but suggests a potential association. Positive psychological interventions have consistently been associated with improved well-being and reduced depressive symptoms, though there have been few such studies in the medically ill. CONCLUSIONS These findings regarding the relationship between positive psychological attributes and cardiac health are promising and suggest that positive psychology interventions may be worth study in this population. However, questions remain about the strength and specificity of these relationships, the most salient positive psychological attributes, and the impact of positive psychological interventions on health outcomes in cardiac patients.

Depression and suicidal ideation in college students.

Background/Aims: Suicide is one of the leading causes of death in college students and is often associated with depression. The aim of this study was to assess the rates of suicidal ideation (SI) on college campuses and to identify its correlates. Methods: On-campus depression screening sessions were conducted at 3 universities (n = 898; 55% female; mean age 20.07 ± 1.85 years). Participants completed the Beck Depression Inventory (BDI; mean ± SD of total score = 6.27 ± 6.31) and other measures. Eighty-four students endorsed a ‘1’ on the BDI suicidality item, suggesting thoughts of suicide. Results: Results showed that students with greater depression severity, higher levels of hopelessness, and poorer quality of life were more likely to endorse SI. Conclusion: Factors associated with SI highlighted in this study may aid in the identification of college students at risk for suicide.

Relationship between sleep disturbance and depression, anxiety, and functioning in college students.

Sleep disturbance (SD) has complex associations with depression, both preceding and following the onset and recurrence of depression. We hypothesized that students with depressive symptoms with SD would demonstrate a greater burden of comorbid psychiatric symptoms and functional impairment compared to students with depressive symptoms without SD.

College Students: Mental Health Problems and Treatment Considerations.

Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms. Given the uniqueness of college students, there is a need to outline critical issues to consider when working with this population. In this commentary, first, the prevalence of psychiatric and substance use problems in college students and the significance of assessing age of onset of current psychopathology are described. Then, the concerning persistent nature of mental health problems among college students and its implications are summarized. Finally, important aspects of treatment to consider when treating college students with mental health problems are outlined, such as the importance of including parents in the treatment, communicating with other providers, and employing of technology to increase adherence. It is concluded that, by becoming familiar with the unique problems characteristic of the developmental stage and environment college students are in, practitioners will be able to better serve them.

Rapid and Sustained Reductions in Current Suicidal Ideation Following Repeated Doses of Intravenous Ketamine: Secondary Analysis of an Open-Label Study.

BACKGROUND Ketamine rapidly reduces thoughts of suicide in patients with treatment-resistant depression who are at low risk for suicide. However, the extent to which ketamine reduces thoughts of suicide in depressed patients with current suicidal ideation remains unknown. METHODS Between April 2012 and October 2013, 14 outpatients with DSM-IV-diagnosed major depressive disorder were recruited for the presence of current, stable (≥ 3 months) suicidal thoughts. They received open-label ketamine infusions over 3 weeks (0.5 mg/kg over 45 minutes for the first 3 infusions; 0.75 mg/kg over 45 minutes for the last 3). In this secondary analysis, the primary outcome measures of suicidal ideation (Columbia-Suicide Severity Rating Scale [C-SSRS] and the Suicide Item of the 28-item Hamilton Depression Rating Scale [HDRS₂₈-SI]) were assessed at 240 minutes postinfusion and for 3 months thereafter in a naturalistic follow-up. RESULTS Over the course of the infusions (acute treatment phase), 7 of 14 patients (50%) showed remission of suicidal ideation on the C-SSRS Ideation scale (even among patients whose depression did not remit). There was a significant linear decrease in this score over time (P < .001), which approached significance even after controlling for severity of 6-item Hamilton Depression Rating Scale (HDRS₆) core depression items (P = .05). Similarly, there were significant decreases in the C-SSRS Intensity (P < .01) and HDRS₂₈-SI (P < .001) scores during the acute treatment phase. Two of the 7 patients who achieved remission during the acute treatment phase (29%) maintained their remission throughout a 3-month naturalistic follow-up. CONCLUSIONS In this preliminary study, repeated doses of open-label ketamine rapidly and robustly decreased suicidal ideation in pharmacologically treated outpatients with treatment-resistant depression with stable suicidal thoughts; this decrease was maintained for at least 3 months following the final ketamine infusion in 2 patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01582945.

Cognitive therapy for anxious depression in STAR⁎D: What have we learned?

BACKGROUND Anxious depression, defined as MDD with high levels of anxiety symptoms, has been associated with lower rates of antidepressant response and remission as well as greater chronicity, suicidality and antidepressant side-effect burden. The primary aim of this study was to assess the effectiveness of cognitive therapy (CT) alone or in combination with medications for anxious versus non-anxious depression. METHODS We assessed the STAR(⁎)D study participants who were partial or non-responders to citalopram. Subjects were then either switched (n=696) to a new antidepressant or to CT alone, or they were kept on citalopram and augmented (n=577) with another antidepressant or CT. We compared response and remission rates, across treatment conditions, between those who met criteria for anxious depression and those who did not. RESULTS Those with anxious depression had significantly lower remission rates based on the QIDS, whether assigned to switch or augmentation, compared to those with non-anxious depression. Those with anxious depression, compared to those without, had significantly lower response rates based on the QIDS only in the switch group. There was no significant interaction between anxious depression and treatment assignment. LIMITATIONS Limitations include the use of citalopram as the only Level 1 pharmacotherapy and medication augmentation option, the relatively small size of the CT arms, use of depression-focused CT rather than anxiety-focused CT, and focus on acute treatment outcomes. CONCLUSIONS Individuals with anxious depression appear to experience higher risk of poorer outcome following pharmacotherapy and/or CT after an initial course of citalopram and continued efforts to target this challenging form of depression are needed.

Paraquat Prohibition and Change in the Suicide Rate and Methods in South Korea

The annual suicide rate in South Korea is the highest among the developed countries. Paraquat is a highly lethal herbicide, commonly used in South Korea as a means for suicide. We have studied the effect of the 2011 paraquat prohibition on the national suicide rate and method of suicide in South Korea. We obtained the monthly suicide rate from 2005 to 2013 in South Korea. In our analyses, we adjusted for the effects of celebrity suicides, and economic, meteorological, and seasonal factors on suicide rate. We employed change point analysis to determine the effect of paraquat prohibition on suicide rate over time, and the results were verified by structural change analysis, an alternative statistical method. After the paraquat prohibition period in South Korea, there was a significant reduction in the total suicide rate and suicide rate by poisoning with herbicides or fungicides in all age groups and in both genders. The estimated suicide rates during this period decreased by 10.0% and 46.1% for total suicides and suicides by poisoning of herbicides or fungicides, respectively. In addition, method substitution effect of paraquat prohibition was found in suicide by poisoning by carbon monoxide, which did not exceed the reduction in the suicide rate of poisoning with herbicides or fungicides. In South Korea, paraquat prohibition led to a lower rate of suicide by paraquat poisoning, as well as a reduction in the overall suicide rate. Paraquat prohibition should be considered as a national suicide prevention strategy in developing and developed countries alongside careful observation for method substitution effects.

Understanding the Construct of Fear of Hypoglycemia in Pediatric Type 1 Diabetes

OBJECTIVE Fear of hypoglycemia (FoH) can be a significant barrier to glycemic control in pediatric type 1 diabetes (T1D). This study aimed to explore underlying constructs of the Hypoglycemia Fear Survey (HFS) for parents (PHFS) and children (CHFS). METHODS Data were aggregated from five studies of 259 youth with T1D and 250 parents. Exploratory Factor Analysis was used to determine the underlying factors of the CHFS and PHFS. RESULTS Similar four-factor solutions were found for the CHFS and PHFS. Both subscales consisted of two factors: Behavior Subscale (1) behaviors used to keep blood glucose (BG) high to prevent hypoglycemia (Maintain High BG) and (2) other actions to avoid hypoglycemia (Avoidance); Worry Subscale (1) concerns about helplessness (Helplessness) and (2) negative social consequences associated with hypoglycemia (Social Consequences). CONCLUSIONS  These constructs provide a more comprehensive understanding of pediatric FoH and have implications for interventions aimed at reducing FoH in this population.

Childhood parental death and lifetime suicide attempt of the opposite-gender offspring in a nationwide community sample of Korea.

Although previous studies have shown that childhood parental death influences suicide attempts of their offspring, few studies have examined influence of gender and age at exposure. Koreans show the third highest suicide rate in the world, and many children and adolescents lost their parents during and after the Korean War. A total of 12,532 adults, randomly selected through a one-person-per-household method, completed the Korean version of the Composite International Diagnostic Interview and questionnaire for suicidal ideation, plan, and attempt (response rate 80.2%). A total of 2,332 subjects experienced biological parental death in childhood (18.6%). Male suicide attempts were associated with age of exposure to maternal death from 0 to 4 years (adjusted OR = 4.48, 95% CI 1.32-15.18) and from 5 to 9 years (adjusted OR = 5.52, 95% CI 1.97-16.46), but not with paternal death, after adjusting for age, education years, marital status, monthly income, and psychiatric comorbidities. Female suicide attempts were associated with paternal death from 5 to 9 years (adjusted OR = 2.20, 95% CI 1.13-4.27), but not with maternal death. Childhood parental death is significantly associated with lifetime suicide attempt in the opposite-gender offspring, especially when exposure occurs before age 10.

Assessing the adequacy of past antidepressant trials: a clinician's guide to the antidepressant treatment response questionnaire.

Many depressed patients do not remit on antidepressant medication despite an adequate dosage and a sufficient duration of treatment.1 This has spawned endeavors to define treatment-resistant depression as a depressive episode that has shown insufficient response to 1 or more adequate trials of an antidepressant.1 What constitutes insufficient, inadequate, or partial response is still a matter of debate. Recently, an operational classification of degree of treatment resistance was proposed,2 with categorical distinctions defined by the percent symptom reduction from baseline as follows: nonresponse, < 25% reduction; partial response, 25%–49% reduction; and response without remission, ≥ 50% reduction but without achievement of remission.1 To determine the adequacy and outcome of treatment in a way that can be communicated among clinicians and researchers, it is crucial to employ a reliable and valid instrument. While historical rating of treatment is not as accurate as a prospective trial, there are many instances in which a decision is needed before the next trial is carried out. Several tools have been proposed, such as the Antidepressant Treatment History Form (ATHF),3 the Harvard Antidepressant Treatment History (HATH),4 and the Massachusetts General Hospital Antidepressant Treatment Response Questionnaire (ATRQ).1,5 The ATHF and HATH have the advantage of integrating clinical judgment in the assessment of treatment resistance, but these questionnaires are quite burdensome.5 The ATRQ (Appendix 1) and accompanying questions are meant to provide clinicians with a user-friendly tool for assessment of prior treatment. It is often the case that a patient remembers whether a past treatment was somewhat helpful, although it is frequently difficult for him or her to remember exactly which antidepressant was taken, how long it was taken, and at what dose. However, it is important that the clinician explore past trials thoroughly using a systematic approach in order to characterize the adequacy of the trial and the degree of improvement. The clinician version of the ATRQ1,5 examines the adequacy of duration and dose of prior and current antidepressant treatments in a step-by-step procedure. It cannot be emphasized enough that, when assessing the duration and dose of clinical trials of antidepressants, clinicians must always inquire about adherence to each treatment trial. In addition, the ATRQ assesses the degree of improvement (in the most efficacious trial or in all trials during the current episode, depending on the version of the instrument) on a scale from 0% (not improved at all) to 100% (completely improved) (Table 1). The previous treatment may have been monotherapy, an augmentation trial, a trial of 2 antidepressants (combination therapy), or a switch to another antidepressant. Our group has adopted conventions to define resistance to each of these approaches. At the outset it is noted that the doses and durations required for adequate treatment are based on expert consensus1 rather than systematic research. We define an adequate monotherapy trial as a trial lasting at least 6 weeks at a minimum effective dose. In the context of this initial trial, the adequate duration for augmentation or combination treatment is at least 3 weeks. However, a combination trial from the onset (ie, starting with 2 drugs together) must be 6 weeks. Six weeks is also required for a switch to a different antidepressant. Each of these trials is considered a new trial. An increase in dose for at least 4 weeks represents optimization and is not considered a new or separate trial. However, if remission is later followed by relapse, a dose increase represents a new trial for the new episode. We recognize that the conventions used to define adequate dose and duration are not established and that other conventions, for example, a duration of 12 weeks, might be preferred. The ATRQ can be adapted to accommodate various definitions of dose and duration. Likewise, the threshold of resistance in terms of percent response may vary, depending on the questions being asked within a given clinical trial.