Martina Mueller

ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE.

Objective To compare the relative efficacy of electroconvulsive therapy (ECT) in psychotic and nonpsychotic patients with unipolar major depression. Methods The outcome of an acute ECT course in 253 patients with nonpsychotic (n = 176) and psychotic (n = 77) unipolar major depression was assessed in the first phase of an ongoing National Institute of Mental Health-supported four-hospital collaborative study of continuation treatments after successful ECT courses. ECT was administered with bilateral electrode placement at 50% above the titrated seizure threshold. The remission criteria were rigorous: a score ≤10 on the 24-item Hamilton Rating Scale for Depression (HRSD) after 2 consecutive treatments, and a decrease of at least 60% from baseline. Results The overall remission rate was 87% for study completers. Among these, patients with psychotic depression had a remission rate of 95% and those with nonpsychotic depression, 83%. Improvement in symptomatology, measured by the HRSD, was more robust and appeared sooner in the psychotic patients compared with the nonpsychotic patients. Conclusion Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial

BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements. AIMS To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT. METHOD This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold. RESULTS All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43-66%) with right unilateral, 61% with bifrontal (95% CI 50-71%) and 64% (95% CI 53-75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments. CONCLUSIONS Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Longitudinal effects of depression on glycemic control in veterans with Type 2 diabetes

OBJECTIVES To examine the longitudinal effects of depression on glycemic control in veterans with Type 2 diabetes. METHODS Data on 11,525 veterans with Type 2 diabetes were analyzed. A person-period dataset for each subject to cover 3-month intervals (36 time intervals) from April 1997 to March 2006 was created. Subjects were classified as depressed based on ICD-9 codes for depression. General linear mixed model regression was used to examine changes over time in HbA(1c) levels and whether the changes from baseline were different in depressed and nondepressed diabetic veterans, sequentially adjusting for baseline age, demographic variables and comorbidities (coronary heart disease, stroke and hypertension). Pooled t-tests were used to compare unadjusted mean HbA(1c) at each time point across the depressed and nondepressed groups. SAS was used for statistical analysis. RESULTS Ninety-seven percent were men, 48% were white, 27% were blacks and 25% were other. Mean age was 66 years and mean follow-up period was 4.1 years. Six percent (696/11,525) of the sample had diagnosed depression. Unadjusted mean HbA(1c) values were significantly higher in depressed vs. nondepressed subjects at all time points. The adjusted mean HbA(1c) values over time in the final mixed model were significantly higher in depressed vs. nondepressed subjects (mean difference of 0.13; 95% CI [0.03; 0.22]; P=.008). In all adjusted models, differences in mean HbA(1c) values were significantly higher in depressed vs. nondepressed subjects with Type 2 diabetes. CONCLUSION This study of veterans with Type 2 diabetes demonstrates that there is a significant longitudinal relationship between depression and glycemic control as measured by HbA(1c) and that depression is associated with persistently higher HbA(1c) levels over time.

Patient Attitudes Toward Mobile Phone-Based Health Monitoring: Questionnaire Study Among Kidney Transplant Recipients

Background Mobile phone based remote monitoring of medication adherence and physiological parameters has the potential of improving long-term graft outcomes in the recipients of kidney transplants. This technology is promising as it is relatively inexpensive, can include intuitive software and may offer the ability to conduct close patient monitoring in a non-intrusive manner. This includes the optimal management of comorbidities such as hypertension and diabetes. There is, however, a lack of data assessing the attitudes of renal transplant recipients toward this technology, especially among ethnic minorities. Objective To assess the attitudes of renal transplant recipients toward mobile phone based remote monitoring and management of their medical regimen; and to identify demographic or clinical characteristics that impact on this attitude. Methods After a 10 minute demonstration of a prototype mobile phone based monitoring system, a 10 item questionnaire regarding attitude toward remote monitoring and the technology was administered to the participants, along with the 10 item Perceived Stress Scale and the 7 item Morisky Medication Adherence Scale. Results Between February and April 2012, a total of 99 renal transplant recipients were identified and agreed to participate in the survey. The results of the survey indicate that while 90% (87/97) of respondents own a mobile phone, only 7% (7/98) had any prior knowledge of mobile phone based remote monitoring. Despite this, the majority of respondents, 79% (78/99), reported a positive attitude toward the use of a prototype system if it came at no cost to themselves. Blacks were more likely than whites to own smartphones (43.1%, 28/65 vs 20.6%, 7/34; P=.03) and held a more positive attitude toward free use of the prototype system than whites (4.25±0.88 vs 3.76±1.07; P=.02). Conclusions The data demonstrates that kidney transplant recipients have a positive overall attitude toward mobile phone based health technology (mHealth). Additionally, the data demonstrates that most kidney transplant recipients own and are comfortable using mobile phones and that many of these patients already own and use smart mobile phones. The respondents felt that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Respondents were comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. The small subset of kidney transplant recipients who are less interested in mHealth may be less technologically adept as reflected by their lower mobile phone ownership rates. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility.

Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study

Objective:The purpose of this randomized pilot study was to collect preliminary data regarding the feasibility and effects of early initiation of milk expression on the onset of lactogenesis stage II and milk volume in mothers of very low birth weight (VLBW) infants.Study Design:Twenty women were randomized to initiate milk expression within 60 min (group 1) or 1 to 6 h (group 2) following delivery. Milk volume and timing of lactogenesis stage II was compared between groups using Wilcoxons rank sum tests.Result:Group 1 produced statistically significantly more milk than group 2 during the first 7 days (P=0.05) and at week 3 (P=0.01). Group 1 also demonstrated a significantly earlier lactogenesis stage II (P=0.03).Conclusion:Initiation of milk expression within 1 h following delivery increases milk volume and decreases time to lactogenesis stage II in mothers of VLBW infants.

Electroconvulsive therapy is equally effective in unipolar and bipolar depression

Bailine S, Fink M, Knapp R, Petrides G, Husain MM, Rasmussen K, Sampson S, Mueller M, McClintock SM, Tobias KG, Kellner CH. Electroconvulsive therapy is equally effective in unipolar and bipolar depression.

Hispanic Migrant Farm Workers' Attitudes Toward Mobile Phone-Based Telehealth for Management of Chronic Health Conditions

Background Mobile phone–based interventions present a means of providing high quality health care to hard-to-reach underserved populations. Migrant farm workers (MFWs) are among the most underserved populations in the United States due to a high prevalence of chronic diseases yet limited access to health care. However, it is unknown if MFWs have access to mobile phone devices used in mobile health (mHealth) interventions, or if they are willing to use such technologies. Objective Determine rates of ownership of mobile devices and willingness to use mHealth strategies in MFWs. Methods A demonstration of mHealth devices and a survey were individually administered to 80 Hispanic MFWs to evaluate use of mobile phones and mHealth devices and willingness to use such technologies. Results Of the 80 participants, 81% (65/80) owned cell phones capable of sending and receiving health-related messages. Most participants (65/80, 81%) were receptive to using mHealth technology and felt it would be helpful in enhancing medication adherence, self-monitoring health conditions, and receiving quicker medication changes from their doctors (median scores ≥4 on 5-point Likert scales). Relations between age and attitudes toward using mHealth were not statistically significant. Conclusions Hispanic MFWs have access to mobile phones and are willing to use mHealth devices. Future work is needed to comprehensively evaluate the degree to which these devices could be used.

An Exploratory Study of Postpartum Depression and Vitamin D

BACKGROUND: Low levels of serum 25-hydroxyvitamin D (25[OH]D), a reliable measurement of vitamin D, have been implicated in several mood disorders. To date, studies exploring the relationship between vitamin D and postpartum depression are absent from the literature. OBJECTIVES: To determine whether a relationship exists between symptoms associated with postpartum depression and vitamin D levels and to determine if serum 25(OH) D levels can predict the incidence of symptoms associated with postpartum depression. STUDY DESIGN: An exploratory, descriptive study using a convenience sample of 97 postpartum women attending seven monthly visits. Women provided serum 25(OH)D samples and completed the Edinburgh Postpartum Depression Scale (EPDS) at each visit. RESULTS: A significant relationship over time was found between low 25(OH)D levels and high EPDS scores, indicative of postpartum depression. CONCLUSIONS: Future rigorous studies investigating vitamin D and postpartum depression are warranted with larger sample sizes using confirmatory methods to diagnose postpartum depression.

Estimating Physician Effects on Glycemic Control in the Treatment of Diabetes: Methods, Effects Sizes, and Implications for Treatment Policy

OBJECTIVE—Researchers have only just begun to investigate physician-related effects on medical outcomes. Such research is necessary for developing empirically informed practice guidelines and policy. The primary goal of this study was to investigate whether glucose management in type 2 diabetes varies by randomly assigned physicians over the course of a year in treatment. A second goal of the study was to investigate whether physician-related effects vary across differential patient characteristics. A tertiary goal was to investigate potential patient-level effects on glucose management. RESEARCH DESIGN AND METHODS—Hierarchical linear models were used to investigate A1C among 1,381 patients, nested within 42 randomly assigned primary care physicians at a Veterans Affairs medical center in the southeastern U.S. The primary outcome measure was change in A1C over the course of 1 year in treatment. On average, each study physician had 33 patients with diabetes. RESULTS—Overall, physician-related factors were associated with statistically significant but modest variability in A1C change (2%), whereas patient-level factors accounted for the majority of variation in A1C change (98%). Physician effects varied by patient characteristics, mattering more for black patients, patients aged 65 years, and patients whose glucose management improved over the treatment year. CONCLUSIONS—The results of this study indicate that differential physician effects have minimal impact on glycemic control. Results suggest that it is logical to support policies encouraging the development of patient-level behavioral interventions because that is the level that accounts for the majority of variance in glycemic control.

DSM melancholic features are unreliable predictors of ECT response : A CORE publication

Objective: To determine the relationship between baseline melancholic features with outcomes in patients with major depressive disorder referred for electroconvulsive therapy (ECT). Method: In a multihospital (Consortium for Research in ECT) collaborative ECT study, SCID-1 interviews were obtained at study entry. Ratings of the 24-item Hamilton Rating Scale for Depression were obtained thrice weekly during the course of ECT, once during a subsequent treatment-free week, and periodically during 6-month continuation treatment with either bitemporal ECT or nortriptyline plus lithium (continuation pharmacotherapy). Results: The evaluable sample was severely ill with a mean 24-item Hamilton Rating Scale for Depression score of 35.2 (±6.9). Of 489 patients, 63.6% (311) met DSM-IV criteria for melancholic features. During acute ECT, 62.1% of those with melancholic features remitted, as compared with 78.7% for those without melancholic features (P = 0.002). During medication continuation treatment (continuation pharmacotherapy), relapse rates were higher for those with melancholic features than for those without these features. Conversely, with continuation ECT, the rate of relapse was lower for those with, compared with those without, melancholic features. Conclusions: Ascertaining melancholic features by SCID-1 criteria does not identify depressed patients more likely to respond to ECT as had been anticipated from the literature. Melancholic features were associated with poorer treatment outcomes in acute ECT. Those with melancholic features were less likely to relapse with continuation ECT, but those with melancholic features were more likely to relapse with continuation pharmacotherapy. The limitations of the DSM-IV criteria for melancholia are discussed.