Neil Jordan

Treating Depression and Oppositional Behavior in Adolescents

Adolescents with depression and high levels of oppositionality often are particularly difficult to treat. Few studies, however, have examined treatment outcomes among youth with both externalizing and internalizing problems. This study examines the effect of fluoxetine, cognitive behavior therapy (CBT), the combination of fluoxetine and CBT, and placebo on co-occurring oppositionality within a sample of depressed adolescents. All treatments resulted in decreased oppositionality at 12 weeks. Adolescents receiving fluoxetine, either alone or in combination with CBT, experienced greater reductions in oppositionality than adolescents not receiving antidepressant medication. These results suggest that treatments designed to alleviate depression can reduce oppositionality among youth with a primary diagnosis of depression.

Effect of Care Setting on Evidence-based Depression Treatment for Veterans with COPD and Comorbid Depression

BackgroundPatients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients.ObjectiveTo examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting.DesignRetrospective cohort study.PatientsA total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder.Measurements and Main ResultsConcordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (≥3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only.ConclusionsMost VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings.

Effect of Depression Care on Outcomes in COPD Patients With Depression

BACKGROUND Although depression among COPD patients is a common problem with important consequences for the management of COPD and overall outcomes, the proportion of those who receive guideline-concordant depression care is low. Guideline-concordant depression care is associated with fewer depressive symptoms and lower risk for psychiatric hospitalization; however, it is unknown whether guideline-concordant depression care favorably impacts COPD-related outcomes for patients with both conditions. METHODS This retrospective cohort study investigated 5,517 veterans with COPD who experienced a new treatment episode for depression. Guideline-concordant depression care was defined as having an adequate supply of antidepressant medication and sufficient follow-up care. Multivariate methods were used to examine the relationship between the receipt of guideline-concordant depression care and (1) COPD-related hospitalization and (2) all-cause mortality 2 years after the depression episode, while controlling for care setting and other covariates. RESULTS There was no association between the receipt of guideline-concordant depression care and COPD-related hospitalization (odds ratio [OR], 0.98) or all-cause mortality (OR, 0.95). However, patients seen in mental health settings during their depressive episode had 30% lower odds of 2-year mortality than patients seen in primary care. CONCLUSIONS For patients with COPD and depression, interacting with a mental health professional may be an important intervention. However, receiving guideline-concordant depression care, as outlined in common quality monitors, was not significantly associated with decreased hospitalization or mortality. These findings suggest that more referrals to specialty care or better care coordination with mental health specialty care may lead to a significant reduction in mortality risk for these patients.

Upfront computed tomography scanning is more cost-beneficial than empiric medical therapy in the initial management of chronic rhinosinusitis

Current treatment algorithms for patients with symptoms of chronic rhinosinusitis (CRS) recommend a trial of empiric medical therapy prior to obtaining a sinus computed tomography (CT) scan, even in cases of negative nasal endoscopy. This empiric approach evolved in an era when same day conventional CT was both impractical and economically irresponsible. The objective of this work was to determine whether upfront CT scanning is more cost‐beneficial than empiric medical therapy for patients presenting with CRS symptoms but negative endoscopic findings.

Factors Associated With Depressive Symptoms and Use of Antidepressant Medications Among Participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC Studies

BACKGROUND Depressive symptoms are correlated with poor health outcomes in adults with chronic kidney disease (CKD). The prevalence, severity, and treatment of depressive symptoms and potential risk factors, including level of kidney function, in diverse populations with CKD have not been well studied. STUDY DESIGN Cross-sectional analysis. SETTINGS & PARTICIPANTS Participants at enrollment into the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies. CRIC enrolled Hispanics and non-Hispanics at 7 centers in 2003-2007, and H-CRIC enrolled Hispanics at the University of Illinois in 2005-2008. MEASUREMENT Depressive symptoms measured by Beck Depression Inventory (BDI). PREDICTORS Demographic and clinical factors. OUTCOMES Elevated depressive symptoms (BDI score ≥11) and antidepressant medication use. RESULTS Of 3,853 participants, 27.4% had evidence of elevated depressive symptoms and 18.2% were using antidepressant medications; 31.0% of persons with elevated depressive symptoms were using antidepressants. The prevalence of elevated depressive symptoms varied by level of kidney function: 23.6% for participants with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2) and 33.8% of those with eGFR <30 mL/min/1.73 m(2). Lower eGFR (OR per 10-mL/min/1.73 m(2) decrease, 1.10; 95% CI, 1.04-1.17), and non-Hispanic black race (OR, 1.42; 95% CI, 1.16-1.74) were each associated with increased odds of elevated depressive symptoms after controlling for other factors. In regression analyses incorporating BDI score, whereas female sex was associated with greater odds of antidepressant use, Hispanic ethnicity, non-Hispanic black race, and higher urine albumin levels were associated with decreased odds of antidepressant use (P < 0.05 for each). LIMITATIONS Absence of clinical diagnosis of depression and use of nonpharmacologic treatments. CONCLUSIONS Although elevated depressive symptoms were common in individuals with CKD, use of antidepressant medications is low. Individuals of racial and ethnic minority background and with more advanced CKD had a greater burden of elevated depressive symptoms and lower use of antidepressant medications.

Predictors of Residential Placement Following a Psychiatric Crisis Episode Among Children and Youth in State Custody

This study examined the extent and correlates of entry into residential care among 603 children and youth in state custody who were referred to psychiatric crisis services. Overall, 27% of the sample was placed in residential care within 12 months after their 1st psychiatric crisis screening. Among the children and youth placed in residential care, 51% were so placed within 3 months of their 1st crisis screening, with an additional 22% placed between 3 and 6 months after screening. Risk behavior and functioning, psychiatric hospitalization following screening, older age, placement type, and caregivers capacity for supervision were associated with increased residential placement. The findings highlight the importance of early identification and treatment of behavior and functioning problems following a crisis episode among children and youth in state custody to reduce the need for subsequent residential placement. Having an inpatient psychiatric episode following a crisis episode places children at greater risk for residential placement, suggesting that the hospital is an important point for diversion programs. Children and youth in psychiatric crisis may also benefit from efforts to include their families in the treatment process.

How Are Iraq/Afghanistan-Era Veterans Faring in the Labor Market?

This study examines labor market status of Veterans of the Iraq/Afghanistan-era and previous eras, and variations by age and by health status, using the Current Population Survey (CPS) March supplement from 2006 to 2011. Although this observational study does not demonstrate a causal effect of military service on labor market outcomes, the authors find that Iraq/Afghanistan-era service among the youngest Veterans (ages 18–24) was associated with higher earnings and greater odds of being enrolled in school, but also higher odds of unemployment. Military service in previous eras by older Veterans, particularly those in fair or poor health, was associated with higher odds of unemployment and lower earnings than their nonveteran counterparts. Future research should examine the reasons for the higher unemployment rates of the youngest Veterans and should examine whether receipt of services such as health care services, disability benefits, and military reintegration programs are associated with improved labor market outcomes.

Dissemination of the nurse-administered Tobacco Tactics intervention versus usual care in six Trinity community hospitals: study protocol for a comparative effectiveness trial

BackgroundThe objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved.Methods/DesignThis effectiveness study will be a quasi-experimental design of six Michigan community hospitals of which three will get the nurse-administered Tobacco Tactics intervention and three will provide their usual care. In both the intervention and usual care sites, research assistants will collect data from patients on their smoking habits and related variables while in the hospital and at thirty days and six months post-recruitment. The intervention will be integrated into the experimental sites by a research nurse who will train Master Trainers at each intervention site. The Master Trainers, in turn, will teach the intervention to all staff nurses. Research nurses will also conduct formative evaluation with nurses to identify barriers and facilitators to dissemination.Descriptive statistics will be used to summarize the results of surveys administered to nurses, nurses’ participation rates, smokers’ receipt of specific cessation services, and satisfaction with services. General estimating equation analyses will be used to determine differences between intervention groups on satisfaction and quit rates, respectively, with adjustment for the clustering of patients within hospital units. Regression analyses will test the moderation of the effects of the interventions by patient characteristics. Cost-effectiveness will be assessed by constructing three ratios including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved.DiscussionGiven that nurses represent the largest group of front-line providers, this intervention, if proven effective, has the potential for having a wide reach and thus decrease smoking, morbidity and mortality among inpatient smokers.Trial registrationDissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217

Virtual Reality Job Interview Training for Veterans with Posttraumatic Stress Disorder.

BACKGROUND Veterans with posttraumatic stress disorder (PTSD) have low employment rates and the job interview presents a critical barrier for them to obtain competitive employment. OBJECTIVE To evaluate the acceptability and efficacy of virtual reality job interview training (VR-JIT) among veterans with PTSD via a small randomized controlled trial (n=23 VR-JIT trainees, n=10 waitlist treatment-as-usual (TAU) controls). METHODS VR-JIT trainees completed up to 10 hours of simulated job interviews and reviewed information and tips about job interviewing, while wait-list TAU controls received services as usual. Primary outcome measures included two pre-test and two post-test video-recorded role-play interviews scored by blinded human resource experts and self-reported interviewing self-confidence. RESULTS Trainees attended 95% of lab-based VR-JIT sessions and found the intervention easy-to-use, helpful, and prepared them for future interviews. VR-JIT trainees demonstrated significantly greater improvement on role-play interviews compared with wait-list TAU controls (p=0.04) and demonstrated a large effect for within-subject change (Cohens d=0.76). VR-JIT performance scores increased significantly over time (R-Squared=0.76). Although VR-JIT trainees showed a moderate effect for within-subject change on self-confidence (Cohens d=0.58), the observed difference between conditions did not reach significance (p=0.09). CONCLUSIONS Results provide preliminary support that VR-JIT is acceptable to trainees and may be efficacious for improving job interview skills and self-confidence in veterans with PTSD.

Examination of the effects of financial risk on the formal treatment costs for a Medicaid population with psychiatric disabilities.

Objectives:We examined the effects of differing financial risk arrangements for mental health, physical health, and pharmacy services on the overall costs of these services with particular attention to cost containment and cost shifting. Methods:Comprehensive service utilization information was obtained from a sample of 458 adults with severe mental illnesses during a 12-month period. Rate information was used to calculate costs for health, mental health and pharmacy. A 2-part model was employed to test for differences among financial risk conditions. Results:Total treatment costs, both those financed by Medicaid and those paid by other sources, were lower in plans that had a broader array of services for which they were at risk. Pharmacy costs were principally responsible for these differences. Conclusions:Treatment costs for adults with severe mental illnesses can be contained by placing providers at financial risk. However, risk arrangements may also increase treatment costs borne by other payers including charity services and self-pay. Evaluating the impact of at-risk financing mechanisms from a public health perspective requires assessing cost shifting, particularly for pharmaceuticals.