Nicole Redmond

Perceived Stress Is Associated With Incident Coronary Heart Disease and All‐Cause Mortality in Low‐ but Not High‐Income Participants in the Reasons for Geographic And Racial Differences in Stroke Study

Background Perceived stress may increase risk for coronary heart disease (CHD) and death, but few studies have examined these relationships longitudinally. We sought to determine the association of perceived stress with incident CHD and all‐cause mortality. Methods and Results Data were from a prospective study of 24 443 participants without CHD at baseline from the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) study cohort. Outcomes were expert‐adjudicated acute CHD and all‐cause mortality. Over a mean follow‐up of 4.2 (maximum 6.9) years, there were 659 incident CHD events and 1320 deaths. Analyses were stratified by income level because of significant interactions with stress. For individuals with low income, 3529 (35.4%) reported high stress, and for those with high income, 2524 (22.1%) did so. Compared with reporting no stress, those reporting the highest stress had higher risk for incident CHD if they reported low income (sociodemographic‐adjusted HR 1.36, 95% CI: 1.04, 1.78) but not high income (sociodemographic‐adjusted HR 0.82, 95% CI: 0.57, 1.16); the finding in low income individuals attenuated with adjustment for clinical and behavioral factors (HR 1.29, 95% CI: 0.99, 1.69, P=0.06). After full adjustment, the highest stress category was associated with higher risk for death among those with low income (HR 1.55, 95% CI: 1.31, 1.82) but not high income (HR 1.13, 95% CI: 0.88, 1.46). Conclusions High stress was associated with greater risks of CHD and death for individuals with low but not high income.

Consequences of Comorbidity of Elevated Stress and/or Depressive Symptoms and Incident Cardiovascular Outcomes in Diabetes: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

OBJECTIVE To evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes. RESEARCH DESIGN AND METHODS Investigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study. RESULTS Subjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern “Stroke Belt”). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]). CONCLUSIONS Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.

Effects of Concurrent Depressive Symptoms and Perceived Stress on Cardiovascular Risk in Low‐ and High‐Income Participants: Findings From the Reasons for Geographical and Racial Differences in Stroke (REGARDS) Study

Background Psychosocial risk for cardiovascular disease (CVD) may be especially deleterious in persons with low socioeconomic status. Most work has focused on psychosocial factors individually, but emerging research suggests that the confluence of psychosocial risk may be particularly harmful. Using data from the Reasons for Geographical and Racial Differences in Stroke (REGARDS) study, we examined associations among depressive symptoms and stress, alone and in combination, and incident CVD and all‐cause mortality as a function of socioeconomic status. Methods and Results At baseline, 22 658 participants without a history of CVD (58.8% female, 41.7% black, mean age 63.9±9.3 years) reported on depressive symptoms, stress, annual household income, and education. Participants were classified into 1 of 3 psychosocial risk groups at baseline: (1) neither depressive symptoms nor stress, (2) either depressive symptoms or stress, or (3) both depressive symptoms and stress. Cox proportional hazards models were used to predict physician‐adjudicated incident total CVD events (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death) and all‐cause mortality over a median of 7.0 years (interquartile range 5.4–8.3 years) of follow‐up. In fully adjusted models, participants with both depressive symptoms and stress had the greatest elevation in risk of developing total CVD (hazard ratio 1.48, 95% CI 1.21–1.81) and all‐cause mortality (hazard ratio 1.33, 95% CI 1.13–1.56) but only for those with low income (<

Antidepressant Medication Use and Its Association With Cardiovascular Disease and All-Cause Mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study:

35 000) and not high (≥

Perfect Storm Concurrent Stress and Depressive Symptoms Increase Risk of Myocardial Infarction or Death

35 000) income. This pattern of results was not observed in models stratified by education. Conclusions Findings suggest that screening for a combination of elevated depressive symptoms and stress in low‐income persons may help identify those at increased risk of incident CVD and mortality.

Factors associated with rapid failure in a Treatment Alternatives for Safer Communities (TASC) program

Background: Mixed evidence suggests that second-generation antidepressants may increase the risk of cardiovascular and cerebrovascular events. Objective: To assess whether antidepressant use is associated with acute coronary heart disease (CHD), stroke, cardiovascular disease (CVD) death, and all-cause mortality. Methods: Secondary analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) longitudinal cohort study were conducted. Use of selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, bupropion, nefazodone, and trazodone was measured during the baseline (2003-2007) in-home visit. Outcomes of CHD, stroke, CVD death, and all-cause mortality were assessed every 6 months and adjudicated by medical record review. Cox proportional hazards time-to-event analysis followed patients until their first event on or before December 31, 2011, iteratively adjusting for covariates. Results: Among 29 616 participants, 3458 (11.7%) used an antidepressant of interest. Intermediate models adjusting for everything but physical and mental health found an increased risk of acute CHD (hazard ratio [HR] = 1.21; 95% CI = 1.04-1.41), stroke (HR = 1.28; 95% CI = 1.02-1.60), CVD death (HR = 1.29; 95% CI = 1.09-1.53), and all-cause mortality (HR = 1.27; 95% CI = 1.15-1.41) for antidepressant users. Risk estimates trended in this direction for all outcomes in the fully adjusted model but only remained statistically associated with increased risk of all-cause mortality (HR = 1.12; 95% CI = 1.01-1.24). This risk was attenuated in sensitivity analyses censoring follow-up time at 2 years (HR = 1.37; 95% CI = 1.11-1.68). Conclusions: In fully adjusted models, antidepressant use was associated with a small increase in all-cause mortality.

Association of Recent Incarceration with Traumatic Injury, Substance Use Related Health Consequences, and Health Care Utilization

Background—Depression and stress have each been found to be associated with poor prognosis in patients with coronary heart disease. A recently offered psychosocial perfect storm conceptual model hypothesizes amplified risk will occur in those with concurrent stress and depressive symptoms. We tested this hypothesis in a large sample of US adults with coronary heart disease. Methods and Results—Participants included 4487 adults with coronary heart disease from the REasons for Geographic and Racial Differences in Stroke study, a prospective cohort study of 30 239 black and white adults. We conducted Cox proportional hazards regression with the composite outcome of myocardial infarction or death and adjustment for demographic, clinical, and behavioral factors. Overall, 6.1% reported concurrent high stress and high depressive symptoms at baseline. During a median 5.95 years of follow-up, 1337 events occurred. In the first 2.5 years of follow-up, participants with concurrent high stress and high depressive symptoms had increased risk for myocardial infarction or death (adjusted hazard ratio, 1.48 [95% confidence interval, 1.08–2.02]) relative to those with low stress and low depressive symptoms. Those with low stress and high depressive symptoms (hazard ratio, 0.92 [95% confidence interval, 0.66–1.28]) or high stress and low depressive symptoms (hazard ratio, 0.86 [95% confidence interval, 0.57–1.29]) were not at increased risk. The association on myocardial infarction or death was not significant after the initial 2.5 years of follow-up (hazard ratio, 0.89 [95% confidence interval, 0.65–1.22]). Conclusions—Our results provide initial support for a psychosocial perfect storm conceptual model; the confluence of depressive symptoms and stress on medical prognosis in adults with coronary heart disease may be particularly destructive in the shorter term.

The Relationship Between Prior Suicidal Behavior and Mortality Among Individuals in Community Corrections

OBJECTIVE Identify factors associated with early treatment failure in a Treatment Alternatives for Safer Communities (TASC) program, a case management criminal justice diversion program for individuals under community corrections supervision. METHODS Demographics, medication history, substance dependence, and criminal history variables for 21,419 individuals were used as predictor variables for successful treatment outcome in a Cox Proportional Hazards Survival analysis which was used to assess the relationship between predictor variables and the length of time before treatment failure. RESULTS Early treatment failure was associated with a number of factors linked to social stability, including: being divorced separated or widowed, being less educated, being without insurance or on government insurance, and being unemployed. Regarding addiction and criminal history, being dependent on cocaine or opioids and being under supervision for person, property, or court offenses were risk factors. Being male and being a member of a racial minority were also risk factors for early treatment failure. Meeting criteria for sedative/hypnotic dependence and being under legal supervision for a substance offense were associated with a longer duration of time to treatment failure. CONCLUSIONS Social stability, addiction history, and current criminal charges all appear to influence performance in TASC. Individuals with multiple risk factors may benefit from referral to a higher level of care upon admittance to TASC.

Erratum. Consequences of Comorbidity of Elevated Stress and/or Depressive Symptoms and Incident Cardiovascular Outcomes in Diabetes: Results From the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Diabetes Care 2016;39:101–109

Objective:The higher risk of death among recently released inmates relative to the general population may be because of the higher prevalence of substance dependence among inmates or an independent effect of incarceration. We explored the effects of recent incarceration on health outcomes that may be intermediate markers for mortality. Methods:Longitudinal multivariable regression analyses were conducted on interview data (baseline, 3-, 6-, and 12-month follow-up) from alcohol- and/or drug-dependent individuals (n = 553) participating in a randomized clinical trial to test the effectiveness of chronic disease management for substance dependence in primary care. The main independent variable was recent incarceration (spending ≥1 night in jail or prison in the past 3 months). The 3 main outcomes of this study were any traumatic injury, substance use–related health consequences, and health care utilization—defined as hospitalization (excluding addiction treatment or detoxification) and/or emergency department visit. Results:Recent incarceration was not significantly associated with traumatic injury (adjusted odds ratio [AOR] = 0.98; 95% confidence interval [CI]: 0.65-1.49) or health care utilization (AOR = 0.88; 95% CI: 0.64-1.20). However, recent incarceration was associated with higher odds for substance use–related health consequences (AOR = 1.42; 95% CI: 1.02-1.98). Conclusions:Among people with alcohol and/or drug dependence, recent incarceration was significantly associated with substance use–related health consequences but not injury or health care utilization after adjustment for covariates. These findings suggest that substance use–related health consequences may be part of the explanation for the increased risk of death faced by former inmates.

Concurrent Stress and Depressive Symptoms Increase Risk of Myocardial Infarction or Death

BACKGROUND Individuals under community corrections have multiple risk factors for mortality including exposure to a criminal environment, drug use, social stress, and a lack of medical care that predispose them to accidents, homicides, medical morbidities, and suicide. The literature suggests that prior suicidal behavior may be a particularly potent risk factor for mortality among individuals in the criminal justice system. AIMS This study looked to extend the link between history of a suicide attempt and future mortality in a community corrections population. METHOD Using an archival dataset (N = 18,260) collected from 2002 to 2007 of individuals being monitored under community corrections supervision for an average of 217 days (SD = 268), we examined the association between past history of a suicide attempt and mortality. RESULTS A Cox Proportional Hazard Model controlling for age, race, gender, and substance dependence indicated that past history of a suicide attempt was independently associated with time to mortality, and demonstrated the second greatest effect after gender. CONCLUSION These data suggest the need for a greater focus on screening and preventive services, particularly for individuals with a history of suicidal behavior, so as to reduce the risk of mortality in community corrections populations.