Nisha Ver Halen

Coping with racism: a selective review of the literature and a theoretical and methodological critique

Racism is a stressor that contributes to racial/ethnic disparities in mental and physical health and to variations in these outcomes within racial and ethnic minority groups. The aim of this paper is to identify and discuss key issues in the study of individual-level strategies for coping with interpersonal racism. We begin with a discussion of the ways in which racism acts as a stressor and requires the mobilization of coping resources. Next, we examine available models for describing and conceptualizing strategies for coping with racism. Third, we discuss three major forms of coping: racial identity development, social support seeking and anger suppression and expression. We examine empirical support for the role of these coping strategies in buffering the impact of racism on specific health-related outcomes, including mental health (i.e., specifically, self-reported psychological distress and depressive symptoms), self-reported physical health, resting blood pressure levels, and cardiovascular reactivity to stressors. Careful examination of the effectiveness of individual-level coping strategies can guide future interventions on both the individual and community levels.

Psychosocial Intervention Improves Depression, Quality of Life, and Fluid Adherence in Hemodialysis

Patients with ESRD have high rates of depression, which is associated with diminished quality of life and survival. We determined whether individual cognitive behavioral therapy (CBT) reduces depression in hemodialysis patients with elevated depressive affect in a randomized crossover trial. Of 65 participants enrolled from two dialysis centers in New York, 59 completed the study and were assigned to the treatment-first group (n=33) or the wait-list control group (n=26). In the intervention phase, CBT was administered chairside during dialysis treatments for 3 months; participants were assessed 3 and 6 months after randomization. Compared with the wait-list group, the treatment-first group achieved significantly larger reductions in Beck Depression Inventory II (self-reported, P=0.03) and Hamilton Depression Rating Scale (clinician-reported, P<0.001) scores after intervention. Mean scores for the treatment-first group did not change significantly at the 3-month follow-up. Among participants with depression diagnosed at baseline, 89% in the treatment-first group were not depressed at the end of treatment compared with 38% in the wait-list group (Fishers exact test, P=0.01). Furthermore, the treatment-first group experienced greater improvements in quality of life, assessed with the Kidney Disease Quality of Life Short Form (P=0.04), and interdialytic weight gain (P=0.002) than the wait-list group, although no effect on compliance was evident at follow-up. In summary, CBT led to significant improvements in depression, quality of life, and prescription compliance in this trial, and studies should be undertaken to assess the long-term effects of CBT on morbidity and mortality in patients with ESRD.

Depression and nonadherence predict mortality in hemodialysis treated end-stage renal disease patients.

The scientific evaluation of depressions impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01–1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (β = 0.452, P = 0.044). In a subgroup of 85 subjects, self‐reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

Depression and Non-adherence Predict Mortality in Hemodialysis Treated ESRD Patients

The scientific evaluation of depressions impact on mortality in hemodialysis (HD) patients has yielded mixed results, with the more recent, more rigorous studies detecting a significant relationship. In this study, 130 HD patients from an urban North American hospital were evaluated for depressive affect and then observed for up to 5 years. In a corrected Cox regression model, which held constant age, gender, dialysis vintage, illness severity and diabetic status, depressive affect emerged as a modest but significant predictor of mortality (relative risk = 1.05, 95% confidence interval = 1.01–1.08). When the subjects were divided according to depressive affect severity, those with severe depressive affect had significantly shorter time to death (β = 0.452, P = 0.044). In a subgroup of 85 subjects, self‐reported medication adherence was also predictive of mortality, with higher rates of nonadherence being associated with increased mortality risk. This paper lends support to the burgeoning literature on depression and reduced survival in HD populations, as well as begins the investigation of understanding the underlying mechanisms.

Depression and mortality in end-stage renal disease.

End-stage renal disease is growing in prevalence and incidence. With technical advancements, patients are living longer on hemodialysis. Depression is the most prevalent comorbid psychiatric condition, estimated at about 25% of end-stage renal disease samples. The identification and assessment of depression are confounded by the overlap between depression symptomatology and uremia. Several recent studies have employed time-varying models and identified a significant association between depression and mortality. Due to the high prevalence of depression and the potential impact on survival, well-constructed investigations are warranted.

A Preliminary Investigation of Depression and Kidney Functioning in Patients with Chronic Kidney Disease

Background: The incidence and prevalence of Chronic Kidney Disease (CKD) is growing rapidly. Understanding the factors associated with declining renal function is of clinical significance. The current studys main goal was to identify variables that could predict decline in glomerular filtration rate (GFR) over time in outpatients with varying stages of CKD. Methods: Seventy CKD patients completed psychological questionnaires and medical variables were extracted from the medical charts. Follow-up GFR was collected 6 months later. CKD patients with elevated depression scores were compared to patients with subclinical depression on medical and psychological variables. Results: Average Beck Depression Inventory (BDI) score was 10.0 ± 7.8, placing the mean below the cut-off for clinical elevation. GFR was significantly different for the two groups (nondepressed, 40.0 ± 11.3 vs. depressed 29.6 ± 8.9; p < 0.05). Similarly, patients with elevated depression scores reported lower quality of life (Short Form 36 Health Survey; p < 0.05) inferior social support (Interpersonal Support Evaluation List; p < 0.05), and worse community integration (Community Integration Questionnaire; p < 0.05). Utilizing a regression, with a model correcting for baseline GFR, the BDI explained 19% of the variance in GFR score (t = -2.0, p < 0.05) for subjects with decreased GFR. Conclusions: Increased levels of preexisting depression were associated with inferior quality of life, social support and kidney functioning. Depression scores explained a significant amount of variance in GFR scores at 6 months even when corrected for baseline variability. Elevated depression scores are prevalent in CKD populations and further research on the impact of depression interventions is warranted.

A Pilot Randomized Controlled Trial to Promote Immunosuppressant Adherence in Adult Kidney Transplant Recipients

Background: Nonadherence to immunosuppressant medication is a prevalent practice among kidney transplant recipients and has been associated with increased risk for graft failure and economic burden. The aim of this pilot study was to test whether a culturally sensitive cognitive-behavioral adherence promotion program could significantly improve medication adherence to tacrolimus prescription as measured by telephone pill counts among kidney transplant recipients. Methods: Thirty-three adult transplant recipients were less than 98% adherent to tacrolimus prescription based on 3 telephone pill counts and were randomized either to the 2-session cognitive-behavioral adherence promotion program or to standard care. The curriculum was developed from an iterative process with transplant recipients into a 2-session group program that provided psychoeducation, addressed barriers to adherence, fostered motivation to improve adherence behavior, and discussed cultural messages on adherence behavior. Results: The intervention group displayed significantly higher levels of adherence when compared to the control group (t = 2.2, p = 0.04) and. similarly, when the amount of change was compared between the groups, the intervention group showed more change than the control condition (F (22,1) = 12.005, p = 0.003). Tacrolimus trough concentration levels were used as a secondary measure of adherence and, while there were no significant between-group differences for mean trough concentration levels, the variability in the trough levels did significantly decrease over time indicating more consistent pill-taking behavior in the intervention group. Conclusions: There is preliminary support for the pilot program as a successful intervention in helping patients with their immunosuppressant medication.

Anxiety and Quality of Life in ESRD

The hallmark features of an Anxiety Disorder are overwhelming feelings of fearfulness, dread, and uncertainty (1). Unlike relatively mild brief anxiety caused by a stressful event, anxiety disorders last at least 6 months and often get worse if not treated. Anxiety disorders are characterized by alterations in a diverse range of neurochemical systems. Recent neuroanatomical and neuroimaging research has focused on the role of the amygdala, reciprocal connections between the amygdala and the prefrontal cortex, and, most recently, alterations in interoceptive processing by the anterior insula (2). Anxiety disorders affect approximately 40 million American adults, accounting for a substantial psychological toll. Additionally, the World Health Organization rates anxiety as a major cause of years lost to disability in theUnited States (3). There is a strong negative impact of anxiety disorders on quality of life (QOL) (4) and disability across multiple illnesses (5). Patients with end-stage renal disease (ESRD)may exhibit anxiety through a range of symptoms. See Table 1 for a list of common anxiety symptoms. The Diagnostic and Statistical Manual (DSM-IV) lists the following as anxiety disorders: panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social phobia, generalized anxiety disorder, and specific phobias (1). Interestingly, the current proposal for DSM-V removes OCD and PTSD and instead lists them as separate chapters on ObsessiveCompulsive and Related Disorders and Traumaand Stressor-Related Disorders (6). Table 2 provides a brief description of the anxiety disorders listed in the DSM-IV. The precise prevalence of anxiety disorders within the US dialysis population remains unclear in the absence of large, nationally representative studies. Numerous smaller studies have examined the rate of anxiety within dialysis patients, but have used a variety of different measures to assess anxiety. A review of 55 studies that examined anxiety symptoms in ESRD patients revealed an average prevalence rate of 38% with levels for individual studies ranging from 12% to 52% (7). Studies that have used the SCID-I to diagnose DSM-IV anxiety disorders report prevalence rates ranging from 0% to 45.7% (8–10). Cukor et al. found a prevalence rate of 45.7% in a sample of predominately Black hemodialysis patients, with the most common anxiety disorders being specific phobias (26.6%) and panic disorder (21.0%) (9). A different study reported a 30% prevalence of anxiety disorders in HD patients using the Primary Care Evaluation of Mental Disorders (PRIME-MD), which indicated a 19% prevalence of anxiety disorders in 2316 general medical patients (11,12). Studies using self-report measures screen for anxiety symptoms rather than actual diagnoses and have found a wide range of prevalence in ESRD patients as well, spanning from 39% (13) to 53% (14). Some of the variation may well be due to anxiety scale used, population parameters, and the natural course of anxiety. Rates of moderate-to-severe symptoms have ranged from 13% to 28% (14,15) in dialysis patients.

A pilot investigation of cognitive improvement across a single hemodialysis treatment

BACKGROUND Uremia has long been associated with cognitive deficits. This study explored the importance of the time of measurement of neurocognitive functioning, by directly comparing changes in neurocognitive functioning from immediately after hemodialysis treatment to immediately before treatment. METHODS Twenty-five hemodynamically stable hemodialysis patients and 6 peritoneal dialysis controls completed 2 computer-based assessment batteries (ANAM), one immediately before dialysis and the second upon completion of that dialysis session. Paired sample t-tests were used to compare postdialysis with predialysis neurocognitive functioning scores for both a composite measure of global functioning and the neurocognitive subtests. RESULTS There was significant improvement in global neuropsychological functioning from predialysis to postdialysis (t (24) = -7.5, p<0.001), showing an average of 18% improvement in the hemodialysis group, with no significant change in the peritoneal dialysis group. CONCLUSION This study suggests that computer-based testing can offer information on the cognitive fluctuations of medically complex populations and suggests that the end of the session may be a better time to discuss important and complex health messages with hemodialysis patients. It further implies that some of the neurocognitive impairment that is associated with end-stage renal disease is a consequence of uremia and is improved by hemodialysis.

Sleep health in a black community sample

BACKGROUND Poor sleep health is a major health disparity and public health concern. The primary goal of this study was to accurately obtain the rates of self-reported sleep disorders, sleep dysfunction, and daytime sleepiness in a true community sample of black adults. METHODS We used a community-based participatory research design to identify a health priority to design a study that could (a) provide an accurate assessment of the problem, (b) help to better understand the barriers to treatment, and (c) provide the community with access to care. Subsequently, 470 black adults, approached at salons, barber shops, and churches throughout Brooklyn participated. They underwent anthropometric measurement and completed a self-reported sleep assessment. RESULTS Sleep disorders (insomnia, obstructive sleep apnea) were found in 34% of the sample, and 75% of the population that had a sleep disorder was unaware of it. Fourteen percent of the sample self-identified as having obstructive sleep apnea, 38.0% reported having Insomnia, and 38% reported having excessive daytime somnolence. People with a sleep disorder described less satisfaction with their sleep quality and poorer health than did those without a sleep disorder. CONCLUSION The variability in the reported rates of sleep disorders in black samples suggests that the true rates of these conditions are not well-known. However, the large number of black individuals who have sleep disturbances warrants increased scientific and public health attention. In addition, with increased community involvement in research, there can be increased buy-in and greater accuracy in the assessments and reduced barriers to treatment.