Paul N. Pfeiffer

Efficacy of peer support interventions for depression: A meta-analysis

OBJECTIVE To assess the efficacy of peer support for reducing symptoms of depression. METHODS Medline, PsycINFO, CINAHL and CENTRAL databases were searched for clinical trials published as of April 2010 using Medical Subject Headings and free text terms related to depression and peer support. Two independent reviewers selected randomized controlled trials (RCTs) that compared a peer support intervention for depression to usual care or a psychotherapy control condition. Meta-analyses were conducted to generate pooled standardized mean differences (SMD) in the change in depressive symptoms between study conditions. RESULTS Seven RCTs of peer support vs. usual care for depression involving 869 participants were identified. Peer support interventions were superior to usual care in reducing depressive symptoms, with a pooled SMD of -0.59 (95% CI, -0.98 to -0.21; P=.002). Seven RCTs with 301 total participants compared peer support to group cognitive behavioral therapy (CBT). There was no statistically significant difference between group CBT and peer interventions, with a pooled SMD of 0.10 (95% CI, -0.20 to 0.39, P=.53). CONCLUSION Based on the available evidence, peer support interventions help reduce symptoms of depression. Additional studies are needed to determine effectiveness in primary care and other settings with limited mental health resources.

Comorbid anxiety as a suicide risk factor among depressed veterans

Background: Depressive disorders greatly increase suicide risk; however, little is known about the contribution of comorbid anxiety disorders or anxiety symptoms to the risk of suicide death among depressed patients. We examined whether depressed veterans with comorbid anxiety had higher risks of suicide death. Methods: Using VA administrative databases we identified 887,859 patients with depression. We then used univariate and multivariate logistic regression, controlling for demographics and substance use disorders, to determine the odds ratios of completed suicide associated with individual comorbid anxiety disorders, the presence of any comorbid anxiety disorder, the prescription of an antianxiety medication, or the prescription of a high dose of an antianxiety medication. Results: In multivariate analyses, the odds of completed suicide were significantly increased for patients with panic disorder (OR 1.26, 95% CI: 1.04–1.53), generalized anxiety disorder (OR 1.27, 95% CI: 1.09–1.47), and anxiety disorder, not otherwise specified (OR 1.25, 95% CI: 1.12–1.38). The odds of completed suicide were also greater among patients who received any antianxiety medication (OR 1.71, 95% CI: 1.55–1.88), and were further increased among those who received high dose treatment (OR 2.26, 95% CI: 1.98–2.57). Odds of completed suicide were decreased among patients with comorbid posttraumatic stress disorder (OR 0.87, 95% CI: 0.77–0.97), and there was no statistically significant relationship between social phobia, obsessive–compulsive disorder, and all other anxiety disorders and suicide. Conclusions: These findings emphasize the importance of comorbid anxiety disorders and symptoms in increasing suicide risk among depressed patients and may inform suicide prevention efforts among these patients. Depression and Anxiety, 2009.

Initiation of Primary Care-Mental Health Integration Programs in the VA Health System: Associations With Psychiatric Diagnoses in Primary Care

Background:Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VAs Primary Care–Mental Health Integration (PC-MHI) program. Objectives:To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. Research Design:Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. Subjects, Measures, and Results:From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18–64) and white. Conclusions:Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

Evaluation of the FDA Warning Against Prescribing Citalopram at Doses Exceeding 40 mg

OBJECTIVE A recent Food and Drug Administration (FDA) warning cautioned that citalopram dosages exceeding 40 mg/day may cause abnormal heart rhythms, including torsade de pointes. The authors assessed relationships between citalopram use and ventricular arrhythmias and mortality. METHOD A cohort study was conducted using Veterans Health Administration data between 2004 and 2009 from depressed patients who received a prescription for citalopram (N=618,450) or for sertraline (N=365,898), a comparison medication with no FDA warning. Cox regression models, adjusted for demographic and clinical characteristics, were used to examine associations of antidepressant dosing with ventricular arrhythmia and cardiac, noncardiac, and all-cause mortality. RESULTS Citalopram daily doses >40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio=0.68, 95% CI=0.61-0.76), all-cause mortality (adjusted hazard ratio=0.94, 95% CI=0.90-0.99), and noncardiac mortality (adjusted hazard ratio=0.90, 95% CI=0.86-0.96) compared with daily doses of 1-20 mg. No increased risks of cardiac mortality were found. Citalopram daily doses of 21-40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio=0.80, 95% CI=0.74-0.86) compared with dosages of 1-20 mg/day but did not have significantly different risks of any cause of mortality. The sertraline cohort revealed similar findings, except there were no significant associations between daily dose and either all-cause or noncardiac mortality. CONCLUSIONS This large study found no elevated risks of ventricular arrhythmia or all-cause, cardiac, or noncardiac mortality associated with citalopram dosages >40 mg/day. Higher dosages were associated with fewer adverse outcomes, and similar findings were observed for a comparison medication, sertraline, not subject to the FDA warning. These results raise questions regarding the continued merit of the FDA warning.

Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia: A Systematic Review and Meta-Analysis

Background Insomnia is of major public health importance. While cognitive behavioral therapy is beneficial, in-person treatment is often unavailable. We assessed the effectiveness of internet-delivered cognitive behavioral therapy for insomnia. Objectives The primary objectives were to determine whether online cognitive behavioral therapy for insomnia could improve sleep efficiency and reduce the severity of insomnia in adults. Secondary outcomes included sleep quality, total sleep time, time in bed, sleep onset latency, wake time after sleep onset, and number of nocturnal awakenings. Data Sources We searched PubMed/MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Library, Embase, and the Web of Science for randomized trials. Methods Studies were eligible if they were randomized controlled trials in adults that reported application of cognitive behavioral therapy for insomnia via internet delivery. Mean differences in improvement in sleep measures were calculated using the Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis. Results We found 15 trials, all utilizing a pretest-posttest randomized control group design. Sleep efficiency was 72% at baseline and improved by 7.2% (95% CI: 5.1%, 9.3%; p<0.001) with internet-delivered cognitive behavioral therapy versus control. Internet-delivered cognitive behavioral therapy resulted in a decrease in the insomnia severity index by 4.3 points (95% CI: -7.1, -1.5; p = 0.017) compared to control. Total sleep time averaged 5.7 hours at baseline and increased by 20 minutes with internet-delivered therapy versus control (95% CI: 9, 31; p = 0.004). The severity of depression decreased by 2.3 points (95% CI: -2.9, -1.7; p = 0.013) in individuals who received internet-delivered cognitive behavioral therapy compared to control. Improvements in sleep efficiency, the insomnia severity index and depression scores with internet-delivered cognitive behavioral therapy were maintained from 4 to 48 weeks after post-treatment assessment. There were no statistically significant differences between sleep efficiency, total sleep time, and insomnia severity index for internet-delivered versus in-person therapy with a trained therapist. Conclusion In conclusion, internet-delivered cognitive behavioral therapy is effective in improving sleep in adults with insomnia. Efforts should be made to educate the public and expand access to this therapy. Registration Number, Prospero: CRD42015017622

Suicide risk assessment received prior to suicide death by Veterans health administration patients with a history of depression

OBJECTIVE To examine the quality of suicide risk assessment provided to veterans with a history of depression who died by suicide between 1999 and 2004. METHOD We conducted a case-control study of suicide risk assessment information recorded in 488 medical charts of veterans previously diagnosed with major depression, depression not otherwise specified, dysthymia, or other, less common ICD-9-CM depression codes. Patients dying by suicide from April 1999 through September 2004 or comparison patients (n = 244 pairs) were matched for age, sex, entry year, and region. RESULTS Seventy-four percent of patients with a history of depression received a documented assessment of suicidal ideation within the past year, and 59% received more than 1 assessment. However, 70% of those who died of suicide did not have a documented assessment for suicidal ideation at their final Veterans Health Administration (VHA) visit, even if that visit occurred within 0 through 7 days prior to suicide death. Most patients dying by suicide denied suicidal ideation when assessed (85%; 95% CI, 75%-92%), even just 0 through 7 days prior to suicide death (73%; 95% CI, 39%-94%). Suicidal ideation was assessed more frequently during outpatient final visits with mental health providers (60%) than during outpatient final visits with primary care (13%) or other non-mental health providers (10%, P < .0001). CONCLUSIONS Most VHA patients with a history of depression received some suicide risk assessment within the past year, but suicide risk assessments were infrequently administered at the final visit of patients who eventually died by suicide. Among patients who had assessments, denial of suicidal ideation appeared to be of limited value. Practice changes are needed to improve suicide risk assessment among patients with histories of depression, including the development of assessment and prevention strategies that are less dependent on the presence or disclosure of suicidal ideation at scheduled medical visits.

Predictors of suicidal ideation among depressed veterans and the interpersonal theory of suicide

BACKGROUND We assessed whether key constructs of the interpersonal theory of suicide were associated with suicidal ideation in depressed US Veterans. METHODS 443 patients of the Veterans Health Administration diagnosed with a depressive disorder completed the Beck Depression Inventory, Interpersonal Support Evaluation List, and Beck Hopelessness Scale, from which we derived measures of burdensomeness, belongingness, and hopelessness consistent with the interpersonal theory of suicide. Measures of active and passive suicidal ideation were constructed from the Beck Suicide Scale and Beck Depression Inventory obtained at baseline and 3-months follow-up. Multivariable logistic regression was used to identify predictors of passive and active suicidal ideation while adjusting for demographic characteristics and somatic-affective symptoms of depression (e.g., anhedonia, insomnia). RESULTS Burdensomeness and hopelessness were significantly associated with passive suicidal ideation at baseline and 3 months follow-up, but belongingness and the interaction between belongingness and burdensomeness were not significant predictors as proposed by the interpersonal theory of suicide. Somatic-affective depressive symptoms, but not any of the main effects predicted by the interpersonal theory of suicide or their interactions, were associated with active suicidal ideation at baseline. No factors were consistently associated with active suicidal ideation at 3 months follow-up. LIMITATIONS The measure of burdensomeness used in this study only partially represents the construct described by the interpersonal theory of suicide. CONCLUSION We found little support for the predictions of the interpersonal theory of suicide. Hopelessness appears to be an important determinant of passive suicidal ideation, while somatic-affective depression symptoms may be a key contributor to active suicidal ideation.

Benzodiazepines and adequacy of initial antidepressant treatment for depression.

In short-term efficacy studies, coprescription of a benzodiazepine improves first-month adherence and response to antidepressant treatment. We used Veterans Health Administration data to examine the impact of coprescribed benzodiazepines on initial antidepressant adherence in routine clinical practice and the risks of long-term benzodiazepine use, abuse, and dependence. Our study population was 43,915 Veterans Health Administration patients diagnosed with depression and started on an antidepressant between October 2006 and September 2007. Using logistic regression, adjusting for demographic and clinical covariates, we predicted the likelihood that patients received antidepressant treatment for an adequate duration (90 days), with our primary independent variable of interest being receipt of a benzodiazepine on the same day as the start of the antidepressant. We also assessed the frequency and characteristics of patients whose benzodiazepine use persisted for 1 year or who were diagnosed with anxiolytic abuse or dependence after receiving combined treatment. The adjusted probability of receiving antidepressant treatment of adequate duration was 42.4% for patients who received a benzodiazepine with their initial antidepressant compared with 39.3% for patients initially treated with an antidepressant alone (P < 0.001). Among patients who received combined treatment, 14.1% subsequently used benzodiazepines for at least 1 year, and 0.7% were diagnosed with anxiolytic abuse or dependence. Anxiolytic abuse or dependence, but not long-term benzodiazepine use, was associated with other substance use disorders. These findings should be considered by clinicians when assessing the individual risks and benefits of combining a benzodiazepine with antidepressant treatment.

Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points.

The military community and its partners have made vigorous efforts to address treatment barriers and increase appropriate mental health services use among returning National Guard soldiers. We assessed whether there were differences in reports of treatment barriers in 3 categories (stigma, logistics, or negative beliefs about treatment) in sequential cross-sectional samples of U.S. soldiers from a Midwestern Army National Guard Organization who were returning from overseas deployments. Data were collected during 3 time periods: September 2007-August 2008 (n = 333), March 2009-March 2010 (n = 884), and August 2011-August 2012 (n = 737). In analyses using discretized time periods and in trend analyses, the percentages of soldiers endorsing negative beliefs about treatment declined significantly across the 3 sequential samples (19.1%, 13.9%, and 11.1%). The percentages endorsing stigma barriers (37.8%, 35.2%, 31.8%) decreased significantly only in trend analyses. Within the stigma category, endorsement of individual barriers regarding negative reactions to a soldier seeking treatment declined, but barriers related to concerns about career advancement did not. Negative treatment beliefs were associated with reduced services use (OR = 0.57; 95% CI [0.33, 0.97]).

Impact of Distance and Facility of Initial Diagnosis on Depression Treatment

OBJECTIVE To assess whether distance to services or diagnosis at a hospital-based medical center compared with a community clinic influences the receipt of psychotherapy versus pharmacotherapy for depression. DATA SOURCE Veterans Affairs (VA) administrative data for 132,329 depressed veterans between October 2003 and September 2004. STUDY DESIGN Multivariable logistic and multinomial regression models were used to examine the relationship between distance to the nearest mental health facility and the facility of initial depression diagnosis on receipt of any and adequate psychotherapy and/or pharmacotherapy, adjusted for patient characteristics. PRINCIPAL FINDINGS Compared with those living within 30 miles of the nearest mental health treatment facility, depressed patients living between 30 and 60 miles away had a decreased likelihood of receiving psychotherapy (OR=0.71; 95 percent CI: 0.66, 0.76) and a greater likelihood of receiving antidepressant treatment (OR=1.27; 95 percent CI: 1.22, 1.33). Initial diagnosis at a small community clinic compared with a VA medical center was not associated with a difference in receipt of any psychotherapy (OR=0.95; 95 percent CI: 0.83, 1.09), but it was associated with decreased likelihood of receiving eight or more psychotherapy visits (OR=0.46; 95 percent CI: 0.35, 0.61) or any antidepressant treatment (OR=0.69; 95 percent CI: 0.63, 0.75). CONCLUSIONS The VA and similar health systems should make efforts to insure adequate psychotherapy is provided to patients who initiate treatment at small community clinics and provide psychotherapy alternatives that may be less sensitive to travel barriers for patients living remote distances from mental health treatment. Extending services to small community clinics that support antidepressant treatment should also be considered.