Ranak Trivedi

Worsening Depressive Symptoms Are Associated With Adverse Clinical Outcomes in Patients With Heart Failure

OBJECTIVES The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients. BACKGROUND Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes. METHODS One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up). RESULTS The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro-B-type natriuretic peptide level, and prior hospitalizations. CONCLUSIONS Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

Brief psychotherapy for depression: a systematic review and meta-analysis

Objective: Because evidence-based psychotherapies of 12 to 20 sessions can be perceived as too lengthy and time intensive for the treatment of depression in primary care, a number of studies have examined abbreviated psychotherapy protocols. The purpose of this study was to conduct a systematic review and meta-analysis to determine the efficacy of brief psychotherapy (i.e., < 8 sessions) for depression. Methods: We used combined literature searches in PubMed, EMBASE, PsycINFO, and an Internet-accessible database of clinical trials of psychotherapy to conduct two systematic searches: one for existing systematic reviews and another for randomized controlled trials (RCTs). Included studies examined evidence-based psychotherapy(s) of eight or fewer sessions, focused on adults with depression, contained an acceptable control condition, were published in English, and used validated measures of depressive symptoms. Results: We retained 2 systematic reviews and 15 RCTs evaluating cognitive behavioral therapy, problem-solving therapy, and mindfulness-based cognitive therapy. The systematic reviews found brief psychotherapies to be more efficacious than control, with effect sizes ranging from −0.33 to −0.25. Our meta-analysis found six to eight sessions of cognitive behavioral therapy to be more efficacious than control (ES −0.42, 95% CI −0.74 to −0.10, I2 = 56%). A sensitivity analysis controlled for statistical heterogeneity but showed smaller treatment effects (ES −0.24, 95% CI −0.42 to −0.06, I2 = 0%). Conclusions: Depression can be efficaciously treated with six to eight sessions of psychotherapy, particularly cognitive behavioral therapy and problem-solving therapy. Access to non-pharmacologic treatments for depression could be improved by training healthcare providers to deliver brief psychotherapies.

The Influence of Informal Caregivers on Adherence in COPD Patients

BackgroundContributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.PurposeThis study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.MethodsThree hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.ResultsCompared with the “no caregiver” group, antihypertensive medications adherence was higher in the “spousal caregiver” (0.68 vs. 0.81; 95 % CI = 0.04 and 0.22) and “non-spousal caregiver” (0.68 vs. 0.80; 95 % CI = 0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the “spousal caregiver” group (0.60 vs.0.80; 95 % CI = 0.05 and 0.43). Patients in the “spousal caregiver” group had fewer current smokers compared with the “no caregiver” (χ2 = 16.08; p < 0.001) and “non-spousal caregiver” (χ2 = 5.07; p < 0.05) groups; those in the “non-spousal caregiver” group reported fewer smokers than the “no caregiver” group (χ2 = 4.54; p < 0.05).ConclusionsCaregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

Genetic and Environmental Influences on Anger Expression, John Henryism, and Stressful Life Events: The Georgia Cardiovascular Twin Study

Objective: To examine the genetic and/or environmental origin of variation and covariation of perceived stressful life events and two stress-related coping styles, anger expression and John Henryism. Methods: Data were available from 306 European American (EA) and 213 African American (AA) twin pairs, including monozygotic and dizygotic of same as well as opposite sex (mean age, 14.8 ± 3.1 years; range, 10.0–25.9 years). Anger expression, John Henryism, and life events were measured with the Anger Expression Scale (subscales: Anger-in, Anger-out, and Anger-control), the John Henryism Active Coping Scale, and the Adolescent Resources Challenges Scale, respectively. Results: Model fitting showed no ethnic or sex differences for any of the scales. All traits showed at least some degree of familial resemblance, best explained by shared environment for Anger-in (18%), heritability for Anger-control (34%), John Henryism (34%), and life events (47%), and a combination of heritability (14% and 15%) and shared environment (10% and 20%) for Anger-out and overall anger expression, respectively. The remaining part of the variation for all traits was explained by environmental influences that are unique to the individual. Anger expression and life events were correlated (r = 0.28), and bivariate genetic modeling showed that 61% of this correlation was mediated by common genetic factors. Conclusions: Individual differences in coping styles and life events in youth can be explained by moderate genetic and substantial environmental influences, of which most are idiosyncratic to the individual. The association between anger expression and life events is largely the result of common genes. AA = African American; A = additive genetic component; AIC = Akaike’s information criterion; ARCS = Adolescent Resources Challenges Scale; C = common environmental component; CVD = cardiovascular disease; D = dominant genetic component; DZ = dizygotic; E = unique environmental component; EA = European American; MZ = monozygotic.

A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial

Background Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers’ needs for information about the patient’s status or how the caregiver can help. Objective We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach. Methods We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a “CarePartner” outside their household. Patients randomized to “standard mHealth” (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients’ responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to “mHealth+CP” (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments. Results Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls. Conclusions Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’ medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys. Trial Registration ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).

Prevalence, comorbidity, and prognosis of mental health among US veterans

OBJECTIVES We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI). METHODS A total of 4 461 208 veterans were seen in the Veterans Health Administrations patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement. RESULTS A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes. CONCLUSIONS Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.

Coping styles in heart failure patients with depressive symptoms

OBJECTIVE Elevated depressive symptoms have been linked to poorer prognosis in heart failure (HF) patients. Our objective was to identify coping styles associated with depressive symptoms in HF patients. METHODS A total of 222 stable HF patients (32.75% female, 45.4% non-Hispanic black) completed multiple questionnaires. Beck Depression Inventory (BDI) assessed depressive symptoms, Life Orientation Test (LOT-R) assessed optimism, ENRICHD Social Support Inventory (ESSI) and Perceived Social Support Scale (PSSS) assessed social support, and COPE assessed coping styles. Linear regression analyses were employed to assess the association of coping styles with continuous BDI scores. Logistic regression analyses were performed using BDI scores dichotomized into BDI<10 vs. BDI> or =10, to identify coping styles accompanying clinically significant depressive symptoms. RESULTS In linear regression models, higher BDI scores were associated with lower scores on the acceptance (beta=-.14), humor (beta=-.15), planning (beta=-.15), and emotional support (beta=-.14) subscales of the COPE, and higher scores on the behavioral disengagement (beta=.41), denial (beta=.33), venting (beta=.25), and mental disengagement (beta=.22) subscales. Higher PSSS and ESSI scores were associated with lower BDI scores (beta=-.32 and -.25, respectively). Higher LOT-R scores were associated with higher BDI scores (beta=.39, P<.001). In logistical regression models, BDI> or =10 was associated with greater likelihood of behavioral disengagement (OR=1.3), denial (OR=1.2), mental disengagement (OR=1.3), venting (OR=1.2), and pessimism (OR=1.2), and lower perceived social support measured by PSSS (OR=.92) and ESSI (OR=.92). CONCLUSION Depressive symptoms in HF patients are associated with avoidant coping, lower perceived social support, and pessimism. Results raise the possibility that interventions designed to improve coping may reduce depressive symptoms.

Diabetes self-management support using mHealth and enhanced informal caregiving

OBJECTIVE To characterize diabetes patient engagement and clinician notifications for an mHealth interactive voice response (IVR) service. DESIGN Observational study. METHODS For three to six months, VA patients with diabetes received weekly IVR calls assessing health status and self-care along with tailored education. Patients could enroll with an informal caregiver who received suggestions on self-management support. Notifications were issued to clinicians when patients reported significant problems. RESULTS Patients (n = 303) participated for a total of 5684 patient-weeks, during which 84% of calls were completed. The odds of call completion decreased over time (AOR = 0.96, p < 0.001), and were lower among unmarried patients (AOR = 0.67, p = 0.038) and those who had difficulties with health literacy (AOR = 0.67, p = 0.039), diabetes-related distress (AOR = 0.30, p = 0.018), or medication nonadherence (AOR = 0.57, p = 0.002). Twenty-one clinician notifications were triggered per 100 patient-weeks. The odds of notification were higher during the early weeks of the program (AOR = 0.95, p < 0.001) and among patients who were older (AOR = 1.03, p = 0.004) or more physically impaired (AOR = 0.97, p < 0.001). CONCLUSIONS By providing information that is reliable, valid, and actionable, IVR-based mHealth services may increase access to between-visit monitoring and diabetes self-management support. The system detects abnormal glycemia and blood pressure levels that might otherwise go unreported, although thresholds for clinician notifications might require adjustment to avoid overloading clinicians. Patient engagement might be enhanced by addressing health literacy and psychological distress.

Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway?

BACKGROUND AND OBJECTIVES There is growing interest in efforts to enhance advance care planning for patients with kidney disease. Our goal was to elicit the perspectives on advance care planning of multidisciplinary providers who care for patients with advanced kidney disease. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between April and December of 2014, we conducted semistructured interviews at the Department of Veterans Affairs Puget Sound Health Care System with 26 providers from a range of disciplines and specialties who care for patients with advanced kidney disease. Participants were asked about their perspectives and experiences related to advance care planning in this population. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory. RESULTS The comments of providers interviewed for this study spoke to significant system-level barriers to supporting the process of advance care planning for patients with advanced kidney disease. We identified four overlapping themes: (1) medical care for this population is complex and fragmented across settings and providers and over time; (2) lack of a shared understanding and vision of advance care planning and its relationship with other aspects of care, such as dialysis decision making; (3) unclear locus of responsibility and authority for advance care planning; and (4) lack of active collaboration and communication around advance care planning among different providers caring for the same patients. CONCLUSIONS The comments of providers who care for patients with advanced kidney disease spotlight both the need for and the challenges to interdisciplinary collaboration around advance care planning for this population. Systematic efforts at a variety of organizational levels will likely be needed to support teamwork around advance care planning among the different providers who care for patients with advanced kidney disease.

Examining the interrelatedness of patient and spousal stress in heart failure: Conceptual model and pilot data

Background and Research Objective:Recent research has highlighted the positive influence that spouses can have on patient outcomes. It is not clear whether patients and spouses influence each other’s well-being reciprocally or whether spousal well-being affects the success of patients’ disease management. Our goals were 2-fold: (a) to propose a conceptual framework to examine the reciprocity between patient and spouses’ well-being, especially as it relates to disease management, and (b) to begin to assess the validity of this model using pilot data. Subjects and Methods:Twenty-three veterans with heart failure (HF) and their spouses were recruited into a pilot cross-sectional observational study. Participants completed psychosocial surveys to assess depressive symptoms, caregiver burden, relationship satisfaction, and disease management. Descriptive analyses and bivariate correlations between these measures were calculated. Results:Using standard cutoffs, analyses suggested clinically significant depressive symptoms in patients (Center for Epidemiological Studies–Depression score >16; mean, 21.8 [SD, 13]) and a high level of caregiver burden among spouses (Zarit Burden Interview score >15; mean, 22.4 [SD, 15.4]). Both patients and spouses reported high relationship satisfaction levels (Dyadic Adjustment Scale score >100; mean, 112.6 [SD, 26.5] and 115.9 [SD, 14.4], respectively). On average, patients reported poor disease management (Self-care of Heart Failure Index subscale <70 across all subscales: confidence = 53.3 [SD, 28.2]; maintenance = 59.7 [SD, 17.3]; management = 54.0 [SD, 19.4]). Patient depressive symptoms were positively correlated with spouse depressive symptoms (r = 0.53) and caregiver burden (r = 0.64; all P’s < .05). Spouses’ depressive symptoms were additionally correlated with lower levels of perceived social support among patients (r = −0.47), poor patient relationship satisfaction (r = −0.51), and worse patient confidence in HF management (r = −0.48). Greater caregiver burden was associated with more patient disease complaints (r = 0.49), poorer patients’ relationship satisfaction (r = −0.72), and poorer patients’ perceived social support (r = −0.73). Conclusions:These results provide preliminary support to the proposed conceptual model. Further research is necessary to determine which spousal factors appear to be most relevant to disease management. Disease management interventions may benefit from engaging spouses in a way that enhances their role without adding to their burden.