Sanjeev Sockalingam

Managing Depression During Hepatitis C Treatment

Objective: The prevalence of hepatitis C virus (HCV) infection in Canada is estimated to be 1% and expected to increase during the next decade. Mental illness, particularly depression, is common among HCV-infected patients and remains an obstacle to interferon-alpha (IFN-α) treatment. We summarize the risk factors for interferon-α–induced major depressive disorder (IFN-α–MDD) in HCV patients and the evidence for antidepressant prophylaxis and symptomatic antidepressant treatment of depression. Methods: We searched MEDLINE, EMBASE, and CINAHL for randomized controlled or quasi-experimental trials evaluating antidepressant prophylactic and symptomatic treatment approaches for depression emerging during IFN-α treatment. Manual searches of references listed in review articles, case series, and anecdotal reports supplemented our literature search. Results: A total of 9 trials involving prophylactic and symptomatic treatment approaches for IFN-α–MDD are summarized in our review. Antidepressant pretreatment is beneficial for patients with elevated baseline depressive symptoms and a preexisting history of IFN-α–MDD. Although limited evidence exists for several antidepressant agents, much of the evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are safe and efficacious in treating depressive symptoms secondary to IFN-α therapy. Conclusion: Both antidepressant pretreatment and symptomatic treatment are viable strategies for treating IFN-α–MDD. Improved treatment outcomes and early identification of depression during HCV treatment can be achieved using an integrated medical and mental health treatment approach.

Clozapine-induced hypersalivation : A review of treatment strategies

Objective: Clozapine-induced hypersalivation (CIH) is a significant side effect affecting about one-third of patients treated with clozapine. CIH can be stigmatizing, can affect quality of life, and can result in discontinuation of clozapine treatment. The purpose of this review is to provide an understanding of CIH, specifically, its pathophysiology, measurement, and the evidence for CIH treatment alternatives. Methods: We searched MEDLINE from 1980 to June 2006 for all reported pharmacologic treatment studies related to CIH. We identified additional references by a manual search of the bibliographies of retrieved articles. Results: Several studies reported improvement of CIH with both selective and nonselective anticholinergic medications. However, with the exception of local anticholinergic agents such as ipratropium bromide and atropine eye drops, potential systemic adverse effects limit the effectiveness of this class of medications. Open-label studies of clonidine, an alpha2 antagonist, suggest that it may be beneficial in managing CIH. Other pharmacologic treatments, such as amisulpride and botulinum toxin, may be useful in refractory CIH cases. Conclusion: Although few randomized controlled trials were found in the literature, this review highlights potential treatment alternatives for this common and disabling cause of hypersalivation. Prompt and effective treatment of CIH may assist with treatment tolerability, adherence, and outcomes in patients with treatment-refractory schizophrenia.

Psychometric properties of the Patient Health Questionnaire (PHQ-9) as a depression screening tool for bariatric surgery candidates.

BACKGROUND Major depressive disorder has been shown in some studies to attenuate weight loss and psychosocial outcomes following surgery. Given the potential implications of depression on surgery outcomes, presurgery psychiatric assessment is recommended to assess suitability for bariatric surgery. OBJECTIVES The purpose of this study was to examine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) in detecting depression in bariatric surgery candidates. METHODS Bariatric surgery candidates (n = 244) completed the PHQ-9 and the Mini International Neuropsychiatric Interview (MINI) as part of their presurgery psychiatric assessment. The operating characteristics of the PHQ-9 were examined. The study was replicated in an independent sample of bariatric surgery candidates (n = 275). RESULTS Rates of current and lifetime major depressive episodes were 1.6% to 3.8% and 33.8% to 35.5%, respectively, as assessed by the MINI. According to the PHQ-9, 52.5% to 54.9% of patients exceeded the cutoff for moderate depression (PHQ-9 ≥ 10), and 27.6% to 29.1% for moderate severe depression (PHQ-9 ≥ 15). The optimal dichotomization cutoff point on the PHQ-9 was ≥15 in both studies (sensitivity 75%, specificity 75% to 76%). CONCLUSIONS Our results suggest that the PHQ-9 has adequate operating characteristics compared with a criterion standard measure. A PHQ-9 cutoff of 15 is recommended to identify bariatric surgery candidates who may require further assessment of depressive symptoms.

A Review of Sleep Disturbance in Hepatitis C

Sleep disturbances occur in up to 60% of patients with chronic hepatitis C (CHC) and is often interrelated with comorbid psychiatric disorders. Moreover, neuropsychiatric complications of interferon-α during CHC treatment can manifest as sleep problems. Newly diagnosed sleep disturbance occurs in up to 60% and 30% of untreated CHC patients and patients undergoing interferon-α therapy, respectively. However, the presentation of insomnia in patients with CHC is influenced by significant psychiatric comorbidity, such as depression, and medical conditions, such as anemia and hypothyroidism. Therefore, prompt recognition using screening tools and exclusion of comorbid conditions contributing sleep pathology can enhance treatment outcomes. Owing to the paucity of studies, treatment recommendations for sleep disorders in CHC patients are derived from recommendations from general sleep disorder treatment guidelines. Further research is needed to elucidate the efficacy of pharmacological and nonpharmacological treatments of sleep disorders in CHC patients.

Interprofessional education for delirium care: a systematic review

Abstract Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick’s evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates post-intervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.

Review of awakening agents

Brain injuries are a serious burden of illness to Canada and the US. Advances in managing head trauma have allowed more patients to emerge from decreased levels of consciousness and helped them cope with neurocognitive, neurobehavioural, and neuropsychiatric deficits. In this article, we review the current (1986-2002) evidence surrounding the pharmacological management of arousal states and the aforementioned neurological sequelae of head injury in either acute or chronic conditions. This article will review the evidence for the use of psychostimulants (methylphenidate), antidepressants (amitriptyline, selective serotonin reuptake inhibitors, and buproprion), Parkinsons medications (amantadine, bromocriptine, carbidopa/levodopa), anticonvulsants (valproic acid), modafinil (Provigil), lactate, hyperbaric oxygen chamber, electroconvulsive therapy, and transmagnetic stimulation, in patients following a head injury. The review did not include all anticonvulsants, neuroleptics, beta-blockers, benzodiazepines, azospirones or cognitive enhancers. Unfortunately, the quality of the evidence is generally poor, and sometimes conflicting, which in turn results in indecisive guidelines for treating patients. Accepting the inherent flaws in the evidence we feel that this paper may serve as a stepping-stone for future researchers to improve data gathering that targets neurocognitive, neurobehavioural and neuropsychiatric symptoms following a head injury.

Body contouring surgery after bariatric surgery: a study of cost as a barrier and impact on psychological well-being.

Background: Body-contouring surgery can be a solution to excess skin folds following bariatric surgery. Many patients desire body-contouring surgery, but the cost of the procedure may be a limiting factor. This study aims to examine barriers to access and to compare socioeconomic variables and psychological variables between bariatric surgery patients who have undergone body contouring and those who have not. Methods: In this cross-sectional study, a questionnaire packet was administered to (1) patients who underwent bariatric but not body-contouring surgery and (2) patients who underwent both. The questionnaire included perceived barriers to body-contouring surgery, socioeconomic barriers, measures of anxiety (Generalized Anxiety Disorder seven-item scale), depression (Patient Health Questionnaire nine-item scale), and quality of life (Short Form-36). Results: Among the 58 study participants, 93.1 percent reported having excess skin folds. Of this sample, 95.4 percent desired body-contouring surgery, and the majority (87.8 percent) of this subsample identified cost as the major barrier to access. Mean scores on the Generalized Anxiety Disorder scale (6.08 ± 5.97 versus 3.50 ± 3.10; p = 0.030) and the Patient Health Questionnaire (6.40 ± 6.77 versus 2.40 ± 2.37; p = 0.002) were significantly higher for the bariatric surgery group versus bariatric surgery plus body contouring group. Patients in the latter group had significantly higher Short Form-36 physical health component scores (56.80 ± 4.88 versus 49.57 ± 8.25; p = 0.010). Conclusions: Bariatric surgery patients who desire body-contouring surgery perceive cost as a major barrier. Patients undergoing body-contouring surgery may experience improved physical quality of life but not mental quality of life; however, body-contouring surgery may improve aspects of depression and anxiety.

Identifying opportunities to improve management of autoimmune hepatitis: Evaluation of drug adherence and psychosocial factors

BACKGROUND & AIMS Recognizing the importance of adherence to therapy in autoimmune hepatitis (AIH) is critical for patient care and avoidance of unnecessary intervention. The influence of psychosocial factors on treatment adherence needs better understanding and prominence. We sought to determine the association between anxiety, depressive symptoms, and avoidant relationship style on self-reported immunosuppressant medication adherence and treatment response in patients with AIH. METHODS Fifty two patients with AIH were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Experiences in Close Relationship Scale (ECR) and a visual analogue scale to measure self-reported adherence. Laboratory markers of adherence and immunosuppressant treatment response were recorded. Chi-square Fishers exact or Wilcox rank sum tests were used for comparison between groups. RESULTS Treatment responders compared to non-responders were older (p=0.035), had normal or mild score ranges for anxiety and depression (p=0.025) and were significantly more likely to report >80% treatment adherence (p=0.007). Non-responders had higher anxiety symptoms (p=0.025), and significantly higher ECR-avoidance scores (p=0.023), suggestive of a tendency towards a more avoidant relationship style. CONCLUSIONS We formally document that patients with AIH who have higher depressive and anxiety symptoms and avoidant relationship styles are more likely to be non-adherent to AIH therapy. We reiterate the need for early recognition and treatment of anxiety and depression in patients with AIH, stress the need for treatment adherence and highlight the need for formal evaluation of these factors in trials of therapy targeting apparent treatment non-responders.

Understanding real-world adherence in the directly acting antiviral era: A prospective evaluation of adherence among people with a history of drug use at a community-based program in Toronto, Canada

BACKGROUND Direct acting antiviral (DAA) treatments for Hepatitis C (HCV) are now widely available with sustained virologic response (SVR) rates of >90%. A major predictor of response to DAAs is adherence, yet few real-world studies evaluating adherence among marginalized people who use drugs and/or alcohol exist. This study evaluates patterns and factors associated with non-adherence among marginalized people with a history of drug use who were receiving care through a primary care, community-based HCV treatment program where opiate substitution is not offered on-site. METHODS Prospective evaluation of chronic HCV patients initiating DAA treatment. Self-report medication adherence questionnaires were completed weekly. Pre/post treatment questionnaires examined socio-demographics, program engagement and substance use. Missing adherence data was counted as a missed dose. RESULTS Of the 74 participants, who initiated treatment, 76% were male, the average age was 54 years, 69% reported income from disability benefits, 30% did not have stable housing and only 24% received opiate substitution therapy. Substance use was common in the month prior to treatment initiation with, 11% reported injection drug use, 30% reported non-injection drug use and 18% moderate to heavy alcohol use. The majority (85%) were treatment naïve, with 76% receiving sofosbuvir/ledipasvir (8-24 weeks) and 22% Sofosbuvir/Ribarvin (12-24 weeks). The intention to treat proportion with SVR12 was 87% (60/69). In a modified ITT analysis (excluding those with undetectable RNA at end of treatment), 91% (60/66) achieved SVR12. Overall, 89% of treatment weeks had no missed doses. 41% of participants had at least one missed dose. In multivariate analysis the only factor independently associated with weeks with missed doses was moderate to heavy alcohol use (p=0.05). CONCLUSION This study demonstrates that strong adherence and SVR with DAAs is achievable, with appropriate supports, even in the context of substance use, and complex health/social issues.

Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation.

Binge eating has a high prevalence among bariatric patients and is associated with post-surgical weight gain. This study examined the potential mediating role of emotion regulation difficulties in the relation between attachment insecurity and binge eating among this population. Participants were 1388 adult pre-bariatric surgery candidates from an accredited bariatric surgery assessment centre in Toronto, Ontario. Participants completed measures of psychological functioning, including attachment style and emotion regulation. Mediation analyses revealed that difficulties with emotion regulation mediated a positive association between insecure-anxious attachment and binge eating. An insecure-avoidant attachment was found to have a non-significant association with binge eating when examining the total effect. However, when difficulties with emotion regulation were controlled for in the model to examine its role as a mediator, this association became significant, and emotion regulation difficulties also mediated the relationship between attachment avoidance and binge eating. These findings suggest that difficulties in emotion regulation may be an important clinical issue to address in order to reduce binge eating in adult bariatric surgery candidates.