Scott R. Beach

Financial Exploitation and Psychological Mistreatment Among Older Adults: Differences Between African Americans and Non-African Americans in a Population-Based Survey

PURPOSE to examine racial differences in (a) the prevalence of financial exploitation and psychological mistreatment since turning 60 and in the past 6 months and (b) the experience-perpetrator, frequency, and degree of upset-of psychological mistreatment in the past 6 months. DESIGN AND METHODS random digit dial telephone recruitment and population-based survey (telephone and in-person) of 903 adults aged 60 years and older in Allegheny County (Pittsburgh), Pennsylvania (693 non-African American and 210 African American). Covariates included sex, age, education, marital status, household composition, cognitive function, instrumental activities of daily living/activities of daily living difficulties, and depression symptoms. RESULTS prevalence rates were significantly higher for African Americans than for non-African Americans for financial exploitation since turning 60 (23.0% vs. 8.4%) and in the past 6 months (12.9% vs. 2.4%) and for psychological mistreatment since turning 60 (24.4% vs. 13.2%) and in the past 6 months (16.1% vs. 7.2%). These differences remained once all covariates were controlled in logistic regression models. There were also racial differences in the experience of psychological mistreatment in the past 6 months. Risk for clinical depression was also a consistent predictor of financial exploitation and psychological mistreatment. IMPLICATIONS although the results will need to be replicated in national surveys, the study suggests that racial differences in elder mistreatment are a potentially serious issue deserving of continued attention from researchers, health providers, and social service professionals.

Negative and positive health effects of caring for a disabled spouse : Longitudinal findings from the Caregiver Health Effects Study

Data from the first 2 waves of the Caregiver Health Effects Study (n = 680) were analyzed to examine the effects of changes in caregiving involvement on changes in caregiver health-related outcomes in a population-based sample of elders caring for a disabled spouse. Caregiving involvement was indexed by levels of (a) spouse physical impairment, (b) help provided to the spouse, and (c) strain associated with providing help. Health-related outcomes included perceived health, health-risk behaviors, anxiety symptoms, and depression symptoms. Increases in spouse impairment and caregiver strain were generally related to poorer outcomes over time (poorer perceived health, increased health-risk behaviors, and increased anxiety and depression), whereas increased helping was related to better outcomes (decreased anxiety and depression). Results suggest that caring for a disabled spouse is a complex phenomenon that can have both deleterious and beneficial consequences.

Exposure effects in the classroom: The development of affinity among students

Abstract Affinity is a complex blend of familiarity, attraction, and similarity that strengthens social relations by fostering a sense of closeness among people. We studied the development of affinity among students in a large college course. Four women of similar appearance attended class sessions, posing as students in the course. To create conditions of mere exposure, they did not interact with any of the other students. Each woman attended a different number (0, 5, 10, or 15) of class sessions. At the end of the term, students ( N = 130) were shown slides of the women and measures of each womans perceived familiarity, attractiveness, and similarity were obtained. Mere exposure had weak effects on familiarity, but strong effects on attraction and similarity. Causal analyses indicated that the effects of exposure on familiarity and similarity were mediated by its effects on atrraction. The potential role of affinity in several kinds of social relations is discussed.

QTc Prolongation, Torsades de Pointes, and Psychotropic Medications

BACKGROUND Prolongation of the corrected QT (QTc) interval is a key issue for patients who receive psychotropic medications. Such patients may have baseline clinical risk factors for QTc prolongation, and many psychotropic medications may further prolong this interval. This has great clinical relevance, as QTc prolongation is linked with dangerous arrhythmias, especially torsades de pointes (TdP). METHODS We summarize current literature regarding appropriate methods of calculating the QTc interval, the association of the QTc interval with TdP, and risk factors for QTc prolongation. We then review connections between psychiatric medications and QTc prolongation, with a specific focus on antidepressants and antipsychotics. RESULTS QTc interval prolongation is an established, though imperfect, risk marker for TdP. There are no well-controlled studies that assess the risk of TdP associated with psychotropic agents. There are limited data that selective serotonin reuptake inhibitors (SSRIs) as a class are linked to QTc prolongation; citalopram appears more likely than others to induce this phenomenon. Among antipsychotics, thioridazine remains the agent most associated with QTc prolongation; intravenous haloperidol also appears to carry an increased risk. Of the atypical antipsychotics, ziprasidone appears most likely to prolong the QTc interval. CONCLUSIONS The majority of patients in need of psychotropic medications display few risk factors for QTc prolongation and should be considered to be at low risk for TdP. The frequency of cardiac monitoring for patients receiving psychiatric medications should be individually determined, based on the prescribed agent(s) and additional risk factors for TdP.

Depression and Cardiac Disease: Epidemiology, Mechanisms, and Diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

Collaborative Care for Depression and Anxiety Disorders in Patients With Recent Cardiac Events The Management of Sadness and Anxiety in Cardiology (MOSAIC) Randomized Clinical Trial

IMPORTANCE Depression and anxiety are associated with adverse cardiovascular outcomes in patients with recent acute cardiac events. There has been minimal study of collaborative care (CC) management models for mental health disorders in high-risk cardiac inpatients, and no prior CC intervention has simultaneously managed depression and anxiety disorders. OBJECTIVE To determine the impact of a low-intensity CC intervention for depression, generalized anxiety disorder, and panic disorder among patients hospitalized for an acute cardiac illness. DESIGN, SETTING, AND PARTICIPANTS Single-blind randomized clinical trial, with study assessors blind to group assignment, from September 2010 through July 2013 of 183 patients admitted to inpatient cardiac units in an urban academic general hospital for acute coronary syndrome, arrhythmia, or heart failure and found to have clinical depression, generalized anxiety disorder, or panic disorder on structured assessment. INTERVENTIONS Participants were randomized to 24 weeks of a low-intensity telephone-based multicomponent CC intervention targeting depression and anxiety disorders (n = 92) or to enhanced usual care (serial notification of primary medical providers; n = 91). The CC intervention used a social work care manager to coordinate assessment and stepped care of psychiatric conditions and to provide support and therapeutic interventions as appropriate. MAIN OUTCOMES AND MEASURES Improvement in mental health-related quality of life (Short Form-12 Mental Component Score [SF-12 MCS]) at 24 weeks, compared between groups using a random-effects model in an intent-to-treat analysis. RESULTS Patients randomized to CC had significantly greater estimated mean improvements in SF-12 MCS at 24 weeks (11.21 points [from 34.21 to 45.42] in the CC group vs 5.53 points [from 36.30 to 41.83] in the control group; estimated mean difference, 5.68 points [95% CI, 2.14-9.22]; P = .002; effect size, 0.61). Patients receiving CC also had significant improvements in depressive symptoms and general functioning, and higher rates of treatment of a mental health disorder; anxiety scores, rates of disorder response, and adherence did not differ between groups. CONCLUSIONS AND RELEVANCE A novel telephone-based, low-intensity model to concurrently manage cardiac patients with depression and/or anxiety disorders was effective for improving mental health-related quality of life in a 24-week trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01201967.

Dementia patient suffering and caregiver depression.

Cross-sectional and longitudinal analyses were carried out to assess the relationship between dementia patient suffering, caregiver depression, and antidepressant medication use in 1222 dementia patients and their caregivers. We assessed the prevalence of 2 types of patient suffering, emotional and existential distress, and examined their independent associations with caregiver depression and antidepressant medication use when controlling for sociodemographic characteristics of caregivers and patients, cognitive and physical disability of the patient, the frequency of patient memory problems and disruptive behaviors, and the amount of time spent caring for the patient. Multiple linear regression models showed that both aspects of perceived patient suffering independently contribute to caregiver depression (emotional distress: β=1.24; P<0.001; existential distress: β=0.66; P<0.01) whereas only existential suffering contributes to antidepressant medication use: odds ratio=1.25 95% confidence interval, 1.10-1.42; P<0.01. In longitudinal analyses, increases in both types of suffering were associated with increases in caregiver depression (emotional distress: β=1.02; P<0.01; existential distress: β=0.64; P<0.01). This is the first study to show in a large sample that perceived patient suffering independently contributes to family caregiver depression and medication use. Medical treatment of patients that maintain or improve memory but do not address suffering may have little impact on the caregiver. Alzheimer disease patient suffering should be systematically assessed and treated by clinicians.

Effects of Depression and Anxiety Improvement on Adherence to Medication and Health Behaviors in Recently Hospitalized Cardiac Patients

Impaired adherence to medications and health behaviors may mediate the connection between psychiatric symptoms and mortality in cardiac patients. This study assessed the association between improvements in depression/anxiety and self-reported adherence to health behaviors in depressed cardiac patients in the 6 months after cardiac hospitalization. Data were analyzed from depressed patients on inpatient cardiac units who were hospitalized for acute coronary syndrome, heart failure, or arrhythmia and enrolled in a randomized trial of collaborative care depression management (n = 134 in primary analysis). Measurements of depression (Patient Health Questionnaire-9), anxiety (Hospital Anxiety and Depression Scale, Anxiety subscale), and adherence to secondary prevention behaviors (Medical Outcomes Study-Specific Adherence Scale items) were obtained at baseline, 6 weeks 12 weeks, and 6 months. The association between improvement in depression/anxiety and adherence was assessed by linear regression after accounting for the effects of multiple relevant covariates. At all time points improvement in the Patient Health Questionnaire-9 was significantly and independently associated with self-reported adherence to medications and secondary prevention behaviors. In contrast, improvement in the Hospital Anxiety and Depression Scale, Anxiety subscale was associated with improved adherence only at 6 weeks. In conclusion, in a cohort of depressed cardiac patients, improvement in depression was consistently and independently associated with superior self-reported adherence to medications and secondary prevention behaviors across a 6-month span, whereas improvement in anxiety was not.

Meta-Analysis of Selective Serotonin Reuptake Inhibitor–Associated QTc Prolongation

OBJECTIVE To evaluate the association between selective serotonin reuptake inhibitors (SSRIs) and corrected QT interval (QTc) prolongation via meta-analysis of prospective studies. DATA SOURCES PubMed/MEDLINE database (January 1, 1975-August 15, 2012), with additional reports identified using hand searches of reference lists of relevant articles. Key words searched were QT, torsades de pointes, and sudden cardiac death, combined with antidepressants, citalopram, escitalopram, fluoxetine, sertraline, paroxetine, and fluvoxamine. English-, Spanish-, and German-language articles were included. STUDY SELECTION Two reviewers independently identified prospective controlled studies in adults that reported data related to QTc intervals prior to and following treatment with SSRIs. DATA EXTRACTION AND SYNTHESIS Three reviewers independently extracted study-level data including population characteristics, method of QTc measurement and treatment and outcome data. Two independent reviewers critiqued study quality. Publication bias was assessed visually using a funnel plot and quantitatively. Heterogeneity was measured using Cochran Q statistic. RESULTS Sixteen articles (with 25 distinct data subsets) involving 4,292 patients were included. SSRIs were associated with a dose-dependent increase in QTc interval compared to placebo (+6.10 milliseconds; 95% CI, 3.47-8.73; P < .001). Tricyclic antidepressants (TCAs) were associated with a significantly greater QTc increase than SSRIs (TCA prolongation, 7.05 milliseconds; 95% CI, 3.84-10.27 greater than SSRIs; P < .001). With respect to specific SSRI agents, citalopram was associated with significantly greater QTc prolongation than sertraline, paroxetine, and fluvoxamine. CONCLUSIONS SSRIs were associated with a modest but statistically significant increase in the QTc interval, although to a lesser extent than TCAs; this finding was not limited to any single study. Citalopram was associated with more QTc prolongation than most other SSRIs.

Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions.

BACKGROUND Intervention research at the intersection of psychiatry and cardiology has primarily focused on the relationship between negative psychological syndromes (e.g., depression) and cardiac outcomes, with less emphasis on positive psychological attributes, such as optimism, gratitude, and well-being, as they relate to cardiac disease. METHODS Literature is reviewed in three specific areas regarding positive attributes and cardiac disease: (1) associations between positive attributes and cardiac outcomes, (2) potential mechanisms-both behavioral and physiologic-by which positive psychological states may impact cardiovascular health, and (3) interventions aimed at cultivating positive psychological attributes in healthy and medically ill persons. RESULTS There is significant evidence that positive psychological attributes--especially optimism--may be independently associated with superior cardiac outcomes. Positive attributes appear to be associated with increased participation in cardiac health behaviors (e.g., healthy eating, physical activity) linked to beneficial outcomes; data linking positive psychological states and biomarkers of cardiac health (e.g., inflammatory markers) is mixed but suggests a potential association. Positive psychological interventions have consistently been associated with improved well-being and reduced depressive symptoms, though there have been few such studies in the medically ill. CONCLUSIONS These findings regarding the relationship between positive psychological attributes and cardiac health are promising and suggest that positive psychology interventions may be worth study in this population. However, questions remain about the strength and specificity of these relationships, the most salient positive psychological attributes, and the impact of positive psychological interventions on health outcomes in cardiac patients.