Shanti P. Tripathi

Differential functional connectivity within an emotion regulation neural network among individuals resilient and susceptible to the depressogenic effects of early life stress

BACKGROUND Early life stress (ELS) is a significant risk factor for depression. The effects of ELS exposure on neural network organization have not been differentiated from the effect of depression. Furthermore, many individuals exposed to ELS do not develop depression, yet the network organization patterns differentiating resiliency versus susceptibility to the depressogenic effects of ELS are not clear. METHOD Women aged 18-44 years with either a history of ELS and no history of depression (n = 7), a history of ELS and current or past depression (n = 19), or a history of neither ELS nor depression (n = 12) underwent a resting-state 3-T functional magnetic resonance imaging (fMRI) scan. An emotion regulation brain network consisting of 21 nodes was described using graph analyses and compared between groups. RESULTS Group differences in network topology involved decreased global connectivity and hub-like properties for the right ventrolateral prefrontal cortex (vlPFC) and decreased local network connectivity for the dorsal anterior cingulate cortex (dACC) among resilient individuals. Decreased local connectivity and increased hub-like properties of the left amygdala, decreased hub-like properties of the dACC and decreased local connectivity of the left vlPFC were observed among susceptible individuals. Regression analyses suggested that the severity of ELS (measured by self-report) correlated negatively with global connectivity and hub-like qualities for the left dorsolateral PFC (dlPFC). CONCLUSIONS These preliminary results suggest functional neural connectivity patterns specific to ELS exposure and resiliency versus susceptibility to the depressogenic effects of ELS exposure.

Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression

CONTEXT Collaborative care interventions for depression in primary care settings are clinically beneficial and cost-effective. Most prior studies were conducted in urban settings. OBJECTIVE To examine the cost-effectiveness of a rural telemedicine-based collaborative care depression intervention. DESIGN Randomized controlled trial of intervention vs usual care. SETTING Seven small (serving 1000 to 5000 veterans) Veterans Health Administration community-based outpatient clinics serving rural catchment areas in 3 mid-South states. Each site had interactive televideo dedicated to mental health but no psychiatrist or psychologist on site. Patients Among 18 306 primary care patients who were screened, 1260 (6.9%) screened positive for depression; 395 met eligibility criteria and were enrolled from April 2003 to September 2004. Of those enrolled, 360 (91.1%) completed a 6-month follow-up and 335 (84.8%) completed a 12-month follow-up. Intervention A stepped-care model for depression treatment was used by an off-site depression care team to make treatment recommendations via electronic medical record. The team included a nurse depression care manager, clinical pharmacist, and psychiatrist. The depression care manager communicated with patients via telephone and was supported by computerized decision support software. MAIN OUTCOME MEASURES The base case cost analysis included outpatient, pharmacy, and intervention expenditures. The effectiveness outcomes were depression-free days and quality-adjusted life years (QALYs) calculated using the 12-Item Short Form Health Survey standard gamble conversion formula. RESULTS The incremental depression-free days outcome was not significant (P = .10); therefore, further cost-effectiveness analyses were not done. The incremental QALY outcome was significant (P = .04) and the mean base case incremental cost-effectiveness ratio was

Childhood maltreatment is associated with a sex-dependent functional reorganization of a brain inhibitory control network

85 634/QALY. Results adding inpatient costs were

How Bad Is Depression? Preference Score Estimates from Depressed Patients and the General Population

111 999/QALY to

Depression-free day to utility-weighted score: is it valid?

132 175/QALY. CONCLUSIONS In rural settings, a telemedicine-based collaborative care intervention for depression is effective and expensive. The mean base case result was

A Budget Impact Analysis of Telemedicine-based Collaborative Care for Depression

85 634/QALY, which is greater than cost per QALY ratios reported for other, mostly urban, depression collaborative care interventions.

One-year medical outcomes and emergency department recidivism after emergency department observation for cocaine-associated chest pain.

Childhood adversity represents a major risk factor for drug addiction and other mental disorders. However, the specific mechanisms by which childhood adversity impacts human brain organization to confer greater vulnerability for negative outcomes in adulthood is largely unknown. As an impaired process in drug addiction, inhibitory control of behavior was investigated as a target of childhood maltreatment (abuse and neglect). Forty adults without Axis‐I psychiatric disorders (21 females) completed a Childhood Trauma Questionnaire (CTQ) and underwent functional MRI (fMRI) while performing a stop‐signal task. A group independent component analysis identified a putative brain inhibitory control network. Graph theoretical analyses and structural equation modeling investigated the impact of childhood maltreatment on the functional organization of this neural processing network. Graph theory outcomes revealed sex differences in the relationship between network functional connectivity and inhibitory control which were dependent on the severity of childhood maltreatment exposure. A network effective connectivity analysis indicated that a maltreatment dose‐related negative modulation of dorsal anterior cingulate (dACC) activity by the left inferior frontal cortex (IFC) predicted better response inhibition and lesser attention deficit hyperactivity disorder (ADHD) symptoms in females, but poorer response inhibition and greater ADHD symptoms in males. Less inhibition of the right IFC by dACC in males with higher CTQ scores improved inhibitory control ability. The childhood maltreatment‐related reorganization of a brain inhibitory control network provides sex‐dependent mechanisms by which childhood adversity may confer greater risk for drug use and related disorders and by which adaptive brain responses protect individuals from this risk factor. Hum Brain Mapp 35:1654–1667, 2014.

Preference-weighted health-related quality of life measures and substance use disorder severity

OBJECTIVE To compare depression health state preference scores across four groups: (1) general population, (2) previous history of depression but not currently depressed, (3) less severe current depression, and (4) more severe current depression. DATA SOURCES Primary data were collected from 95 general population, 163 primary care, and 83 specialty mental health subjects. STUDY DESIGN Stratified sampling frames were used to recruit general population and patient subjects. Subjects completed cross-sectional surveys. Key variables included rating scale and standard gamble scores assigned to depression health state descriptions developed from the Patient Health Questionnaire-9 (PHQ-9) and SF-12. DATA COLLECTION/EXTRACTION METHODS Each subject completed an in-person interview. Forty-nine subjects completed test/retest reliability interviews. PRINCIPAL FINDINGS Depressed patient preference scores for three of six SF-12 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. Depressed patient scores for five of six PHQ-9 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. CONCLUSIONS Depressed patients report lower preference scores for depression health states than the general population. In effect, they perceived depression to be worse than the general public perceived it to be. Additional research is needed to examine the implications for cost-effectiveness ratios using general population preference scores versus depressed patient preference scores.

Individual Differences in Attentional Bias Associated with Cocaine Dependence Are Related to Varying Engagement of Neural Processing Networks

Background:Cost-utility analyses using formulas to convert depression-free days (DFDs) to utility-weighted scores are increasingly common. These formulas are based on linear extrapolation of data documenting the correlation between depression symptom severity and generic health-related quality of life. Objective:We sought to examine the validity of formulas converting DFDs to utility weights. Methods:We undertook an observational study with data collection at baseline, 1 week and 1, 3, 6, 9, and 12 months on 77 subjects (42 inpatient, 35 outpatient) diagnosed with current major depression. Subjects were divided into treatment response categories based on changes in depression severity. Depression severity measures used were the Hamilton Rating Scale for Depression (HAM-17) and Beck Depression Inventory (BDI) and the health-related quality of life measure was the self-administered Quality of Well-Being scale (QWB-SA). DFD calculations were based on depression severity scores and converted to utility weights using available formulas. Utility-weighted data collected over the course of 1 year were used to estimate quality-adjusted life years (QALYs). Results:QALYs estimated from the QWB-SA were significantly lower than those based on utility-weighted DFD calculations but the incremental QALYs were not significantly different. Using a slightly lower utility-weighted conversion factor for the BDI or a larger BDI severity range to calculate DFDs resulted in a better fit compared with the QWB-SA. Conclusions:Our results support the validity of the existing HAM-17 utility-weighted formula and suggest modifications for the BDI formula. If generic health-related quality of life measures are not available for conducting cost-utility analyses of depression interventions then the existing HAM-17 and modified BDI formulas appear to be reasonable alternatives.

Longitudinal association of preference-weighted health-related quality of life measures and substance use disorder outcomes.

BackgroundPatients with depression use more health services than patients without depression. However, when depression symptoms respond to treatment, use of health services declines. Most depression quality improvement studies increase total cost in the short run, which if unevenly distributed across stakeholders, could compromise buy-in and sustainability. The objective of this budget impact analysis was to examine patterns of utilization and cost associated with telemedicine-based collaborative care, an intervention that targets patients treated in small rural primary care clinics. MethodsPatients with depression were recruited from VA Community-based Outpatient Clinics, and 395 patients were enrolled and randomized to telemedicine-based collaborative care or usual care. Dependent variables representing utilization and cost were collected from administrative data. Independent variables representing clinical casemix were collected from self-report at baseline. ResultsThere were no significant group differences in the total number or cost of primary care encounters. However, as intended, patients in the intervention group had significantly greater depression-related primary care encounters (marginal effect=0.34, P=0.004) and cost (marginal effect=