Thomas Rutledge

A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain

Summary Acceptance and commitment therapy (ACT) and cognitive‐behavioral therapy are both effective for pain interference and mood in chronic pain patients; ACT may be more satisfactory. ABSTRACT Individuals reporting chronic, nonmalignant pain for at least 6 months (N = 114) were randomly assigned to 8 weekly group sessions of acceptance and commitment therapy (ACT) or cognitive‐behavioral therapy (CBT) after a 4–6 week pretreatment period and were assessed after treatment and at 6‐month follow‐up. The protocols were designed for use in a primary care rather than specialty pain clinic setting. All participants remained stable on other pain and mood treatments over the course of the intervention. ACT participants improved on pain interference, depression, and pain‐related anxiety; there were no significant differences in improvement between the treatment conditions on any outcome variables. Although there were no differences in attrition between the groups, ACT participants who completed treatment reported significantly higher levels of satisfaction than did CBT participants. These findings suggest that ACT is an effective and acceptable adjunct intervention for patients with chronic pain.

Depression, the metabolic syndrome and cardiovascular risk.

Background: The relationship between depression and the metabolic syndrome is unclear, and whether metabolic syndrome explains the association between depression and cardiovascular disease (CVD) risk is unknown. Methods: We studied 652 women who received coronary angiography as part of the Womens Ischemia Syndrome Evaluation (WISE) study and completed the Beck Depression Inventory (BDI). Women who had both elevated depressive symptoms (BDI ≥10) and a previous diagnosis of depression were considered at highest risk, whereas those with one of the two conditions represented an intermediate group. The metabolic syndrome was defined according to the ATP-III criteria. The main outcome was incidence of adverse CVD events (hospitalizations for myocardial infarction, stroke, congestive heart failure, and CVD-related mortality) over a median follow-up of 5.9 years. Results: After adjusting for demographic factors, lifestyle and functional status, both depression categories were associated with about 60% increased odds for metabolic syndrome compared with no depression (p = .03). The number of metabolic syndrome risk factors increased gradually across the three depression categories (p = .003). During follow-up, 104 women (15.9%) experienced CVD events. In multivariable analysis, women with both elevated symptoms and a previous diagnosis of depression had 2.6 times higher risk of CVD. When metabolic syndrome was added to the model, the risk associated with depression only decreased by 7%, and both depression and metabolic syndrome remained significant predictors of CVD. Conclusions: In women with suspected coronary artery disease, the metabolic syndrome is independently associated with depression but explains only a small portion of the association between depression and incident CVD. BDI = Beck Depression Inventory; CAD = coronary artery disease; CVD = cardiovascular disease; DASI = Duke Activity Status Inventory; HDL = high-density lipoprotein; LDL = low-density lipoprotein; WISE = Womens Ischemia Syndrome Evaluation; NHLBI = National Heart, Lung, and Blood Institute.

Depressive Symptom Dimensions and Cardiovascular Prognosis Among Women With Suspected Myocardial Ischemia: A Report From the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation

CONTEXT Symptoms of depression and cardiovascular disease (CVD) overlap substantially. Differentiating between dimensions of depressive symptoms may improve our understanding of the relationship between depression and physical health. OBJECTIVE To compare symptom dimensions of depression as predictors of cardiovascular-related death and events among women with suspected myocardial ischemia. DESIGN Cohort study of women with suspected myocardial ischemia who underwent evaluation at baseline for a history of cardiovascular-related problems, depressive symptoms using the Beck Depression Inventory, and coronary artery disease severity via coronary angiography. Principal components analyses (PCAs) of the Beck Depression Inventory items were conducted to examine differential cardiovascular prognosis according to symptom dimensions of depression. SETTING The Womens Ischemia Syndrome Evaluation (WISE), a multicenter study sponsored by the National Heart, Lung, and Blood Institute to assess cardiovascular function using state-of-the-art techniques in women referred for coronary angiography to evaluate chest pain or suspected myocardial ischemia. PARTICIPANTS Five hundred fifty women (mean [SD] age, 58.4 [11.2] years) enrolled in the WISE study and followed up for a median of 5.8 years. MAIN OUTCOME MEASURES Cardiovascular-related mortality and events (stroke, myocardial infarction, and congestive heart failure). RESULTS When a 3-factor structure from PCA was used, somatic/affective (hazards ratio, 1.35; 95% confidence interval, 1.04-1.74) and appetitive (1.42; 1.21-1.68) but not cognitive/affective (0.89; 0.70-1.14) symptoms predicted cardiovascular prognosis in adjusted multivariate Cox regression analysis. When a 2-factor structure from PCA was used, adjusted results indicated that somatic (hazards ratio, 1.63; 95% confidence interval, 1.28-2.08) but not cognitive/affective (0.87; 0.68-1.11) symptoms predicted worse prognosis. CONCLUSIONS In a sample of women with suspected myocardial ischemia, somatic but not cognitive/affective depressive symptoms were associated with an increased risk of cardiovascular-related mortality and events. These results support the need to research dimensions of depression in CVD populations and have implications for understanding the connection between depression and CVD.

Social networks are associated with lower mortality rates among women with suspected coronary disease: the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation study.

Objective: To examine the association between social relationships measured by the Social Network Scale and coronary artery disease (CAD) risk and mortality among a sample of women with suspected CAD. Methods: Five hundred three women (mean age, 59 years) with suspected CAD warranting clinical investigation completed a diagnostic protocol including psychosocial testing, CAD risk factor assessment, and quantitative coronary angiography. Patients were subsequently followed for a mean of 2.3 years to track all-cause mortality. Results: Women reporting higher social network scores showed a consistent pattern of reduced coronary artery disease risk, including lower blood glucose levels (r = −0.11; p = .03), lower smoking rates (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71–0.93; p = .002), lower waist-hip ratios (r = −0.18; p < .01), and lower rates of hypertension (OR = 0.90; 95% CI = 0.81–0.99; p = .04) and diabetes (OR = 0.83; 95% CI = 0.73–0.94; p = .004). Based on quantitative angiogram findings, high social network scorers also had less severe CAD (mean angiogram stenosis value, 40.8 vs. 27.2 for low and high scoring social network groups, respectively; p < .001). Finally, mortality rates over follow-up showed a dose-response pattern in relation to quartile scorers on the Social Network Index, with low scorers showing more than twice the death rate of high scorers (relative risk = 2.4; p = .03). Conclusions: Among a cohort of women with suspected CAD, smaller social circles were associated with increased CAD risk factors and mortality, an effect that appeared to be explained largely by income level. The findings extend previous studies of social network effects on health by highlighting risk among women with suspected CAD, and suggest mechanisms for further study. CAD = coronary artery disease; WISE = Women’s Ischemia Syndrome Evaluation; SES = socioeconomic status; SNI = Social Network Index; CI = confidence interval; RR = relative risk.

A Meta-Analysis of Mental Health Treatments and Cardiac Rehabilitation for Improving Clinical Outcomes and Depression Among Patients With Coronary Heart Disease

Objective To quantify the efficacy of mental health (antidepressants & psychotherapies) and cardiac rehabilitation treatments for improving secondary event risk and depression among patients with coronary heart disease (CHD). Methods Using meta-analytic methods, we evaluated mental health and cardiac rehabilitation therapies for a) reducing secondary events and 2) improving depression severity in patients with CHD. Key word searches of PubMed and Psychlit databases and previous reviews identified relevant trials. Results Eighteen mental health trials evaluated secondary events and 22 trials evaluated depression reduction. Cardiac rehabilitation trials for the same categories numbered 17 and 13, respectively. Mental health treatments did not reduce total mortality (absolute risk reduction [ARR] = −0.001, confidence interval [95% CI] = −0.016 to 0.015; number needed to treat [NNT] = ∞), showed moderate efficacy for reducing CHD events (ARR = 0.029, 95% CI = 0.007 to 0.051; NNT = 34), and a medium effect size for improving depression (Cohen d = 0.297). Cardiac rehabilitation showed similar efficacy for treating depression (d = 0.23) and reducing CHD events (ARR = 0.017, 95% CI = 0.007 to 0.026; NNT = 59) and reduced total mortality (ARR = 0.016, 95% CI = 0.005 to 0.027; NNT = 63). Conclusions Among patients with CHD, mental health treatments and cardiac rehabilitation may each reduce depression and CHD events, whereas cardiac rehabilitation is superior for reducing total mortality risk. The results support a continued role for mental health treatments and a larger role for mental health professionals in cardiac rehabilitation.

Comorbid depression and anxiety symptoms as predictors of cardiovascular events: Results from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study

Objective: To study the independent and interactive effects of depression and anxiety symptoms as predictors of cardiovascular disease (CVD) events in a sample of women with suspected myocardial ischemia. Symptoms of depression and anxiety overlap strongly and are independent predictors of CVD events. Although these symptoms commonly co-occur in medical patients, little is known about combined effects of depression and anxiety on CVD risk. Method: A total of 489 women completed a baseline protocol including coronary angiogram, CVD risk factor assessment, and questionnaire-based measures of depression and anxiety symptoms, using the Beck Depression Inventory (BDI) and State Trait Anxiety Inventory (STAI), respectively. Participants were followed for a median 5.9 years to track the prevalence of CVD events (stroke, myocardial infarction, heart failure, and CVD-related mortality). We tested the BDI × STAI interaction effect in addition to the BDI and STAI main effects. Results: Seventy-five women (15.3% of sample) experienced a CVD event, of which 18 were deaths attributed to cardiovascular causes. Results using Cox regression indicated a significant BDI × STAI interaction effect in the prediction of CVD events (p = .02) after covariate adjustment. Simple effect analyses indicated that depression scores were significant predictors of CVD events among women with low anxiety scores (hazard ratio [HR] = 2.3 [in standard deviation units]; 95% Confidence Interval [CI] = 1.3–3.9; p = .005) but not among women with higher levels of anxiety (HR = 0.99; 95% CI = 0.70–1.4; p = .95). Conclusion: Among women with suspected myocardial ischemia, the value of depression symptoms for predicting CVD events varied by the severity of comorbid anxiety. These results suggest that the clinical utility of depression measures may be improved by using them in combination with measures of anxiety. WISE = Womens Ischemia Syndrome Evaluation; CVD = cardiovascular disease; CAD = coronary artery disease; GAD = generalized anxiety disorder; CHF = congestive heart failure; MI = myocardial infarction; BDI = Beck Depression Inventory; STAI = State Trait Anxiety Inventory.

Psychosocial Variables Are Associated With Atherosclerosis Risk Factors Among Women With Chest Pain: The WISE Study

Objective We investigated associations between atherosclerosis risk factors (smoking behavior, serum cholesterol, hypertension, body mass index, and functional capacity) and psychological characteristics with suspected linkages to coronary disease (depression, hostility, and anger expression) in an exclusively female cohort. Methods Six hundred eighty-eight middle-aged women with chest pain warranting clinical investigation completed a comprehensive diagnostic protocol that included quantitative coronary angiography to assess coronary artery disease (CAD). Primary analyses controlled for menopausal status, age, and socioeconomic status variables (income and education). Results High depression scores were associated with a nearly three-fold risk of smoking (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 1.4–5.7) after covariate adjustment, and women reporting higher depression symptoms were approximately four times more likely to describe themselves in the lowest category of functional capacity (OR = 3.7, 95% CI = 1.7–7.8). High anger-out scores were associated with a four-fold or greater risk of low high-density lipoprotein cholesterol concentration (<50 mg/dl; OR = 4.0, 95% CI = 1.4–11.1) and high low-density lipoprotein cholesterol concentration (>160 mg/dl; OR = 4.8, 95% CI = 1.5–15.7) and a larger body mass index (OR = 3.5, 95% CI = 1.1–10.8) after covariate adjustment. Conclusions These results demonstrate consistent and clinically relevant relationships between psychosocial factors and atherosclerosis risk factors among women and may aid our understanding of the increased mortality risk among women reporting high levels of psychological distress.

Depression and Cardiovascular Health Care Costs Among Women With Suspected Myocardial Ischemia: Prospective Results From the WISE (Women's Ischemia Syndrome Evaluation) Study

OBJECTIVES This study evaluated 3 novel questions in a prospective clinical cohort of women undergoing evaluation for suspected myocardial ischemia: 1) What is the relationship between depression and cardiovascular costs? 2) Does the relationship vary by definition of depression? 3) Do depression-cost relationship patterns differ among women with versus without coronary artery disease (CAD)? BACKGROUND Comorbid depression has been linked to higher medical costs in previous studies of cardiovascular patients. METHODS A total of 868 women presenting with suspected myocardial ischemia completed an extensive baseline examination including cardiovascular risk factor assessment and coronary angiogram. Depression was defined by: 1) current use of antidepressants; 2) a reported history of depression treatment; and 3) Beck Depression Inventory scores. Direct (hospitalizations, office visits, procedures, and medications) and indirect (out-of-pocket, lost productivity, and travel) costs were collected through 5 years of follow-up to estimate cardiovascular costs. RESULTS Using the study criteria, 17% to 45% of the women studied met study depression criteria. Depressed women showed adjusted annual cardiovascular costs

A Real-Time Assessment of Work Stress in Physicians and Nurses

1,550 to

Social networks and incident stroke among women with suspected myocardial ischemia

3,300 higher than nondepressed groups (r = 0.08 to 0.12, p < 0.05). Depression-cost relationships also varied by CAD status, with stronger associations present among women without evidence of significant CAD. CONCLUSIONS Depression was associated with 15% to 53% increases in 5-year cardiovascular costs, and cost differences were present using 3 definitions of depression. The results reinforce the importance of assessing depression in clinical populations and support the hypothesis that improved management of depression in women with suspected myocardial ischemia could reduce medical costs.