Diana Mahoney

ATLANTA — Sleep problems in perimenopausal women can diminish quality of life significantly and should not be minimized or overlooked, according to Hadine Joffe, M.D.

In general, hormonal fluctuations may be to blame, but hot flushes and night sweats in particular are often linked to insomnia, disturbed sleep, and sleep loss during the menopausal period, Dr. Joffe said in a satellite presentation at the annual meeting of the American Psychiatric Association.

“Considering the median duration of perimenopause is 4 years, many women may suffer from issues related to insomnia for a long time if they don't get treatment,” said Dr. Joffe, director of endocrine studies in the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital, Boston.

The data on the association between hot flushes and sleep quality and duration during perimenopause are contradictory, Dr. Joffe said. “A number of studies have shown that total sleep time in perimenopausal women who experience frequent hot flushes does not suffer, compared with women who don't have hot flushes, while other studies have shown that what does suffer is sleep quality,” she said. “Hot flushes and night sweats interrupt sleep, causing lower sleep efficiency and longer REM latency, and the frequent awakenings cause next-day fatigue.”

Still other studies have shown that mood symptoms, which are common in perimenopausal women, may influence the perceived intensity of hot flushes as well as self-reported sleep quality, Dr. Joffe said.

Whether driven by mood or the nature and frequency of hot flushes, menopause-related sleep disturbances can improve with treatment. “The most effective treatment continues to be hormonal therapy. Estrogen therapy in particular has been shown to improve subjective sleep quality and continuity and to increase REM and reduce REM latency,” she said. “And the impact of estrogen on sleep is greatest in women with hot flushes.”

However, concerns about using hormonal therapy for long periods as well as its contraindication in some patients have led to the consideration of other treatment strategies for improving sleep, including the use of serotonergic antidepressants and hypnotic agents, she said.

In a recent Finish study, investigators looked at the impact of the selective serotonin reuptake inhibitors fluoxetine and citalopram on menopausal symptoms. While neither appeared to have a significant effect on hot flushes, insomnia improved significantly in the citalopram group versus placebo (Menopause 2005;12:18–26).

Several studies also have shown that paroxetine and venlafaxine can significantly decrease hot flashes, and as such may improve sleep. Similarly, there is some evidence that the anticonvulsant gabapentin and the antihypertensive clonidine can effectively treat the vasomotor symptoms of menopause, Dr. Joffe said.

Hypnotic agents also may improve sleep quality compromised by multiple factors, including hot flushes, she explained.

In one 4-week randomized, multicenter, double-blind, placebo-controlled study, women taking the benzodiazepine receptor agonist zolpidem reported an increase in total sleep time, a decrease in the number of awakenings, improved sleep quality, and improvements in sleep-related difficulty with daytime functioning (Clin. Ther. 2004;26:1578–86).

Preliminary data from an ongoing trial of eszopiclone at Massachusetts General Hospital also has been linked to significantly improved sleep onset, sleep maintenance, total sleep time, and sleep quality, compared with placebo.

When treating menopause-related insomnia, first rule out underlying conditions, then consider patient factors and the severity of the problem, Dr. Joffe advised. Some antidepressants may take 3–4 weeks before noticeable improvement, so patients with severe symptoms might be reluctant to wait that long, she noted. Hypnotics may work faster, but they do have the potential for morning “hangover,” and they are not appropriate in the presence of any coexisting chemical dependency.

Dr. Joffe receives research support from Abbott Laboratories. She also is on the speakers' bureau for Eli Lilly & Co. The APA-sponsored satellite symposium was supported by an unrestricted educational grant from Neurocrine Biosciences Inc. and Pfizer Inc.

ATLANTA — Sleep problems in perimenopausal women can diminish quality of life significantly and should not be minimized or overlooked, according to Hadine Joffe, M.D.

In general, hormonal fluctuations may be to blame, but hot flushes and night sweats in particular are often linked to insomnia, disturbed sleep, and sleep loss during the menopausal period, Dr. Joffe said in a satellite presentation at the annual meeting of the American Psychiatric Association.

“Considering the median duration of perimenopause is 4 years, many women may suffer from issues related to insomnia for a long time if they don't get treatment,” said Dr. Joffe, director of endocrine studies in the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital, Boston.

The data on the association between hot flushes and sleep quality and duration during perimenopause are contradictory, Dr. Joffe said. “A number of studies have shown that total sleep time in perimenopausal women who experience frequent hot flushes does not suffer, compared with women who don't have hot flushes, while other studies have shown that what does suffer is sleep quality,” she said. “Hot flushes and night sweats interrupt sleep, causing lower sleep efficiency and longer REM latency, and the frequent awakenings cause next-day fatigue.”

Still other studies have shown that mood symptoms, which are common in perimenopausal women, may influence the perceived intensity of hot flushes as well as self-reported sleep quality, Dr. Joffe said.

Whether driven by mood or the nature and frequency of hot flushes, menopause-related sleep disturbances can improve with treatment. “The most effective treatment continues to be hormonal therapy. Estrogen therapy in particular has been shown to improve subjective sleep quality and continuity and to increase REM and reduce REM latency,” she said. “And the impact of estrogen on sleep is greatest in women with hot flushes.”

However, concerns about using hormonal therapy for long periods as well as its contraindication in some patients have led to the consideration of other treatment strategies for improving sleep, including the use of serotonergic antidepressants and hypnotic agents, she said.

In a recent Finish study, investigators looked at the impact of the selective serotonin reuptake inhibitors fluoxetine and citalopram on menopausal symptoms. While neither appeared to have a significant effect on hot flushes, insomnia improved significantly in the citalopram group versus placebo (Menopause 2005;12:18–26).

Several studies also have shown that paroxetine and venlafaxine can significantly decrease hot flashes, and as such may improve sleep. Similarly, there is some evidence that the anticonvulsant gabapentin and the antihypertensive clonidine can effectively treat the vasomotor symptoms of menopause, Dr. Joffe said.

Hypnotic agents also may improve sleep quality compromised by multiple factors, including hot flushes, she explained.

In one 4-week randomized, multicenter, double-blind, placebo-controlled study, women taking the benzodiazepine receptor agonist zolpidem reported an increase in total sleep time, a decrease in the number of awakenings, improved sleep quality, and improvements in sleep-related difficulty with daytime functioning (Clin. Ther. 2004;26:1578–86).

Preliminary data from an ongoing trial of eszopiclone at Massachusetts General Hospital also has been linked to significantly improved sleep onset, sleep maintenance, total sleep time, and sleep quality, compared with placebo.

When treating menopause-related insomnia, first rule out underlying conditions, then consider patient factors and the severity of the problem, Dr. Joffe advised. Some antidepressants may take 3–4 weeks before noticeable improvement, so patients with severe symptoms might be reluctant to wait that long, she noted. Hypnotics may work faster, but they do have the potential for morning “hangover,” and they are not appropriate in the presence of any coexisting chemical dependency.

Dr. Joffe receives research support from Abbott Laboratories. She also is on the speakers' bureau for Eli Lilly & Co. The APA-sponsored satellite symposium was supported by an unrestricted educational grant from Neurocrine Biosciences Inc. and Pfizer Inc.

ATLANTA — Sleep problems in perimenopausal women can diminish quality of life significantly and should not be minimized or overlooked, according to Hadine Joffe, M.D.

In general, hormonal fluctuations may be to blame, but hot flushes and night sweats in particular are often linked to insomnia, disturbed sleep, and sleep loss during the menopausal period, Dr. Joffe said in a satellite presentation at the annual meeting of the American Psychiatric Association.

“Considering the median duration of perimenopause is 4 years, many women may suffer from issues related to insomnia for a long time if they don't get treatment,” said Dr. Joffe, director of endocrine studies in the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital, Boston.

The data on the association between hot flushes and sleep quality and duration during perimenopause are contradictory, Dr. Joffe said. “A number of studies have shown that total sleep time in perimenopausal women who experience frequent hot flushes does not suffer, compared with women who don't have hot flushes, while other studies have shown that what does suffer is sleep quality,” she said. “Hot flushes and night sweats interrupt sleep, causing lower sleep efficiency and longer REM latency, and the frequent awakenings cause next-day fatigue.”

Still other studies have shown that mood symptoms, which are common in perimenopausal women, may influence the perceived intensity of hot flushes as well as self-reported sleep quality, Dr. Joffe said.

Whether driven by mood or the nature and frequency of hot flushes, menopause-related sleep disturbances can improve with treatment. “The most effective treatment continues to be hormonal therapy. Estrogen therapy in particular has been shown to improve subjective sleep quality and continuity and to increase REM and reduce REM latency,” she said. “And the impact of estrogen on sleep is greatest in women with hot flushes.”

However, concerns about using hormonal therapy for long periods as well as its contraindication in some patients have led to the consideration of other treatment strategies for improving sleep, including the use of serotonergic antidepressants and hypnotic agents, she said.

In a recent Finish study, investigators looked at the impact of the selective serotonin reuptake inhibitors fluoxetine and citalopram on menopausal symptoms. While neither appeared to have a significant effect on hot flushes, insomnia improved significantly in the citalopram group versus placebo (Menopause 2005;12:18–26).

Several studies also have shown that paroxetine and venlafaxine can significantly decrease hot flashes, and as such may improve sleep. Similarly, there is some evidence that the anticonvulsant gabapentin and the antihypertensive clonidine can effectively treat the vasomotor symptoms of menopause, Dr. Joffe said.

Hypnotic agents also may improve sleep quality compromised by multiple factors, including hot flushes, she explained.

In one 4-week randomized, multicenter, double-blind, placebo-controlled study, women taking the benzodiazepine receptor agonist zolpidem reported an increase in total sleep time, a decrease in the number of awakenings, improved sleep quality, and improvements in sleep-related difficulty with daytime functioning (Clin. Ther. 2004;26:1578–86).

Preliminary data from an ongoing trial of eszopiclone at Massachusetts General Hospital also has been linked to significantly improved sleep onset, sleep maintenance, total sleep time, and sleep quality, compared with placebo.

When treating menopause-related insomnia, first rule out underlying conditions, then consider patient factors and the severity of the problem, Dr. Joffe advised. Some antidepressants may take 3–4 weeks before noticeable improvement, so patients with severe symptoms might be reluctant to wait that long, she noted. Hypnotics may work faster, but they do have the potential for morning “hangover,” and they are not appropriate in the presence of any coexisting chemical dependency.

Dr. Joffe receives research support from Abbott Laboratories. She also is on the speakers' bureau for Eli Lilly & Co. The APA-sponsored satellite symposium was supported by an unrestricted educational grant from Neurocrine Biosciences Inc. and Pfizer Inc.

BOSTON – A prescription for exercise may do more than boost obese children's physical health. It also may improve how they think, results of a study have shown.

The findings are consistent with recent work demonstrating exercise-induced improvements in cognition in older adults and add fuel to the argument for increasing physical education requirements in schools and community-based opportunities for physical activity, according to Mathew Gregoski of the Georgia Prevention Institute of the Medical College of Georgia in Augusta.

As part of an ongoing investigation of a possible dose-response relationship between a 3-month exercise program and adiposity, insulin sensitivity, and executive functioning in overweight youth, 30 children aged 8–11 years with a body mass index at or above the 85th percentile for their age and gender were randomized to one of three intervention conditions–no exercise, low-dose exercise (20 min/day), and high-dose exercise (40 min/day)–to test the effect of aerobic exercise training on cognitive measures.

Both of the exercise conditions included vigorous aerobic activities and games that maintained average heart rate above 150 beats per minute, Mr. Gregoski reported at the annual meeting of the Society for Behavioral Medicine.

Before and after the interventions, all participants underwent standardized mental functioning testing using the Cognitive Assessment System (CAS). The investigators calculated the changes from baseline in four scales of the CAS, including planning, attention, successive, and simultaneous, said Mr. Gregoski, who conducted the investigation under the direction of Catherine Davis, Ph.D.

The planning scale measures an individual's ability to generate and implement hypotheses and to use decision-making structures to evaluate them.

This aspect of mental functioning is thought to underlie cognitive control, intentionality, and self-regulation–all of which have been identified as challenges for obese children.

The attention scale measures an individual's ability to focus attention, take in information, and maintain sufficient alertness to attempt problem solving.

The successive scale is associated with the ability to integrate information in serial order, and the simultaneous scale is associated with mental operations that require consideration of all elements of a complex stimulus concurrently.

Analysis of variance revealed significant improvement following both exercise interventions in the planning scale of the CAS, with the high-dose exercise group experiencing the most change from baseline. The other cognitive measures did not show an effect, Mr. Gregoski said.

That a significant cognitive benefit was observed with the 20-minute intervention in addition to the longer duration is notable in that such a program could readily be introduced during regular physical education sessions, he said at the conference.

These results “provide evidence for a direct relationship between physical activity and children's cognitive development,” Mr. Gregoski said.

The findings may be important not only for developing interventions targeting this population, but also for breaking down the barriers to physical education and activity in schools.

BOSTON – A prescription for exercise may do more than boost obese children's physical health. It also may improve how they think, results of a study have shown.

The findings are consistent with recent work demonstrating exercise-induced improvements in cognition in older adults and add fuel to the argument for increasing physical education requirements in schools and community-based opportunities for physical activity, according to Mathew Gregoski of the Georgia Prevention Institute of the Medical College of Georgia in Augusta.

As part of an ongoing investigation of a possible dose-response relationship between a 3-month exercise program and adiposity, insulin sensitivity, and executive functioning in overweight youth, 30 children aged 8–11 years with a body mass index at or above the 85th percentile for their age and gender were randomized to one of three intervention conditions–no exercise, low-dose exercise (20 min/day), and high-dose exercise (40 min/day)–to test the effect of aerobic exercise training on cognitive measures.

Both of the exercise conditions included vigorous aerobic activities and games that maintained average heart rate above 150 beats per minute, Mr. Gregoski reported at the annual meeting of the Society for Behavioral Medicine.

Before and after the interventions, all participants underwent standardized mental functioning testing using the Cognitive Assessment System (CAS). The investigators calculated the changes from baseline in four scales of the CAS, including planning, attention, successive, and simultaneous, said Mr. Gregoski, who conducted the investigation under the direction of Catherine Davis, Ph.D.

The planning scale measures an individual's ability to generate and implement hypotheses and to use decision-making structures to evaluate them.

This aspect of mental functioning is thought to underlie cognitive control, intentionality, and self-regulation–all of which have been identified as challenges for obese children.

The attention scale measures an individual's ability to focus attention, take in information, and maintain sufficient alertness to attempt problem solving.

The successive scale is associated with the ability to integrate information in serial order, and the simultaneous scale is associated with mental operations that require consideration of all elements of a complex stimulus concurrently.

Analysis of variance revealed significant improvement following both exercise interventions in the planning scale of the CAS, with the high-dose exercise group experiencing the most change from baseline. The other cognitive measures did not show an effect, Mr. Gregoski said.

That a significant cognitive benefit was observed with the 20-minute intervention in addition to the longer duration is notable in that such a program could readily be introduced during regular physical education sessions, he said at the conference.

These results “provide evidence for a direct relationship between physical activity and children's cognitive development,” Mr. Gregoski said.

The findings may be important not only for developing interventions targeting this population, but also for breaking down the barriers to physical education and activity in schools.

BOSTON – A prescription for exercise may do more than boost obese children's physical health. It also may improve how they think, results of a study have shown.

The findings are consistent with recent work demonstrating exercise-induced improvements in cognition in older adults and add fuel to the argument for increasing physical education requirements in schools and community-based opportunities for physical activity, according to Mathew Gregoski of the Georgia Prevention Institute of the Medical College of Georgia in Augusta.

As part of an ongoing investigation of a possible dose-response relationship between a 3-month exercise program and adiposity, insulin sensitivity, and executive functioning in overweight youth, 30 children aged 8–11 years with a body mass index at or above the 85th percentile for their age and gender were randomized to one of three intervention conditions–no exercise, low-dose exercise (20 min/day), and high-dose exercise (40 min/day)–to test the effect of aerobic exercise training on cognitive measures.

Both of the exercise conditions included vigorous aerobic activities and games that maintained average heart rate above 150 beats per minute, Mr. Gregoski reported at the annual meeting of the Society for Behavioral Medicine.

Before and after the interventions, all participants underwent standardized mental functioning testing using the Cognitive Assessment System (CAS). The investigators calculated the changes from baseline in four scales of the CAS, including planning, attention, successive, and simultaneous, said Mr. Gregoski, who conducted the investigation under the direction of Catherine Davis, Ph.D.

The planning scale measures an individual's ability to generate and implement hypotheses and to use decision-making structures to evaluate them.

This aspect of mental functioning is thought to underlie cognitive control, intentionality, and self-regulation–all of which have been identified as challenges for obese children.

The attention scale measures an individual's ability to focus attention, take in information, and maintain sufficient alertness to attempt problem solving.

The successive scale is associated with the ability to integrate information in serial order, and the simultaneous scale is associated with mental operations that require consideration of all elements of a complex stimulus concurrently.

Analysis of variance revealed significant improvement following both exercise interventions in the planning scale of the CAS, with the high-dose exercise group experiencing the most change from baseline. The other cognitive measures did not show an effect, Mr. Gregoski said.

That a significant cognitive benefit was observed with the 20-minute intervention in addition to the longer duration is notable in that such a program could readily be introduced during regular physical education sessions, he said at the conference.

These results “provide evidence for a direct relationship between physical activity and children's cognitive development,” Mr. Gregoski said.

The findings may be important not only for developing interventions targeting this population, but also for breaking down the barriers to physical education and activity in schools.

ATLANTA — There is no one-size-fits-all formula for the course of posttraumatic stress disorder and depression among battle-injured soldiers, Capt. Thomas A. Grieger, MC, USN, reported in a poster presentation at the annual meeting of the American Psychiatric Association.

Delayed symptom presentation and interpatient variations in the progression of both conditions suggest that current methods for screening injured soldiers' mental health, which focus on symptom assessment upon hospitalization, may cast too small a net, according to Dr. Grieger.

Of 613 consecutive soldiers evacuated from Afghanistan and Iraq to a U.S. military tertiary care hospital for treatment of combat injuries, 4% screened positive for probable posttraumatic stress disorder (PTSD) on admission and 4% screened positive for probable depression. All of the soldiers included in the study had serious injuries requiring hospitalization lasting from weeks to months.

However, after 3 months, 12.2% and 8.9% of the soldiers screened positive for probable PTSD and depression, respectively. After 6 months, 12.0% and 9.3% of the soldiers screened positive for the respective conditions. Based on a longitudinal analysis, 79% of the patients who screened positive for either condition at 6 months had screened negative for both conditions at the time of their initial assessment. No baseline demographic characteristics were associated with risk for PTSD or depression at either the 3- or 6-month follow-ups, he said.

The results demonstrate that “screening battle-injured soldiers for PTSD and depression during initial hospitalization does not accurately identify those who will have symptoms of the disorders at later follow-up,” said Dr. Grieger of the Uniformed Services University of the Health Sciences in Bethesda, Md.

The low initial rates might be reflective of the soldiers' lack of realization of the severity of their injuries or the extent of their rehabilitation programs. As time goes by, symptoms of mental illness might present if the pain and/or disability has not diminished substantially, he suggested.

Patients who initially screen positive for either PTSD or depression seem to fare better than those whose symptoms present later. “Of those soldiers who met the criteria for either condition during initial evaluation, approximately half had remission 6 months later,” Dr. Grieger said. It is unclear whether this occurs as a consequence of the natural course of the conditions or because such patients tend to receive more intense mental health interventions from the outset.

Continuity of psychiatric care for combat-injured soldiers notwithstanding, the stand-alone results of initial assessments are critical for identifying and managing most soldiers at risk for related psychiatric illnesses, Dr. Grieger concluded.

To assess the presence or absence of probable PTSD in this study, Dr. Grieger and his colleagues used the 17-item National Center for PTSD Checklist of the Department of Veterans Affairs (PCL-17). They used the Patient Health Questionnaire Depression Scale (PHQ-9) to assess probable depression.

ATLANTA — There is no one-size-fits-all formula for the course of posttraumatic stress disorder and depression among battle-injured soldiers, Capt. Thomas A. Grieger, MC, USN, reported in a poster presentation at the annual meeting of the American Psychiatric Association.

Delayed symptom presentation and interpatient variations in the progression of both conditions suggest that current methods for screening injured soldiers' mental health, which focus on symptom assessment upon hospitalization, may cast too small a net, according to Dr. Grieger.

Of 613 consecutive soldiers evacuated from Afghanistan and Iraq to a U.S. military tertiary care hospital for treatment of combat injuries, 4% screened positive for probable posttraumatic stress disorder (PTSD) on admission and 4% screened positive for probable depression. All of the soldiers included in the study had serious injuries requiring hospitalization lasting from weeks to months.

However, after 3 months, 12.2% and 8.9% of the soldiers screened positive for probable PTSD and depression, respectively. After 6 months, 12.0% and 9.3% of the soldiers screened positive for the respective conditions. Based on a longitudinal analysis, 79% of the patients who screened positive for either condition at 6 months had screened negative for both conditions at the time of their initial assessment. No baseline demographic characteristics were associated with risk for PTSD or depression at either the 3- or 6-month follow-ups, he said.

The results demonstrate that “screening battle-injured soldiers for PTSD and depression during initial hospitalization does not accurately identify those who will have symptoms of the disorders at later follow-up,” said Dr. Grieger of the Uniformed Services University of the Health Sciences in Bethesda, Md.

The low initial rates might be reflective of the soldiers' lack of realization of the severity of their injuries or the extent of their rehabilitation programs. As time goes by, symptoms of mental illness might present if the pain and/or disability has not diminished substantially, he suggested.

Patients who initially screen positive for either PTSD or depression seem to fare better than those whose symptoms present later. “Of those soldiers who met the criteria for either condition during initial evaluation, approximately half had remission 6 months later,” Dr. Grieger said. It is unclear whether this occurs as a consequence of the natural course of the conditions or because such patients tend to receive more intense mental health interventions from the outset.

Continuity of psychiatric care for combat-injured soldiers notwithstanding, the stand-alone results of initial assessments are critical for identifying and managing most soldiers at risk for related psychiatric illnesses, Dr. Grieger concluded.

To assess the presence or absence of probable PTSD in this study, Dr. Grieger and his colleagues used the 17-item National Center for PTSD Checklist of the Department of Veterans Affairs (PCL-17). They used the Patient Health Questionnaire Depression Scale (PHQ-9) to assess probable depression.

ATLANTA — There is no one-size-fits-all formula for the course of posttraumatic stress disorder and depression among battle-injured soldiers, Capt. Thomas A. Grieger, MC, USN, reported in a poster presentation at the annual meeting of the American Psychiatric Association.

Delayed symptom presentation and interpatient variations in the progression of both conditions suggest that current methods for screening injured soldiers' mental health, which focus on symptom assessment upon hospitalization, may cast too small a net, according to Dr. Grieger.

Of 613 consecutive soldiers evacuated from Afghanistan and Iraq to a U.S. military tertiary care hospital for treatment of combat injuries, 4% screened positive for probable posttraumatic stress disorder (PTSD) on admission and 4% screened positive for probable depression. All of the soldiers included in the study had serious injuries requiring hospitalization lasting from weeks to months.

However, after 3 months, 12.2% and 8.9% of the soldiers screened positive for probable PTSD and depression, respectively. After 6 months, 12.0% and 9.3% of the soldiers screened positive for the respective conditions. Based on a longitudinal analysis, 79% of the patients who screened positive for either condition at 6 months had screened negative for both conditions at the time of their initial assessment. No baseline demographic characteristics were associated with risk for PTSD or depression at either the 3- or 6-month follow-ups, he said.

The results demonstrate that “screening battle-injured soldiers for PTSD and depression during initial hospitalization does not accurately identify those who will have symptoms of the disorders at later follow-up,” said Dr. Grieger of the Uniformed Services University of the Health Sciences in Bethesda, Md.

The low initial rates might be reflective of the soldiers' lack of realization of the severity of their injuries or the extent of their rehabilitation programs. As time goes by, symptoms of mental illness might present if the pain and/or disability has not diminished substantially, he suggested.

Patients who initially screen positive for either PTSD or depression seem to fare better than those whose symptoms present later. “Of those soldiers who met the criteria for either condition during initial evaluation, approximately half had remission 6 months later,” Dr. Grieger said. It is unclear whether this occurs as a consequence of the natural course of the conditions or because such patients tend to receive more intense mental health interventions from the outset.

Continuity of psychiatric care for combat-injured soldiers notwithstanding, the stand-alone results of initial assessments are critical for identifying and managing most soldiers at risk for related psychiatric illnesses, Dr. Grieger concluded.

To assess the presence or absence of probable PTSD in this study, Dr. Grieger and his colleagues used the 17-item National Center for PTSD Checklist of the Department of Veterans Affairs (PCL-17). They used the Patient Health Questionnaire Depression Scale (PHQ-9) to assess probable depression.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 women without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling reported at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of mental health diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer.

Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or mental health hospitalization.

A moderately severe classification was noted for women who had either a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible that the fragmentation of the current mental health care system may serve as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said.

More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care in order to develop effective interventions for increasing screening rates in this population, she concluded.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 women without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling reported at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of mental health diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer.

Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or mental health hospitalization.

A moderately severe classification was noted for women who had either a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible that the fragmentation of the current mental health care system may serve as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said.

More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care in order to develop effective interventions for increasing screening rates in this population, she concluded.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 women without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling reported at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of mental health diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer.

Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or mental health hospitalization.

A moderately severe classification was noted for women who had either a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible that the fragmentation of the current mental health care system may serve as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said.

More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care in order to develop effective interventions for increasing screening rates in this population, she concluded.

The prevalence of mental illness in the United States continues to be high despite increases in mental health awareness, new medications, changes in public perceptions about mental illness, and advances in treatment financing, according to a national mental health tracking study.

The results of the latest National Comorbidity Survey Replication (NCS-R) indicate that most Americans experience mental illness at some point in their lives, and many go untreated. Additionally, those who eventually seek treatment often receive substandard care, survey director Ronald C. Kessler, Ph.D., said in a press teleconference sponsored by Harvard Medical School and the National Institute of Mental Health.

Led by Harvard, the University of Michigan Institute for Social Research, and NIMH, the NCS-R is a nationally representative, face-to-face household survey taken every 10 years to assess the mental health of the country. The survey examined anxiety, mood, impulse control, and substance abuse disorders and quantified lifetime prevalence, age of onset, delay in treatment seeking, prevalence and severity in a given year, treatment and quality of care in a given year, and barriers to treatment.

In one of four papers analyzing the survey results from 9,282 English-speaking respondents, Dr. Kessler and his colleagues at Harvard Medical School, Boston, reported that about half of the population met the criteria for a DSM-IV disorder sometime in their lives, with first onset usually in childhood or adolescence. The lifetime prevalence estimates for anxiety and impulse control disorders were highest, at 29% and 25%, respectively, and the median age of onset for both was 11 years.

The lifetime prevalence estimates for mood disorders and substance use disorders were 21% and 15%, respectively, and the median age of onset was 30 years for mood disorders and 20 years for substance use disorders (Arch. Gen. Psychiatry 2005;62:593–640).

Because first onset so often occurs in childhood or adolescence, “prevention and treatment interventions have to focus on youth,” Dr. Kessler stressed. “Early interventions should be aimed at preventing the progression of primary disorders in the child and adolescent years” as a way to mitigate the societal and personal burdens associated with mental disorders into adulthood, he said.

Analyses of the 12-month prevalence, severity, and comorbidity data showed that more than 26% of adults had symptoms meeting the criteria for a DSM-IV mental disorder in the previous 12 months, but he said most of the cases were mild (40.4%) or moderate (37.3%). Impulse-control disorders, which have been neglected in previous epidemiologic studies, according to Dr. Kessler, were found in nearly one-third of individuals meeting diagnostic criteria, “and these cases were typically more serious than the other disorders,” he said.

More than 40% of the 12-month cases had more than one disorder, “and severity was strongly related to comorbidity,” Dr. Kessler said.

The latter findings suggest that public health interventions should take the presence of comorbidities into account when considering treatment for specific populations, he said.

Regarding the 12-month mental health service utilization data, “most people with mental disorders in the United States remain either untreated or poorly treated,” said Philip S. Wang, M.D., also of Harvard. Less than 42% of people with a mental disorder received treatment for that disorder within the 12-month period prior to the survey.

Of those who received treatment, 12.3% were treated by a psychiatrist, 16% by a nonpsychiatrist mental health specialist, 22.8% by a general medical provider, 8.1% by a human service provider, and 6.8% by a complementary and alternative medical provider.

Of particular interest, noted Dr. Wang, was that patients treated in the mental health specialty sector received more visits than those treated in the general medical sector, and more patients in the specialty sector, compared with the general medicine sector received treatment that exceeded a minimal threshold of adequacy. Not surprising was the finding that the unmet need for treatment continued to be greatest in traditionally underserved groups, including the elderly, racial and ethnic minorities, the uninsured, and residents of rural areas, he said.

The cumulative lifetime probability curves derived from the survey data showed that the majority of people with lifetime mental health disorders eventually get some sort of treatment, but the time it took to actually make treatment contact after first onset of a mental disorder ranged from 6 to 8 years for mood disorders, 9 to 23 years for anxiety disorders, 4 to 13 years for impulse-control disorders, and 5 to 9 years for substance disorders.

Predictors of treatment delay included early age of onset, being in an older cohort, and various sociodemographic characteristics, including being male, racial/ethnic minority, poorly educated, and married, Dr. Wang said at the teleconference.

Although the data show that there is a significant need for interventions that speed initial treatment contact to reduce the later burdens of untreated mental health disorders, it is not enough to design and test prevention and treatment interventions, according to Dr. Kessler.

The prevalence of mental illness in the United States continues to be high despite increases in mental health awareness, new medications, changes in public perceptions about mental illness, and advances in treatment financing, according to a national mental health tracking study.

The results of the latest National Comorbidity Survey Replication (NCS-R) indicate that most Americans experience mental illness at some point in their lives, and many go untreated. Additionally, those who eventually seek treatment often receive substandard care, survey director Ronald C. Kessler, Ph.D., said in a press teleconference sponsored by Harvard Medical School and the National Institute of Mental Health.

Led by Harvard, the University of Michigan Institute for Social Research, and NIMH, the NCS-R is a nationally representative, face-to-face household survey taken every 10 years to assess the mental health of the country. The survey examined anxiety, mood, impulse control, and substance abuse disorders and quantified lifetime prevalence, age of onset, delay in treatment seeking, prevalence and severity in a given year, treatment and quality of care in a given year, and barriers to treatment.

In one of four papers analyzing the survey results from 9,282 English-speaking respondents, Dr. Kessler and his colleagues at Harvard Medical School, Boston, reported that about half of the population met the criteria for a DSM-IV disorder sometime in their lives, with first onset usually in childhood or adolescence. The lifetime prevalence estimates for anxiety and impulse control disorders were highest, at 29% and 25%, respectively, and the median age of onset for both was 11 years.

The lifetime prevalence estimates for mood disorders and substance use disorders were 21% and 15%, respectively, and the median age of onset was 30 years for mood disorders and 20 years for substance use disorders (Arch. Gen. Psychiatry 2005;62:593–640).

Because first onset so often occurs in childhood or adolescence, “prevention and treatment interventions have to focus on youth,” Dr. Kessler stressed. “Early interventions should be aimed at preventing the progression of primary disorders in the child and adolescent years” as a way to mitigate the societal and personal burdens associated with mental disorders into adulthood, he said.

Analyses of the 12-month prevalence, severity, and comorbidity data showed that more than 26% of adults had symptoms meeting the criteria for a DSM-IV mental disorder in the previous 12 months, but he said most of the cases were mild (40.4%) or moderate (37.3%). Impulse-control disorders, which have been neglected in previous epidemiologic studies, according to Dr. Kessler, were found in nearly one-third of individuals meeting diagnostic criteria, “and these cases were typically more serious than the other disorders,” he said.

More than 40% of the 12-month cases had more than one disorder, “and severity was strongly related to comorbidity,” Dr. Kessler said.

The latter findings suggest that public health interventions should take the presence of comorbidities into account when considering treatment for specific populations, he said.

Regarding the 12-month mental health service utilization data, “most people with mental disorders in the United States remain either untreated or poorly treated,” said Philip S. Wang, M.D., also of Harvard. Less than 42% of people with a mental disorder received treatment for that disorder within the 12-month period prior to the survey.

Of those who received treatment, 12.3% were treated by a psychiatrist, 16% by a nonpsychiatrist mental health specialist, 22.8% by a general medical provider, 8.1% by a human service provider, and 6.8% by a complementary and alternative medical provider.

Of particular interest, noted Dr. Wang, was that patients treated in the mental health specialty sector received more visits than those treated in the general medical sector, and more patients in the specialty sector, compared with the general medicine sector received treatment that exceeded a minimal threshold of adequacy. Not surprising was the finding that the unmet need for treatment continued to be greatest in traditionally underserved groups, including the elderly, racial and ethnic minorities, the uninsured, and residents of rural areas, he said.

The cumulative lifetime probability curves derived from the survey data showed that the majority of people with lifetime mental health disorders eventually get some sort of treatment, but the time it took to actually make treatment contact after first onset of a mental disorder ranged from 6 to 8 years for mood disorders, 9 to 23 years for anxiety disorders, 4 to 13 years for impulse-control disorders, and 5 to 9 years for substance disorders.

Predictors of treatment delay included early age of onset, being in an older cohort, and various sociodemographic characteristics, including being male, racial/ethnic minority, poorly educated, and married, Dr. Wang said at the teleconference.

Although the data show that there is a significant need for interventions that speed initial treatment contact to reduce the later burdens of untreated mental health disorders, it is not enough to design and test prevention and treatment interventions, according to Dr. Kessler.

The prevalence of mental illness in the United States continues to be high despite increases in mental health awareness, new medications, changes in public perceptions about mental illness, and advances in treatment financing, according to a national mental health tracking study.

The results of the latest National Comorbidity Survey Replication (NCS-R) indicate that most Americans experience mental illness at some point in their lives, and many go untreated. Additionally, those who eventually seek treatment often receive substandard care, survey director Ronald C. Kessler, Ph.D., said in a press teleconference sponsored by Harvard Medical School and the National Institute of Mental Health.

Led by Harvard, the University of Michigan Institute for Social Research, and NIMH, the NCS-R is a nationally representative, face-to-face household survey taken every 10 years to assess the mental health of the country. The survey examined anxiety, mood, impulse control, and substance abuse disorders and quantified lifetime prevalence, age of onset, delay in treatment seeking, prevalence and severity in a given year, treatment and quality of care in a given year, and barriers to treatment.

In one of four papers analyzing the survey results from 9,282 English-speaking respondents, Dr. Kessler and his colleagues at Harvard Medical School, Boston, reported that about half of the population met the criteria for a DSM-IV disorder sometime in their lives, with first onset usually in childhood or adolescence. The lifetime prevalence estimates for anxiety and impulse control disorders were highest, at 29% and 25%, respectively, and the median age of onset for both was 11 years.

The lifetime prevalence estimates for mood disorders and substance use disorders were 21% and 15%, respectively, and the median age of onset was 30 years for mood disorders and 20 years for substance use disorders (Arch. Gen. Psychiatry 2005;62:593–640).

Because first onset so often occurs in childhood or adolescence, “prevention and treatment interventions have to focus on youth,” Dr. Kessler stressed. “Early interventions should be aimed at preventing the progression of primary disorders in the child and adolescent years” as a way to mitigate the societal and personal burdens associated with mental disorders into adulthood, he said.

Analyses of the 12-month prevalence, severity, and comorbidity data showed that more than 26% of adults had symptoms meeting the criteria for a DSM-IV mental disorder in the previous 12 months, but he said most of the cases were mild (40.4%) or moderate (37.3%). Impulse-control disorders, which have been neglected in previous epidemiologic studies, according to Dr. Kessler, were found in nearly one-third of individuals meeting diagnostic criteria, “and these cases were typically more serious than the other disorders,” he said.

More than 40% of the 12-month cases had more than one disorder, “and severity was strongly related to comorbidity,” Dr. Kessler said.

The latter findings suggest that public health interventions should take the presence of comorbidities into account when considering treatment for specific populations, he said.

Regarding the 12-month mental health service utilization data, “most people with mental disorders in the United States remain either untreated or poorly treated,” said Philip S. Wang, M.D., also of Harvard. Less than 42% of people with a mental disorder received treatment for that disorder within the 12-month period prior to the survey.

Of those who received treatment, 12.3% were treated by a psychiatrist, 16% by a nonpsychiatrist mental health specialist, 22.8% by a general medical provider, 8.1% by a human service provider, and 6.8% by a complementary and alternative medical provider.

Of particular interest, noted Dr. Wang, was that patients treated in the mental health specialty sector received more visits than those treated in the general medical sector, and more patients in the specialty sector, compared with the general medicine sector received treatment that exceeded a minimal threshold of adequacy. Not surprising was the finding that the unmet need for treatment continued to be greatest in traditionally underserved groups, including the elderly, racial and ethnic minorities, the uninsured, and residents of rural areas, he said.

The cumulative lifetime probability curves derived from the survey data showed that the majority of people with lifetime mental health disorders eventually get some sort of treatment, but the time it took to actually make treatment contact after first onset of a mental disorder ranged from 6 to 8 years for mood disorders, 9 to 23 years for anxiety disorders, 4 to 13 years for impulse-control disorders, and 5 to 9 years for substance disorders.

Predictors of treatment delay included early age of onset, being in an older cohort, and various sociodemographic characteristics, including being male, racial/ethnic minority, poorly educated, and married, Dr. Wang said at the teleconference.

Although the data show that there is a significant need for interventions that speed initial treatment contact to reduce the later burdens of untreated mental health disorders, it is not enough to design and test prevention and treatment interventions, according to Dr. Kessler.

NEW ORLEANS — A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study out of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from San Francisco-area outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

The instrument can be easily integrated into outpatient visits in the busiest practices, he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD. Study participants, whose mean age is 67, were recruited from the Veterans Affairs medical centers of San Francisco and Palo Alto, Calif., the University of California at San Francisco Medical Center, and nine public health clinics in the Community Health Network of San Francisco.

NEW ORLEANS — A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study out of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from San Francisco-area outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

The instrument can be easily integrated into outpatient visits in the busiest practices, he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD. Study participants, whose mean age is 67, were recruited from the Veterans Affairs medical centers of San Francisco and Palo Alto, Calif., the University of California at San Francisco Medical Center, and nine public health clinics in the Community Health Network of San Francisco.

NEW ORLEANS — A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study out of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from San Francisco-area outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

The instrument can be easily integrated into outpatient visits in the busiest practices, he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD. Study participants, whose mean age is 67, were recruited from the Veterans Affairs medical centers of San Francisco and Palo Alto, Calif., the University of California at San Francisco Medical Center, and nine public health clinics in the Community Health Network of San Francisco.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling said at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer. Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or related hospitalization. A moderately severe classification was noted for those who had a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible the fragmentation of the current mental health care system serves as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said. More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care to develop effective interventions for increasing screening rates in this population, she concluded.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling said at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer. Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or related hospitalization. A moderately severe classification was noted for those who had a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible the fragmentation of the current mental health care system serves as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said. More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care to develop effective interventions for increasing screening rates in this population, she concluded.

NEW ORLEANS — Women being treated for a mental health disorder may be getting shortchanged when it comes to preventive medical care, said Caroline C. Carney-Doebbeling, M.D.

A comparison of insurance claims data for 59,673 women with a mental illness diagnosis and 131,683 without one showed that the presence, type, and severity of the mental illness significantly influenced receipt of mammography during the 5-year period being considered, Dr. Carney-Doebbeling said at the annual meeting of the Society of General Internal Medicine.

The mammography rates for women diagnosed with severe anxiety and mood disorders “were abysmal,” she noted.

Compared with women with no mental illness diagnosis, women who were classified as having moderately severe or highly severe symptoms of mental illness had odds ratios of 62% and 38%, respectively, for receiving a mammogram. Women with “low-severity” mental health symptoms were as likely as their peers without mental illness to undergo mammography, said Dr. Carney-Doebbeling of the University of Iowa.

The type of diagnosis also influenced mammography rates. “Women with any psychotic disorder, regardless of the severity, received fewer than half the number of mammograms as women in the control group,” Dr. Carney-Doebbeling said.

The women who fared the worst were those with highly severe mental illness and a diagnosis of a somatoform disorder. “The likelihood of receiving a mammography in these women was only 17%,” she said.

Data for the study came from an analysis of all Wellmark Blue Cross Blue Shield claims records during 1996–2001 for women aged 40–65 years who had filed at least one medical claim and who did not have a diagnosis of breast cancer. Women were classified as having a mental health disorder if this diagnosis was reflected in at least one claim during the eligibility period.

The criterion for low-severity mental health disorder was the absence of a dual mental health diagnosis or related hospitalization. A moderately severe classification was noted for those who had a dual diagnosis or hospitalization; a high-severity classification required the presence of both.

The investigators used multivariate logistic regression to compare mammography rates among women who had any mental illness diagnosis with those who had none, and to determine if there were associations between specific type and severity of mental health disorders. The analyses were adjusted for age, number of months of eligibility, rural residence, and number of non-mental health visits to primary care physicians and ob.gyns.

“With few exceptions, mental illness was a significant barrier to mammography receipt among women in this study,” Dr. Carney-Doebbeling said. “There is no clear indication of why this should be, considering all of the women were insured and should have had similar access to mammography facilities.”

It is possible the fragmentation of the current mental health care system serves as a barrier, she said, “as prior studies have noted that women with chronic mental health disorders often have difficulty with care disparities.”

“These data have significant implications for the overall health of women,” particularly in light of the high incidence and prevalence of mood and anxiety disorders in women, Dr. Carney-Doebbeling said. More research is needed to understand the relationship between the underuse of mammography and mental illness/mental health care to develop effective interventions for increasing screening rates in this population, she concluded.

BOSTON – Children who experiment with smoking even minimally before age 11 are more likely to take up smoking as teens than are their nonexposed peers, Jennifer Fidler reported at the annual meeting of the Society of Behavioral Medicine.

Because there is an apparent protracted period of dormant vulnerability–or “sleeper effect”–before social or environmental conditions trigger the onset of a stable smoking pattern, “interventions should target the prevention of first, short experimentation with smoking,” she said.

Using data from the 5-year longitudinal Health and Behavior in Teenagers Study (HABITS) of 5,000 British adolescents, which included yearly assessments of smoking status, Ms. Fidler and her colleagues at University College London calculated the probability of becoming a smoker as a function of having tried smoking just once by age 11.

Early one-time triers were significantly more likely than those who had never smoked at age 11–12 to take up current smoking for the first time up to 3 years later. The study data showed that very few participants reported current smoking at age 11–12, “making this an ideal time to study smoking progression,” she said.

After the investigators controlled for personal factors known to influence smoking–including ethnicity, socioeconomic deprivation, gender, family/peer smoking, and conduct problems–logistic regression analyses confirmed a statistically significant sleeper effect, Ms. Fidler said. The adjusted odds for taking up smoking at 1, 2, and 3 years following initial exposure relative to same-age nonexposed peers were 6.3, 2.9, and 2.1, respectively.

“Only after 4 years of nonsmoking following an initial try before age 11 was the difference between triers and nontriers not significant,” she said.

Various behavioral and biophysical conditions may contribute to the sleeper effect, including the possibility “that early nicotine exposure alters neurologic reward pathways,” Ms. Fidler said. “Or it may be that the first smoking experience breaks down such barriers to smoking as fear and insecurities about how to smoke, or that personality traits leading to the initial try may continue to stand individuals at an increased risk.”

From a policy perspective, the findings suggest that community interventions should be aimed at preventing early experimentation with smoking to reduce the risk of smoking uptake, Ms. Fidler said. Additionally, interventions should target adolescents who report having tried smoking, albeit just once, because of their increased risk of later smoking.

BOSTON – Children who experiment with smoking even minimally before age 11 are more likely to take up smoking as teens than are their nonexposed peers, Jennifer Fidler reported at the annual meeting of the Society of Behavioral Medicine.

Because there is an apparent protracted period of dormant vulnerability–or “sleeper effect”–before social or environmental conditions trigger the onset of a stable smoking pattern, “interventions should target the prevention of first, short experimentation with smoking,” she said.

Using data from the 5-year longitudinal Health and Behavior in Teenagers Study (HABITS) of 5,000 British adolescents, which included yearly assessments of smoking status, Ms. Fidler and her colleagues at University College London calculated the probability of becoming a smoker as a function of having tried smoking just once by age 11.

Early one-time triers were significantly more likely than those who had never smoked at age 11–12 to take up current smoking for the first time up to 3 years later. The study data showed that very few participants reported current smoking at age 11–12, “making this an ideal time to study smoking progression,” she said.

After the investigators controlled for personal factors known to influence smoking–including ethnicity, socioeconomic deprivation, gender, family/peer smoking, and conduct problems–logistic regression analyses confirmed a statistically significant sleeper effect, Ms. Fidler said. The adjusted odds for taking up smoking at 1, 2, and 3 years following initial exposure relative to same-age nonexposed peers were 6.3, 2.9, and 2.1, respectively.

“Only after 4 years of nonsmoking following an initial try before age 11 was the difference between triers and nontriers not significant,” she said.

Various behavioral and biophysical conditions may contribute to the sleeper effect, including the possibility “that early nicotine exposure alters neurologic reward pathways,” Ms. Fidler said. “Or it may be that the first smoking experience breaks down such barriers to smoking as fear and insecurities about how to smoke, or that personality traits leading to the initial try may continue to stand individuals at an increased risk.”

From a policy perspective, the findings suggest that community interventions should be aimed at preventing early experimentation with smoking to reduce the risk of smoking uptake, Ms. Fidler said. Additionally, interventions should target adolescents who report having tried smoking, albeit just once, because of their increased risk of later smoking.

BOSTON – Children who experiment with smoking even minimally before age 11 are more likely to take up smoking as teens than are their nonexposed peers, Jennifer Fidler reported at the annual meeting of the Society of Behavioral Medicine.

Because there is an apparent protracted period of dormant vulnerability–or “sleeper effect”–before social or environmental conditions trigger the onset of a stable smoking pattern, “interventions should target the prevention of first, short experimentation with smoking,” she said.

Using data from the 5-year longitudinal Health and Behavior in Teenagers Study (HABITS) of 5,000 British adolescents, which included yearly assessments of smoking status, Ms. Fidler and her colleagues at University College London calculated the probability of becoming a smoker as a function of having tried smoking just once by age 11.

Early one-time triers were significantly more likely than those who had never smoked at age 11–12 to take up current smoking for the first time up to 3 years later. The study data showed that very few participants reported current smoking at age 11–12, “making this an ideal time to study smoking progression,” she said.

After the investigators controlled for personal factors known to influence smoking–including ethnicity, socioeconomic deprivation, gender, family/peer smoking, and conduct problems–logistic regression analyses confirmed a statistically significant sleeper effect, Ms. Fidler said. The adjusted odds for taking up smoking at 1, 2, and 3 years following initial exposure relative to same-age nonexposed peers were 6.3, 2.9, and 2.1, respectively.

“Only after 4 years of nonsmoking following an initial try before age 11 was the difference between triers and nontriers not significant,” she said.

Various behavioral and biophysical conditions may contribute to the sleeper effect, including the possibility “that early nicotine exposure alters neurologic reward pathways,” Ms. Fidler said. “Or it may be that the first smoking experience breaks down such barriers to smoking as fear and insecurities about how to smoke, or that personality traits leading to the initial try may continue to stand individuals at an increased risk.”

From a policy perspective, the findings suggest that community interventions should be aimed at preventing early experimentation with smoking to reduce the risk of smoking uptake, Ms. Fidler said. Additionally, interventions should target adolescents who report having tried smoking, albeit just once, because of their increased risk of later smoking.

NEW ORLEANS – Fear and misconceptions about how antidepressant medication works contribute to older adults' reluctance to use pharmacologic treatment for depression, a qualitative study has shown.

“Depression is highly prevalent but undertreated in elderly primary care patients, despite the availability of effective medications,” Jane L. Givens, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Among the patient-level factors preventing appropriate treatment in this population are fear of addiction, concern about experiencing unnatural happiness or inability to feel grief and sadness, and fear of side effects.

Dr. Givens and her colleagues at the University of Pennsylvania in Philadelphia recruited a subsample of 68 older adults (mean age 75 years) with depression who participated in one of two qualitative, randomized treatment studies–the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) or the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E).

Each of the patients in the study participated in semistructured home-based interviews.

Those interviews were subsequently audiotaped, transcribed, and entered into qualitative data analysis software for coding and analysis.

The investigators used the coded transcripts to identify key features of the patient narratives concerning reluctance or refusal to consider drug therapy for depression.

“Four themes emerged from this review,” according to Dr. Givens.

“Many expressed a fear of needing to take antidepressants for the rest of their lives or of becoming addicted.

Some did not want to be unnaturally happy or to mute their capacity to feel sadness or to 'face reality.'”

Other patients resisted treating symptoms of sadness associated with the loss of a loved one, and some had previous histories of treatment with psychiatric medications, including tranquilizers, and were concerned about the side effects, particularly sedation, Dr. Givens noted.

Many studies have linked depression to excess morbidity and mortality in elderly patients because of insufficient screening and detection and inadequate treatment.

The findings of this study suggest that when it comes to the elderly, identifying depressed patients and offering them pharmacologic therapy may not be enough. “There is a need for more patient education and dialogue about the characteristics of current antidepressant therapy,” taking specific care to correct lingering misconceptions, she concluded.

NEW ORLEANS – Fear and misconceptions about how antidepressant medication works contribute to older adults' reluctance to use pharmacologic treatment for depression, a qualitative study has shown.

“Depression is highly prevalent but undertreated in elderly primary care patients, despite the availability of effective medications,” Jane L. Givens, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Among the patient-level factors preventing appropriate treatment in this population are fear of addiction, concern about experiencing unnatural happiness or inability to feel grief and sadness, and fear of side effects.

Dr. Givens and her colleagues at the University of Pennsylvania in Philadelphia recruited a subsample of 68 older adults (mean age 75 years) with depression who participated in one of two qualitative, randomized treatment studies–the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) or the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E).

Each of the patients in the study participated in semistructured home-based interviews.

Those interviews were subsequently audiotaped, transcribed, and entered into qualitative data analysis software for coding and analysis.

The investigators used the coded transcripts to identify key features of the patient narratives concerning reluctance or refusal to consider drug therapy for depression.

“Four themes emerged from this review,” according to Dr. Givens.

“Many expressed a fear of needing to take antidepressants for the rest of their lives or of becoming addicted.

Some did not want to be unnaturally happy or to mute their capacity to feel sadness or to 'face reality.'”

Other patients resisted treating symptoms of sadness associated with the loss of a loved one, and some had previous histories of treatment with psychiatric medications, including tranquilizers, and were concerned about the side effects, particularly sedation, Dr. Givens noted.

Many studies have linked depression to excess morbidity and mortality in elderly patients because of insufficient screening and detection and inadequate treatment.

The findings of this study suggest that when it comes to the elderly, identifying depressed patients and offering them pharmacologic therapy may not be enough. “There is a need for more patient education and dialogue about the characteristics of current antidepressant therapy,” taking specific care to correct lingering misconceptions, she concluded.

NEW ORLEANS – Fear and misconceptions about how antidepressant medication works contribute to older adults' reluctance to use pharmacologic treatment for depression, a qualitative study has shown.

“Depression is highly prevalent but undertreated in elderly primary care patients, despite the availability of effective medications,” Jane L. Givens, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Among the patient-level factors preventing appropriate treatment in this population are fear of addiction, concern about experiencing unnatural happiness or inability to feel grief and sadness, and fear of side effects.

Dr. Givens and her colleagues at the University of Pennsylvania in Philadelphia recruited a subsample of 68 older adults (mean age 75 years) with depression who participated in one of two qualitative, randomized treatment studies–the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) or the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E).

Each of the patients in the study participated in semistructured home-based interviews.

Those interviews were subsequently audiotaped, transcribed, and entered into qualitative data analysis software for coding and analysis.

The investigators used the coded transcripts to identify key features of the patient narratives concerning reluctance or refusal to consider drug therapy for depression.

“Four themes emerged from this review,” according to Dr. Givens.

“Many expressed a fear of needing to take antidepressants for the rest of their lives or of becoming addicted.

Some did not want to be unnaturally happy or to mute their capacity to feel sadness or to 'face reality.'”

Other patients resisted treating symptoms of sadness associated with the loss of a loved one, and some had previous histories of treatment with psychiatric medications, including tranquilizers, and were concerned about the side effects, particularly sedation, Dr. Givens noted.

Many studies have linked depression to excess morbidity and mortality in elderly patients because of insufficient screening and detection and inadequate treatment.

The findings of this study suggest that when it comes to the elderly, identifying depressed patients and offering them pharmacologic therapy may not be enough. “There is a need for more patient education and dialogue about the characteristics of current antidepressant therapy,” taking specific care to correct lingering misconceptions, she concluded.

NEW ORLEANS — Depressed patients with heart disease are less likely than their nondepressed peers to follow risk-reduction behaviors after acute coronary syndromes, and they are less likely to adhere to their heart medications, two studies have shown.

The findings may help explain previous findings linking depression to increased mortality in patients with heart disease, according to Ian M. Kronish, M.D., of Mount Sinai Medical School in New York.

The studies enrolled 421 patients at three university hospitals who had experienced an acute coronary syndrome (ACS) in the week prior to their enrollment. Of these, 355 patients completed the study's 3-month follow-up.

The investigators used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and at 3 months. A BDI score of 10 or higher indicated depression of at least mild to moderate severity.

They also assessed risk-factor-modification behavior, as reported by the patient, at 3 months. The risk-reduction behaviors that were considered were smoking cessation, medication compliance, exercise, cardiac rehabilitation, and diet modification, Dr. Kronish reported at the annual meeting of the Society of General Internal Medicine.

The investigators compared differences in risk-reduction behaviors in patients who had BDI scores less than 10 both at hospitalization and at 3 months (never depressed), those who had BDI scores of 10 or more at hospitalization and less than 10 at 3 months (remitted depressed), and those who had BDI scores of 10 or more at both time points (persistently depressed). “We did not include the small number of patients who became newly depressed at 3 months,” Dr. Kronish said.

Compared with never-depressed patients, both remitted-depressed and persistently depressed patients reported significantly lower adherence to smoking cessation, medications, exercise, cardiac rehabilitation, and diet modification. In addition, patients with persistent depression were significantly less likely than those with remitted depression to quit smoking, exercise, or participate in cardiac rehabilitation.

The average age of patients in the study was 61 years. Socioeconomic status, severity of cardiac disease, and comorbidities were similar across the comparison groups.

“Adherence to these preventive behaviors reduces the risk of subsequent cardiac events. The fact that depressed patients were significantly less likely to participate in risk-reducing activities may in part explain why depression predicts mortality post ACS,” Dr. Kronish said.

Results from another investigation, the Heart and Soul Study (conducted at the University of California, San Francisco) echo the findings of the Mount Sinai study with regard to medication adherence. Mary A. Whooley, M.D., and colleagues performed a cross-sectional study of 940 outpatients with stable coronary heart disease who were taking a cardiac medication (β-blocker, renin-angiotensin system inhibitor, aspirin, or statin).

The investigators assessed current major depression using the Diagnostic Interview Schedule and asked all the participants the question, “Overall, in the past month, how often did you take your medications as the doctor prescribed?” Patients who said they took their medication all the time or nearly all the time were considered adherent. Those who reported taking their medication most of the time, about half the time, or less than half the time were considered nonadherent.

Of the 940 patients, 204 had current depression. Of these, 28 patients (14%) were nonadherent, compared with 40 (5%) of the 736 nondepressed patients. Logistic regression showed that the odds ratio for nonadherence among depressed individuals was 2.8, and this persisted after adjustment for potential confounding variables, including age, ethnicity, education, cognitive function, and measures of cardiac disease severity, Dr. Whooley reported.

“This association was similar in users and nonusers of aspirin, renin-angiotensin system inhibitors, and statins, but differed in users and nonusers of statins,” she said. Depression was “strongly associated” with medication nonadherence among the 590 participants taking β-blockers but not among the participants not taking them, she said.

NEW ORLEANS — Depressed patients with heart disease are less likely than their nondepressed peers to follow risk-reduction behaviors after acute coronary syndromes, and they are less likely to adhere to their heart medications, two studies have shown.

The findings may help explain previous findings linking depression to increased mortality in patients with heart disease, according to Ian M. Kronish, M.D., of Mount Sinai Medical School in New York.

The studies enrolled 421 patients at three university hospitals who had experienced an acute coronary syndrome (ACS) in the week prior to their enrollment. Of these, 355 patients completed the study's 3-month follow-up.

The investigators used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and at 3 months. A BDI score of 10 or higher indicated depression of at least mild to moderate severity.

They also assessed risk-factor-modification behavior, as reported by the patient, at 3 months. The risk-reduction behaviors that were considered were smoking cessation, medication compliance, exercise, cardiac rehabilitation, and diet modification, Dr. Kronish reported at the annual meeting of the Society of General Internal Medicine.

The investigators compared differences in risk-reduction behaviors in patients who had BDI scores less than 10 both at hospitalization and at 3 months (never depressed), those who had BDI scores of 10 or more at hospitalization and less than 10 at 3 months (remitted depressed), and those who had BDI scores of 10 or more at both time points (persistently depressed). “We did not include the small number of patients who became newly depressed at 3 months,” Dr. Kronish said.

Compared with never-depressed patients, both remitted-depressed and persistently depressed patients reported significantly lower adherence to smoking cessation, medications, exercise, cardiac rehabilitation, and diet modification. In addition, patients with persistent depression were significantly less likely than those with remitted depression to quit smoking, exercise, or participate in cardiac rehabilitation.

The average age of patients in the study was 61 years. Socioeconomic status, severity of cardiac disease, and comorbidities were similar across the comparison groups.

“Adherence to these preventive behaviors reduces the risk of subsequent cardiac events. The fact that depressed patients were significantly less likely to participate in risk-reducing activities may in part explain why depression predicts mortality post ACS,” Dr. Kronish said.

Results from another investigation, the Heart and Soul Study (conducted at the University of California, San Francisco) echo the findings of the Mount Sinai study with regard to medication adherence. Mary A. Whooley, M.D., and colleagues performed a cross-sectional study of 940 outpatients with stable coronary heart disease who were taking a cardiac medication (β-blocker, renin-angiotensin system inhibitor, aspirin, or statin).

The investigators assessed current major depression using the Diagnostic Interview Schedule and asked all the participants the question, “Overall, in the past month, how often did you take your medications as the doctor prescribed?” Patients who said they took their medication all the time or nearly all the time were considered adherent. Those who reported taking their medication most of the time, about half the time, or less than half the time were considered nonadherent.

Of the 940 patients, 204 had current depression. Of these, 28 patients (14%) were nonadherent, compared with 40 (5%) of the 736 nondepressed patients. Logistic regression showed that the odds ratio for nonadherence among depressed individuals was 2.8, and this persisted after adjustment for potential confounding variables, including age, ethnicity, education, cognitive function, and measures of cardiac disease severity, Dr. Whooley reported.

“This association was similar in users and nonusers of aspirin, renin-angiotensin system inhibitors, and statins, but differed in users and nonusers of statins,” she said. Depression was “strongly associated” with medication nonadherence among the 590 participants taking β-blockers but not among the participants not taking them, she said.

NEW ORLEANS — Depressed patients with heart disease are less likely than their nondepressed peers to follow risk-reduction behaviors after acute coronary syndromes, and they are less likely to adhere to their heart medications, two studies have shown.

The findings may help explain previous findings linking depression to increased mortality in patients with heart disease, according to Ian M. Kronish, M.D., of Mount Sinai Medical School in New York.

The studies enrolled 421 patients at three university hospitals who had experienced an acute coronary syndrome (ACS) in the week prior to their enrollment. Of these, 355 patients completed the study's 3-month follow-up.

The investigators used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and at 3 months. A BDI score of 10 or higher indicated depression of at least mild to moderate severity.

They also assessed risk-factor-modification behavior, as reported by the patient, at 3 months. The risk-reduction behaviors that were considered were smoking cessation, medication compliance, exercise, cardiac rehabilitation, and diet modification, Dr. Kronish reported at the annual meeting of the Society of General Internal Medicine.

The investigators compared differences in risk-reduction behaviors in patients who had BDI scores less than 10 both at hospitalization and at 3 months (never depressed), those who had BDI scores of 10 or more at hospitalization and less than 10 at 3 months (remitted depressed), and those who had BDI scores of 10 or more at both time points (persistently depressed). “We did not include the small number of patients who became newly depressed at 3 months,” Dr. Kronish said.

Compared with never-depressed patients, both remitted-depressed and persistently depressed patients reported significantly lower adherence to smoking cessation, medications, exercise, cardiac rehabilitation, and diet modification. In addition, patients with persistent depression were significantly less likely than those with remitted depression to quit smoking, exercise, or participate in cardiac rehabilitation.

The average age of patients in the study was 61 years. Socioeconomic status, severity of cardiac disease, and comorbidities were similar across the comparison groups.

“Adherence to these preventive behaviors reduces the risk of subsequent cardiac events. The fact that depressed patients were significantly less likely to participate in risk-reducing activities may in part explain why depression predicts mortality post ACS,” Dr. Kronish said.

Results from another investigation, the Heart and Soul Study (conducted at the University of California, San Francisco) echo the findings of the Mount Sinai study with regard to medication adherence. Mary A. Whooley, M.D., and colleagues performed a cross-sectional study of 940 outpatients with stable coronary heart disease who were taking a cardiac medication (β-blocker, renin-angiotensin system inhibitor, aspirin, or statin).

The investigators assessed current major depression using the Diagnostic Interview Schedule and asked all the participants the question, “Overall, in the past month, how often did you take your medications as the doctor prescribed?” Patients who said they took their medication all the time or nearly all the time were considered adherent. Those who reported taking their medication most of the time, about half the time, or less than half the time were considered nonadherent.

Of the 940 patients, 204 had current depression. Of these, 28 patients (14%) were nonadherent, compared with 40 (5%) of the 736 nondepressed patients. Logistic regression showed that the odds ratio for nonadherence among depressed individuals was 2.8, and this persisted after adjustment for potential confounding variables, including age, ethnicity, education, cognitive function, and measures of cardiac disease severity, Dr. Whooley reported.

“This association was similar in users and nonusers of aspirin, renin-angiotensin system inhibitors, and statins, but differed in users and nonusers of statins,” she said. Depression was “strongly associated” with medication nonadherence among the 590 participants taking β-blockers but not among the participants not taking them, she said.