The role of interpersonal sensitivity, social support, and quality of life in rural older adults.

The mental health of elderly individuals in rural areas is increasingly relevant as populations age and social structures change. While social support satisfaction is a well-established predictor of quality of life, interpersonal sensitivity symptoms may diminish this relation. The current study extends the findings of Scogin et al by investigating the relationship among interpersonal sensitivity, social support satisfaction, and quality of life among rural older adults and exploring the mediating role of social support in the relation between interpersonal sensitivity and quality of life (N = 128). Hierarchical regression revealed that interpersonal sensitivity and social support satisfaction predicted quality of life. In addition, bootstrapping resampling supported the role of social support satisfaction as a mediator between interpersonal sensitivity symptoms and quality of life. These results underscore the importance of nurses and allied health providers in assessing and attending to negative self-perceptions of clients, as well as the perceived quality of their social networks.

Predictors of quality of life in patients with diabetes mellitus in two tertiary health institutions in Ghana and Nigeria.

BACKGROUND: Patients with chronic diseases such as Type 2 diabetes mellitus (DM) usually have a relatively poor quality of life (QoL), because the cost of care (living expenses and health) or diet restrictions are heavily felt by these patients, and this is of a public health concern. However, limited data on DM QoL exist in Ghana and Nigeria. This makes it imperative for data to be collated in that regard. MATERIALS AND METHODS: We adopted the Strengthening The reporting of observational studies in epidemiology (STROBE) consensus checklist to survey the patients with DM seen at the diabetic clinic at the Department of Medicine of the Korle-Bu Teaching Hospital and University College Hospital, Ibadan, Nigeria. Patients with Type 2 DM aged 40 years and older were recruited by using systematic random sampling method. The World Health Organization Quality of Life-BREF, diabetes empowerment scale, and DM knowledge scale were used to assess QoL, patient empowerment, and knowledge of DM, respectively. The predictors of QoL were determined using multiple linear regression analyses. RESULTS: A total of 198 patients in Ghana and 203 patients in Nigeria completed the survey, with female-to-male ratio being 3:1 and 2:1, respectively. The overall QoL in both countries was relatively low: 56.19 ± 8.23 in Ghana and 64.34 ± 7.34 in Nigeria. In Ghana, significant correlates of higher scores on the QoL scale were medication adherence (P = 0.02) and employment status (P = 0.02). Among patients in Nigeria, employment status (P = 0.02) and DM empowerment (0.03) were significant predictors of QoL in patients with DM. CONCLUSION: Our study revealed an association between a number of psychosocial factors and QoL among patients with DM in Ghana and Nigeria.

Perceived discrimination and medication adherence in black hypertensive patients: the role of stress and depression.

OBJECTIVE: To examine the relationship between perceived discrimination and medication adherence among black people with hypertension and the role of stress and depressive symptoms in this relationship. Perceived racial discrimination has been associated with poor health outcomes in blacks; its relationship to medication adherence among hypertensive patients remains untested. METHODS: We measured perceived racial discrimination at baseline, stress and depressive symptoms at 6 months, and medication adherence at 12 months among patients enrolled in a 30-site cluster-randomized controlled trial testing a patient and physician-targeted intervention to improve blood pressure. A mediational method with bootstrapping (stratified by site) confidence intervals was used to estimate the indirect association between perceived discrimination and medication adherence through stress and depression. RESULTS: Of 1056 patients from 30 sites enrolled in the trial, 463 had complete data on all four measures at 6 and 12 months and were included in the analyses. Adjusting for clustering, perceived discrimination was associated with poor medication adherence (B = 0.138, p = .011) at 12 months, and with stress (B = 2.24, p = .001) and depression (B = 1.47, p = .001) at 6 months. When stress and depression were included in the model, there was a 65% reduction in the total association of perceived discrimination with medication adherence, and the relationship was no longer significant (B = 0.049, p = .35). CONCLUSIONS: Perceived discrimination is associated with poor medication adherence among hypertensive blacks, and stress and depressive symptoms may account for this relationship. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00233220.

Translational Research of the Acute Effects of Negative Emotions on Vascular Endothelial Health: Findings From a Randomized Controlled Study.

BACKGROUND: Provoked anger is associated with an increased risk of cardiovascular disease events. The underlying mechanism linking provoked anger as well as other core negative emotions including anxiety and sadness to cardiovascular disease remain unknown. The study objective was to examine the acute effects of provoked anger, and secondarily, anxiety and sadness on endothelial cell health. METHODS AND RESULTS: Apparently healthy adult participants (n=280) were randomized to an 8-minute anger recall task, a depressed mood recall task, an anxiety recall task, or an emotionally neutral condition. Pre-/post-assessments of endothelial health including endothelium-dependent vasodilation (reactive hyperemia index), circulating endothelial cell-derived microparticles (CD62E+, CD31+/CD42-, and CD31+/Annexin V+) and circulating bone marrow-derived endothelial progenitor cells (CD34+/CD133+/kinase insert domain receptor+ endothelial progenitor cells and CD34+/kinase insert domain receptor+ endothelial progenitor cells) were measured. There was a group×time interaction for the anger versus neutral condition on the change in reactive hyperemia index score from baseline to 40 minutes (P=0.007) with a mean±SD change in reactive hyperemia index score of 0.20±0.67 and 0.50±0.60 in the anger and neutral conditions, respectively. For the change in reactive hyperemia index score, the anxiety versus neutral condition group by time interaction approached but did not reach statistical significance (P=0.054), and the sadness versus neutral condition group by time interaction was not statistically significant (P=0.160). There were no consistent statistically significant group×time interactions for the anger, anxiety, and sadness versus neutral condition on endothelial cell-derived microparticles and endothelial progenitor cells from baseline to 40 minutes. CONCLUSIONS: In this randomized controlled experimental study, a brief provocation of anger adversely affected endothelial cell health by impairing endothelium-dependent vasodilation.

Development and evaluation of a novel, real time mobile telesonography system in management of patients with abdominal trauma: study protocol.

BACKGROUND: Despite the use of e-FAST in management of patients with abdominal trauma, its utility in prehospital setting is not widely adopted. The goal of this study is to develop a novel portable telesonography (TS) system and evaluate the comparability of the quality of images obtained via this system among healthy volunteers who undergo e-FAST abdominal examination in a moving ambulance and at the ED. We hypothesize that: (1) real-time ultrasound images of acute trauma patients in the pre-hospital setting can be obtained and transmitted to the ED via the novel TS system; and (2) Ultrasound images transmitted to the hospital from the real-time TS system will be comparable in quality to those obtained in the ED. METHODS: Study participants are three healthy volunteers (one each with normal, overweight and obese BMI category). The ultrasound images will be obtained by two ultrasound-trained physicians The TS is a portable sonogram (by Sonosite) interfaced with a portable broadcast unit (by Live-U). Two UTPs will conduct e-FAST examinations on healthy volunteers in moving ambulances and transmit the images via cellular network to the hospital server, where they are stored. Upon arrival in the ED, the same UTPs will obtain another set of images from the volunteers, which are then compared to those obtained in the moving ambulances by another set of blinded UTPs (evaluators) using a validated image quality scale, the Questionnaire for User Interaction Satisfaction (QUIS). DISCUSSION: Findings from this study will provide needed data on the validity of the novel TS in transmitting live images from moving ambulances to images obtained in the ED thus providing opportunity to facilitate medical care of a patient located in a remote or austere setting.

Transfusion in Root Replacement for Aortic Dissection: The STS Adult Cardiac Surgery Database Analysis.

BACKGROUND: Transfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for acute (Stanford) type A aortic dissection (July 2014 to June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity. RESULTS: Transfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell transfusion portended reduced short-term survival (odds ratio [OR] 2.00, P = .025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, P < .001), sepsis (OR 4.13, P < .001), and new dialysis-dependent renal failure (OR 2.43, P < .001). Women were more likely to require transfusion (OR 3.03, P < .001), as were patients who had coronary artery bypass (OR 1.57, P = .009), and those in shock (OR 2.27, P < .001). Valve-sparing aortic root replacement was associated with reduced transfusion requirements vs composite roots. Institutional case volume was not appreciably correlated with transfusion. CONCLUSIONS: Most patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality.

Directionality of the relationship between depressive symptom dimensions and C-reactive protein in patients with acute coronary syndromes.

OBJECTIVE: Previous theoretical models predict that elevated inflammation may predict later depressive symptoms, but bidirectional associations are possible. We examined whether depressive symptoms or inflammation predicts change in the other for a 3-month period in a sample of adults with acute coronary syndromes (ACS). METHODS: During hospitalization for their index ACS event (baseline) and then again 1 and 3 months later, 163 post-ACS patients completed the Beck Depression Inventory, a measure of depressive symptom severity with cognitive-affective and somatic-affective subscales. C-reactive protein (CRP) was also assessed at each visit; known correlates of depression and CRP were assessed at baseline. Path analyses were conducted to evaluate prospective associations between depressive symptoms and log-transformed CRP values and whether strength and/or directionality varied by specific depressive symptom dimensions. RESULTS: Baseline total depressive symptom severity predicted a smaller decrease in CRP from baseline to 1 month (unstandardized parameter estimates [B] = 0.04, p < .001) controlling for all covariates, as did baseline cognitive-affective depressive symptom severity (B = 0.10, p = .02). Baseline somatic-affective depressive symptom severity did not predict change in CRP (B = -0.002, p = .94). CRP did not predict 1- or 3-month change in total, cognitive-affective, or somatic-affective depressive symptom severity. The results did not differ for men and women. CONCLUSIONS: Greater cognitive-affective and total depressive symptom severity at the time of a cardiac event predicts a smaller decrease in CRP 1 month later, but there was no evidence in this study that CRP predicts change in depressive symptoms.

Complex trauma and Trauma-Focused Cognitive-Behavioral Therapy: How do trauma chronicity and PTSD presentation affect treatment outcome?

BACKGROUND: Traumatic experiences are common in youth and can be classified as acute (one incident or short-term) or complex (chronic exposure to multiple traumas) experiences. Posttraumatic stress disorder (PTSD) is a common response to trauma, often co-occurring with other mental health symptoms. According to the International Classification of Diseases, 11th Edition (World Health Organization, 2018), complex PTSD includes difficulties with affect regulation, interpersonal relationships, and self-blame. OBJECTIVE: The aims of this study were to evaluate trauma chronicity and PTSD presentation as moderators of outcomes of trauma-focused cognitive behavior therapy (TF-CBT). PARTICIPANTS AND SETTING: Participants included 176 youth and caregiver dyads who were participants in an ongoing effectiveness study of TF-CBT at a community-based clinic in NYC. METHODS: Multilevel modeling was used to examine longitudinal, within-subject variability. Moderation analyses were used to assess the role of trauma chronicity and levels of PTSD on change in the outcomes. RESULTS: There were no baseline differences between youth with acute versus chronic trauma. At baseline, participants who had PTSD plus 2 or 3 of the ICD-11 Complex PTSD symptom domains had significantly worse functioning than those with simple PTSD. We found significant improvement on most measures of PTSD and complex PTSD domains. Level of improvement was found to vary based on PTSD presentation at baseline. CONCLUSIONS: This is the first study to evaluate both trauma chronicity and PTSD presentation in the context of evidence-based treatment, and findings support the effectiveness of TF-CBT for simple and complex PTSD for youth who have experienced acute and chronic trauma.

An Exploratory Trial of Cognitive-Behavioral vs Client-Centered Therapies for Child-Mother Dyads Bereaved from Terrorism.

The study was an evaluation of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT; Cohen et al. 2017) with child-caregiver dyads who experienced the death of a loved one from terrorism, using a hybrid efficacy/effectiveness design in which there were no required minimum symptom levels. Forty children ages 4-17 years old whose fathers died in the line of duty on 9/11/2001 and their mothers participated in an RCT comparing TF-CBT and Client-Centered Therapy (CCT). At baseline, mothers' PTSD, depression, and prolonged grief symptoms were highly elevated, whereas children's were at normative levels. Using intent-to-treat analysis, condition-by-time interactions showed significantly greater symptom reduction for mothers receiving CBT than those receiving CCT. For the children, both treatments led to significant symptom improvements.

Uptake of Task-Strengthening Strategy for Hypertension (TASSH) control within Community-Based Health Planning Services in Ghana: study protocol for a cluster randomized controlled trial.

BACKGROUND: Physician shortage is a major barrier to hypertension (HTN) control in Ghana, with only one physician to 10,000 patients in 2015, thus limiting its capacity for HTN control at the primary care level such as the Community Health Planning and Services (CHPS) compounds, where most Ghanaians receive care. A Task-Shifting Strategy for HTN control (TASSH) based on the WHO Cardiovascular (CV) Risk Package is an evidence-based strategy for mitigating provider- and systems-level barriers to optimal HTN control. Despite its effectiveness, TASSH remains untested in CHPS zones. Additionally, primary care practices in low- and middle-income countries (LMICs) lack resources and expertise needed to coordinate multilevel system changes without assistance. The proposed study will evaluate the effectiveness of practice facilitation (PF) as a quality improvement strategy for implementing TASSH within CHPS zones in Ghana. METHODS: Guided by the Consolidated Framework for Implementation Research and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, we will evaluate, in a hybrid clinical effectiveness-implementation design, the effect of PF on the uptake of an evidence-based TASSH, among 700 adults who present to 70 CHPS zones with uncontrolled HTN. Components of the PF strategy include (a) an advisory board that provides leadership support for implementing the intervention within the CHPS zones and (b) trained task-strengthening facilitators (TSFs) who serve as practice coaches to provide training, and performance feedback to community health officers (CHOs) who will deliver TASSH at the CHPS zones. For this purpose, the TSFs are trained to identify, counsel, and refer adults with uncontrolled HTN to community health centers in Bono East Region of Ghana. DISCUSSION: Uptake of community-based evidence-supported interventions for hypertension control in Ghana is urgently needed to address the CVD epidemic and its associated morbidity, mortality, and societal costs. Findings from this study will provide policymakers and other stakeholders the "how to do it" empirical literature on the uptake of evidence-based task-strengthening interventions for HTN control in Ghana and will serve as a model for similar action in other low, middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03490695 . Registered on 6 April 2018. PROTOCOL VERSION AND DATE: Version 1, date: 21 August, 2019.

Provider communication effects medication adherence in hypertensive African Americans.

OBJECTIVE: To evaluate the effect of patients' perceptions of providers' communication on medication adherence in hypertensive African Americans. METHODS: Cross-sectional study of 439 patients with poorly controlled hypertension followed in community-based healthcare practices in the New York metropolitan area. Patients' rating of their providers' communication was assessed with a perceived communication style questionnaire,while medication adherence was assessed with the Morisky self-report measure. RESULTS: Majority of participants were female, low-income, and had high school level educations, with mean age of 58 years. Fifty-five percent reported being nonadherent with their medications; and 51% rated their provider's communication to be non-collaborative. In multivariate analysis adjusted for patient demographics and covariates (depressive symptoms, provider degree), communication rated as collaborative was associated with better medication adherence (beta=-.11, p=.03). Other significant correlates of medication adherence independent of perceived communication were age (beta=.13, p=.02) and depressive symptoms (beta=-.18, p=.001). CONCLUSION: Provider communication rated as more collaborative was associated with better adherence to antihypertensive medications in a sample of low-income hypertensive African-American patients. PRACTICE IMPLICATIONS: The quality of patient-provider communication is a potentially modifiable element of the medical relationship that may affect health outcomes in this high-risk patient population.

Caregiver Report of Child Symptoms Predicts Attrition in Abuse-Specific Cognitive Behavioral Therapies.

A common critique of empirically supported treatments for abuse-related psychopathology is attrition during critical phases of therapy (i.e., exposure). The goal of this study was to examine whether child and caregiver symptoms were predictive of attrition among families in abuse-specific cognitive-behavioral therapies (CBTs). Children ( N = 104) and their caregivers completed baseline assessments of internalizing symptoms, externalizing problems, and post-traumatic stress disorder (PTSD) and were enrolled in abuse-specific CBTs. Logistic regressions were conducted with baseline symptoms as predictor variables and treatment status (attrition vs. completion) as the criterion variable. Caregiver report of child internalizing symptoms showed the predicted quadratic relation to attrition. Caregiver report of child externalizing symptoms at moderate and high (vs. low) levels was associated with attrition. Child self-report and caregiver self-report of symptoms were not associated with the dyad's attrition. These results underscore the importance of attending to caregivers' initial perceptions of children's symptoms in abuse-specific therapy.

Putative mechanisms Underlying Myocardial infarction onset and Emotions (PUME): a randomised controlled study protocol.

INTRODUCTION: The experience of negative emotions (eg, anger, anxiety and sadness) is associated with an increased short-term risk of incident cardiovascular disease (CVD) events, independent of traditional CVD risk factors. Impairment in endothelial function is one possible biological mechanism which may explain the association between negative emotions and incident CVD events. This laboratory-based, single-blind, randomised controlled experimental study aims to investigate the impact of induced negative emotions including anger, anxiety and sadness on endothelial function. METHODS AND ANALYSIS: In a between-subjects design, 280 healthy participants are randomised to one of four experimental negative emotion inductions: anger, anxiety, sadness or a neutral condition. Endothelium-dependent vasodilation, circulating levels of endothelial cell-derived microparticles and bone marrow-derived endothelial progenitor cells, and indices of nitric oxide inhibition are assessed before and 3, 40, 70 and 100 min after negative emotion induction. Finally, in a subsample of 84 participants, the potential moderating effects of cardiorespiratory fitness and habitual physical activity on the adverse effects of an acute negative emotion on endothelial function are investigated. ETHICS AND DISSEMINATION: This study is conducted in compliance with the Helsinki Declaration and the Columbia University Medical Center Institutional Review Board. The results of the study will be disseminated at several research conferences and as published articles in peer reviewed journals. The study will be implemented and reported in line with the SPIRIT statement. TRIAL REGISTRATION NUMBER: NCT01909895; Pre-results.

Validation of Nurse Practitioner Primary Care Organizational Climate Questionnaire: A New Tool to Study Nurse Practitioner Practice Settings.

BACKGROUND AND PURPOSE: Favorable organizational climate in primary care settings is necessary to expand the nurse practitioner (NP) workforce and promote their practice. Only one NP-specific tool, the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), measures NP organizational climate. We confirmed NP-PCOCQ's factor structure and established its predictive validity. METHODS: A crosssectional survey design was used to collect data from 314 NPs in Massachusetts in 2012. Confirmatory factor analysis and regression models were used. RESULTS: The 4-factor model characterized NP-PCOCQ. The NP-PCOCQ score predicted job satisfaction (beta = .36; p < .001) and intent to leave job (odds ratio = .28; p = .011). CONCLUSION: NP-PCOCQ can be used by researchers to produce new evidence and by administrators to assess organizational climate in their clinics. Further testing of NP-PCOCQ is needed.

Development of the Healthcare Triggering Questionnaire in adult sexual abuse survivors.

OBJECTIVE: One in 4 women and 1 in 10 men in the United States are survivors of sexual abuse (SA). For these survivors, healthcare experiences may trigger memories, thoughts, feelings or sensations related to this past abuse. Such triggering can be associated with negative responses to healthcare (e.g., anxiety, avoidance). However, to date, no healthcare triggering assessment tool exists. Therefore, the study goal was to describe the prevalence of healthcare triggering, to develop a brief Healthcare Triggering Questionnaire (HTQ), and to examine its initial validity. METHOD: An initial pool of 117 items was developed based on previous research. Two-parameter logistic item response theory models were used to develop the scales. SA survivors [male (n = 233), female (n = 222)] and a comparison group of non-SA individuals [male (n = 114), female (n = 106)] were recruited through Amazon Mechanical Turk and completed the study anonymously online. RESULTS: Three 10-item scales were developed: (a) the HTQ-M for males; (b) the HTQ-F for females; and (c) the HTQ-U (unisex) for all respondents. The results supported the utility and initial validity of the gender-specific and unisex scales. CONCLUSIONS: The HTQ scales are a psychometrically sound approach to evaluating healthcare triggering experienced by adult sexual abuse survivors. The HTQ may be considered for use by researchers interested in studying healthcare triggering, healthcare retraumatization, and healthcare adherence. The HTQ may also be of use to clinicians interested in identifying trauma survivors who are more likely to experience triggering in healthcare settings. (PsycINFO Database Record

Effects of aggressive versus conventional lipid-lowering therapy by simvastatin on human atherosclerotic lesions: a prospective, randomized, double-blind trial with high-resolution magnetic resonance imaging.

OBJECTIVES: This study sought to compare the effects of aggressive and conventional lipid lowering by two different dosages of the same statin on early human atherosclerotic lesions using serial noninvasive magnetic resonance imaging (MRI). BACKGROUND: Regression of atherosclerotic lesions by lipid-lowering therapy has been reported. METHODS: Using a double-blind design, newly diagnosed hypercholesterolemic patients (n = 51) with asymptomatic aortic and/or carotid atherosclerotic plaques were randomized to 20 mg/day (n = 29) or 80 mg/day (n = 22) simvastatin. Mean follow-up was 18.1 months. A total of 93 aortic and 57 carotid plaques were detected and sequentially followed up by MRI every six months after lipid-lowering initiation. The primary MRI end point was change in vessel wall area (VWA) as a surrogate for atherosclerotic burden. RESULTS: Both statin doses reduced significantly total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) versus baseline (p < 0.001). Total cholesterol decreased by 26% versus 33% and LDL-C by 36% versus 46% in the conventional (20 mg) versus aggressive (80 mg) simvastatin groups, respectively. Although the simvastatin 80-mg group had significantly higher baseline TC and LDL-C levels, both groups reached similar absolute values after treatment. A significant reduction in VWA was already observed by 12 months. No difference on vascular effects was detected between the randomized doses. Post-hoc analysis showed that patients reaching mean on-treatment LDL-C < or = 100 mg/dl had larger decreases in plaque size. CONCLUSIONS: Effective and protracted lipid-lowering therapy with simvastatin is associated with a significant regression of atherosclerotic lesions. No difference in vessel wall changes was seen between high and conventional doses of simvastatin. Changes in vessel wall parameters are more related to LDL-C reduction rather than to the dose of statin.

Persistent depressive symptoms lower aspirin adherence after acute coronary syndromes.

BACKGROUND: Even mild depressive symptoms during hospitalization are an independent risk factor for mortality after acute coronary syndromes (ACS). The mortality risk is highest for patients whose depressive symptoms persist after ACS. Low adherence to medications that reduce the risk of subsequent cardiac events may be one of the mechanisms underlying the relationship between persistent depression and risk of ACS recurrence. We compared electronically monitored adherence to aspirin in 3 groups of patients with ACS: persistently depressed, remittent depressed, and persistently nondepressed. METHODS: Using an electronic device stored in the cap of a pill bottle, we monitored aspirin adherence over a 3-month period in 165 consecutive patients recruited within 1 week of an ACS event. Depressive symptom severity was assessed by using the Beck Depression Inventory at baseline and at 3 months. Adherence was determined by the percentage of days aspirin was taken as prescribed. RESULTS: Among the patients, 10.5% of nondepressed patients, 9.8% of remittent depressed patients, and 42.1% of persistently depressed patients took aspirin < or of the time (P < .001). Examined a different way, the mean percentage of days that the correct aspirin dosage (1 pill per day for all patients) was taken was significantly lower in the persistently depressed patients (76.1%) than in the remittent depressed (87.4%) and persistently nondepressed (89.5%) patients (P < .01). Remittent depressed patients did not differ from nondepressed patients. Results remained unchanged after controlling for baseline depressive symptom severity and medical comorbidity. CONCLUSIONS: Poor medication adherence--a potentially modifiable behavior--may contribute to the high mortality risk observed in patients with persistent symptoms of depression after ACS.