The impact of supervision on internal medicine residents' attitudes and management of depression in primary care: a pilot study.

OBJECTIVE: The authors examined the effect of supervision on internal medicine residents' attitudes toward and management of depression. METHOD: Internal medicine residents completed a survey during preclinical conferences. The survey included a published, validated questionnaire, the Depression Attitude Questionnaire, and items developed by the researchers. RESULTS: Of residents in attendance on the day of survey administration, 94% (51/54) agreed to participate. The study sample contained 39% of the 139-member residency program. About half (49%) reported feeling uncomfortable managing depression. Perceived training adequacy was correlated with a greater feeling of ease managing depression. Most residents reported screening ≤20% of patients for depression, although 71% indicated they are more likely to screen if it were a priority for their supervisor. Fifty-eight percent indicated that supervisors' attitudes affect their own attitudes. However, significant correlations between supervisor and resident attitudes were not observed. CONCLUSION: The results of this pilot study suggest that supervision can encourage screening and promote resident preparedness to manage depression.

Psychobiology of depression/distress in congestive heart failure.

Heart failure affects millions of Americans and new diagnosis rates are expected to almost triple over the next 30 years as our population ages. Affective disorders including clinical depression and anxiety are common in patients with congestive heart failure. Furthermore, the presence of these disorders significantly impacts quality of life, medical outcomes, and healthcare service utilization. In recent years, the literature has attempted to describe potential pathophysiologic mechanisms relating affective disorders and psychosocial stress to heart failure. Several potential mechanisms have been proposed including autonomic nervous system dysfunction, inflammation, cardiac arrhythmias, and altered platelet function. These mechanisms are reviewed in this article. Additional novel mechanisms such as mental stress-induced myocardial ischemia are also discussed.

Association of beta1-adrenergic receptor genetic polymorphism with mental stress-induced myocardial ischemia in patients with coronary artery disease.

BACKGROUND: Mental stress is associated with sympathetic adrenergic stimulation and concomitant increases in blood pressure and heart rate. Heritable individual differences in cardiovascular functional response to mental stress may arise from genetic variations in adrenergic receptors, which might produce excessive hemodynamic response to mental stress or create other conditions favoring the development of myocardial ischemia. METHODS: We examined the relationship between hemodynamic response to mental stress and mental stress-induced myocardial ischemia (MSIMI) and 5 common functional polymorphisms of beta1-adrenergic receptors (ADRB1 [OMIM 109630, accession No. 153]) and beta2-adrenergic receptors (ADRB2 [OMIM 109690, accession No. 154]). Participants were 148 patients (45 female [30.4%]) with a documented history of coronary artery disease and a mean (SD) age of 64 (9) years. Patients were enrolled between December 9, 2004, and February 21, 2007. Mental stress was induced via a public-speaking task. Rest and stress myocardial perfusion imaging was performed. Blood samples were collected and genotyped for 5 common functional polymorphisms of ADRB1 (codons 49 and 389) and ADRB2 (codons 16 and 27 and nucleotide 523). The main outcome measures were hemodynamic and myocardial ischemic responses to mental stress. Mental stress-induced myocardial ischemia was defined as new or worsening perfusion defects during mental stress with a summed (stress to rest) difference score of at least 3. RESULTS: A statistically significant difference was noted in the prevalences of MSIMI between genotype groups for codon 49 of ADRB1. Mental stress-induced myocardial ischemia occurred 3 times more frequently among patients homozygous for the Ser49 allele (31 of 104 patients [29.8%]) compared with 4 of 39 patients (10.3%) among the Gly49 allele carriers (P=.02). The adjusted odds ratio for the effect of genotype (Ser/Ser vs Gly carriers) on MSIMI was 3.9 (95% confidence interval, 1.2-12.5) (P=.02). CONCLUSIONS: Our findings indicate an association between a common genetic variation in ADRB1 and myocardial ischemic response to mental stress in patients with coronary artery disease. This polymorphic genetic marker may help identify patients at increased risk for mental stress-induced adverse outcomes.

Depressive symptoms predict heart rate recovery after exercise treadmill testing in patients with coronary artery disease: results from the Psychophysiological Investigation of Myocardial Ischemia study.

BACKGROUND: Depression is associated with increased risk of death among patients with coronary disease. Cardiovascular autonomic dysregulation may be one of the mechanisms by which depression exerts its effects on cardiovascular function. The purpose of this study was to determine whether depressive symptoms are associated with low heart rate variability (HRV) and prolonged HR recovery after exercise testing in patients with coronary artery disease (CAD). METHODS: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) was a large, multicenter study designed to assess psychological and physiological correlates of stress in patients with CAD. One hundred and eighty-eight patients with CAD as evidenced by at least 50% blockage of one major artery and a previous positive exercise stress test were included in this study. Patients included in this report were not taking beta blockers. Cardiovascular functioning was assessed by a modified Bruce protocol treadmill stress test. Measures of psychological functioning, including the Beck Depression Inventory (BDI), were also obtained. RESULTS: BDI scores were negatively correlated with HR recovery (r = -0.15, p = .04). Depression scores accounted for 3.5% of the variance in HR recovery when controlling for participant age (p < .01). Depressive symptoms were related to two HRV indices (ultra-low frequency, high frequency). CONCLUSIONS: Depressive symptoms are associated with cardiovascular autonomic nervous system dysfunction as assessed by HR recovery. This relationship is not merely due to an association of depression severity with beta blocker usage or a failure of depressed patients to achieve an adequate chronotropic response.

Social networks and incident stroke among women with suspected myocardial ischemia.

OBJECTIVE: To describe the prospective relationship between social networks and nonfatal stroke events in a sample of women with suspected myocardial ischemia. Social networks are an independent predictor of all-cause and cardiovascular mortality, but their relationship with stroke events in at-risk populations is largely unknown. METHOD: A total of 629 women (mean age = 59.6 +/- 11.6 years) were evaluated at baseline for cardiovascular disease risk factors as part of a protocol including coronary angiography; the subjects were followed over a median 5.9 years to track the incidence of cardiovascular events including stroke. Participants also completed the Social Network Index (SNI), measuring the presence/absence of 12 types of common social relationships. RESULTS: Stroke events occurred among 5.1% of the sample over follow-up. More isolated women were older and less educated, with higher rates of smoking and hypertension, and increased use of cardiovascular medications. Women with smaller social networks were also more likely to show elevations (scores of > or =10) on the Beck Depression Inventory (54% versus 41%, respectively; p = .003). Relative to women with higher SNI scores, Cox regression results indicated that more isolated women experienced strokes at greater than twice the rate of those with more social relationships after adjusting for covariates (hazard ratio = 2.7; 95% Confidence Interval = 1.1-6.7). CONCLUSIONS: Smaller social networks are a robust predictor of stroke in at-risk women, and the magnitude of the association rivals that of conventional risk factors.

Variability of myocardial ischemic responses to mental versus exercise or adenosine stress in patients with coronary artery disease.

BACKGROUND: Mental stress precipitates myocardial ischemia in a significant percentage of coronary artery disease (CAD) patients. Exercise or adenosine stresses produce different physiologic responses and cause myocardial ischemia via different mechanisms. Little is known about the comparative severity and location of myocardial ischemia provoked by these different stressors. In this study we sought to compare the within-individual ischemic responses to mental versus exercise or adenosine stress in a cohort of CAD patients. METHODS AND RESULTS: All patients underwent mental stress and either exercise or adenosine testing within a 1-week period. Mental stress was induced via a public speaking task. Rest-stress myocardial perfusion imaging was used with all testing protocols. Participants were 187 patients (65 women [35%]) with a documented history of CAD and a mean age of 64 +/- 9 years. Mental stress-induced myocardial ischemia (MSIMI) was less prevalent and frequently of less magnitude than exercise- or adenosine-induced ischemia. Ischemia induced by exercise or adenosine testing did not accurately predict the development or the location of MSIMI. The overall concordance between these stressors for provoking ischemia was weak (percent agreement, 71%; kappa [+/- SE], 0.26 +/- 0.07). In a minority of patients (11%) mental stress provoked ischemia in the absence of exercise- or adenosine-induced ischemia. Moreover, in patients who had myocardial ischemia during both stressors, there were significant within-individual differences in the coronary artery distribution of the ischemic regions. MSIMI was more likely to occur in a single-vessel distribution (86%) compared with exercise- or adenosine-induced ischemia (54%). The stressors had moderate agreement if the ischemic region was in the right coronary artery territory (percent agreement, 76%; kappa, 0.52 +/- 0.19) or the left anterior descending coronary artery (percent agreement, 76%; kappa, 0.51 +/- 0.19) and significantly lower agreement in the left circumflex territory (percent agreement, 62%; kappa, 0.22 +/- 0.18). CONCLUSIONS: Our findings indicate that mental and exercise or adenosine stresses provoke different myocardial ischemic responses. These observations suggest that exercise or adenosine testing may not adequately assess the likelihood of occurrence or severity of MSIMI and that different mechanisms are operative in each condition.

Coronary artery disease and depression: patients with more depressive symptoms have lower cardiovascular reactivity during laboratory-induced mental stress.

OBJECTIVE: To investigate the relationship between symptoms of depression and cardiovascular reactivity during mental stress in patients with coronary artery disease (CAD). Depressive symptoms are common in patients with CAD and are related to an increased risk of cardiac events and death. Some researchers have proposed that negative outcomes in depressed patients with CAD may be related to exaggerated cardiovascular reactivity and psychological stress. However, the data are unclear. METHODS: Patients with CAD (n = 128; mean age = 64 years) were recruited for this study. Participants underwent psychological stress testing and 2-day (stress/rest) radionuclide imaging. The Beck Depression Inventory (BDI) results were collected at baseline. Cardiac function data were also gathered and stress data were compared with baseline findings. RESULTS: The change in systolic blood pressure (SBP) from rest to stress was 47 +/- 18 (mean +/- standard deviation) mm Hg, diastolic blood pressure (DBP) = 30 +/- 11 mm Hg, double product difference (DP) = 5887 +/- 3095, and heart rate (HR) = 20 +/- 13 beats/minute (p < .001 for all). The BDI score was 8.7 +/- 5.6. The BDI score was negatively correlated with all hemodynamic variables, although only significant with stress SBP and DP, and HR and DP changes. BDI scores also predicted changes in HR and DP. HR remained significant in regression analyses controlling for other sample characteristics. CONCLUSIONS: This study showed a negative relationship between depressive symptoms and cardiovascular reactivity to mental stress. In contrast to the mechanism proposed by earlier researchers, this study suggests that decreased cardiovascular reactivity occurs with increased depressive symptomology. The mechanism by which this effect occurs and its clinical significance are still unknown.

Do men and women differ on measures of mental stress-induced ischemia?

OBJECTIVE: To consider the effects of gender on ischemia in a larger sample, with broadly defined coronary artery disease (CAD). Mental stress has been shown to cause transient myocardial ischemia in a significant percentage of people with CAD. However, little is known about the effects of mental stress on ischemic processes in women. Most studies to date either had few women or required a positive exercise stress test. METHODS: Participants (61 women, 93 men; average age = 63 years) had documented CAD (positive stress test, abnormal catheterization even with minimal disease, or previous myocardial infarction). They underwent mental stress testing and radionuclide perfusion imaging (stress/ rest). Cardiac function data were collected and stress was compared with baseline. The data were then submitted to a series of analyses of variance. RESULTS: A total of 50 (32%) participants exhibited reversible ischemia post psychological stress. This reflects a relative rate of 33% (n = 31 of 93) for men and 31% (n = 19 of 61) for women. No difference between men and women were observed on any measure of hemodynamic functioning (blood pressure, heart rate, or cardiac perfusion). CONCLUSIONS: Results of this study showed no significant differences between men and women on measures of hemodynamic functioning or cardiac perfusion.

Mental stress-induced myocardial ischemia in coronary artery disease patients with left ventricular dysfunction.

BACKGROUND: Reduced left ventricular ejection fraction (LVEF) is a risk factor for poor outcomes in patients with coronary artery disease (CAD). Mental stress-induced myocardial ischemia (MSIMI) also identifies a subset of CAD patients at increased risk for future cardiovascular events. Susceptibility to MSIMI in patients with CAD and reduced LVEF is unknown. METHODS AND RESULTS: We enrolled 182 patients (67 women) with a mean age of 64 years and a documented history of CAD in this study. Baseline resting ejection fraction was determined by use of technetium 99m sestamibi gated single photon emission computed tomography. Abnormal LVEF was defined as less than 45% for men and less than 50% for women (based on published norms for our software [Cedars-Sinai Medical Center]). All participants underwent mental stress testing with a public speaking task. Rest/stress myocardial perfusion single photon emission computed tomography was performed via conventional methodology. Images were visually compared for number and severity of perfusion defects by use of a scoring method from 0 to 4. A summed difference score was calculated as the difference between summed stress and rest scores. A score of greater than 3 was considered abnormal. MSIMI developed in 19% of patients with normal LVEF and 31% of those with reduced LVEF. There is no statistically significant difference between the two groups (P = .11). CONCLUSIONS: CAD patients with left ventricular dysfunction are equally susceptible to MSIMI as those with normal LVEF.

Initial heart rate and systolic blood pressure predict outcomes in chronic heart failure patients who are evaluated for cardiac transplant.

BACKGROUND: Heart rate (HR) and systolic blood pressure (SBP) are currently not considered among common clinical indicators of prognosis in patients referred for heart transplant (Htx). We sought to determine whether an initial hemodynamic profile of HR and SBP could be used to predict outcomes in chronic heart failure patients evaluated for Htx. METHODS: We analyzed the medical records of patients evaluated for Htx and obtained demographic and clinical data collected at the initial transplant clinic visit or inpatient encounter. We assigned patients to groups based on their HR and SBP. Groups were compared after follow-up for differences in freedom from death or Htx. RESULTS: From 1999 to 2003, 400 consecutive patients were considered by the local Htx medical review board. The median duration of follow-up was 26 months (interquartile range 1 to 45 months). Patients with initial >or= 90 beats per minute (bpm) and initial SBP < 100 mmHg ((n = 34) had worse New York Heart Association functional class (p=0.02), lower cardiac output ((p =0.02 ), and greater hyponatremia (>0.001;). These patients were more likely to be hospitalized at the time of referral (p >0.001) and more likely to have experienced death or Htx during follow-up than patients with other hemodynamic profiles (p = 0.001). CONCLUSIONS: A hemodynamic profile of HR and SBP can be used with other prognostic indicators to identify high-risk patients at the time of initial evaluation for Htx.

Pediatric behavior management techniques: a survey of predoctoral dental students.

Dental schools are increasingly incorporating behavioral management strategies into the curriculum; however, little is known about the efficacy of this instruction. The purposes of this study were to evaluate student exposure to several categories of behavioral management techniques, assess student opportunity to observe faculty use of these techniques, and determine the extent of students' personal use of various behavioral management techniques. Third-year dental students (n=98, X age=26.52; s=4.05) were administered a survey assessing their exposure to and willingness to use behavioral management strategies. Results indicated differences between the techniques students recalled being taught and what they indicated they plan to use in their own future clinical practices. Student technique endorsement also varied as a function of student age, gender, ethnicity, and patient age. Despite increasing concerns regarding the use of these techniques, a significant minority of students stated that they were taught to use hand-over-mouth, verbal intimidation, and various forms of active and passive restraint/immobilization. While appreciation for behavioral management strategies within the dental school curriculum was demonstrated by the amount of didactic exposure students received, the need for increased experiential training is evident. Furthermore, student endorsement of controversial techniques appears to reflect the changing view of these techniques within the professional dental community.

Modafinil facilitates performance on a delayed nonmatching to position swim task in rats.

Modafinil is a wake-promoting drug approved by the FDA for the treatment of narcolepsy. Recent evidence suggests that modafinil may improve learning and memory processes. To further evaluate possible cognitive properties associated with modafinil, male Sprague-Dawley rats were tested in a delayed nonmatching to position (DNMTP) task. A modified water maze allowed animals to make one of two choices for the location of the escape platform. Each trial consisted of two swims. On the information swim (IS), only one choice was open to the animal for escape. One minute later, a choice swim (CS) presented the animal with two choices with the escape platform in the opposite position. There were 10 trials per day for 10 days. Rats received 0, 30, 55, or 100 mg/kg ip of modafinil 30 min prior to testing. Locomotor activity was also assessed. Animals that received 55 and 100 mg/kg made significantly more correct choices, indicating that higher doses of modafinil learned the task faster than did controls. While animals that received 100 mg/kg did exhibit an enhancement of locomotor activity, this effect did not result in more efficient goal-directed behavior. The evidence is consistent with previous research showing that modafinil facilitates cognitive processes.

Implementing brief cognitive behavioral therapy in primary care: A pilot study.

Effective implementation strategies are needed to improve the adoption of evidence-based psychotherapy in primary care settings. This study provides pilot data on the test of an implementation strategy conducted as part of a multisite randomized controlled trial examining a brief cognitive-behavioral therapy versus usual care for medically ill patients in primary care, using a hybrid (type II) effectiveness/implementation design. The implementation strategy was multifaceted and included (1) modular-based online clinician training, (2) treatment fidelity auditing with expert feedback, and (3) internal and external facilitation to provide ongoing consultation and support of practice. Outcomes included descriptive and qualitative data on the feasibility and acceptability of the implementation strategy, as well as initial indicators of clinician adoption and treatment fidelity. Results suggest that a comprehensive implementation strategy to improve clinician adoption of a brief cognitive-behavioral therapy in primary care is feasible and effective for reaching high levels of adoption and fidelity.

Risk of obstructive sleep apnea lower in double reed wind musicians.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is caused by a collapse of the upper airway. Respiratory muscle training with a wind instrument (didgeridoo) in patients with moderate OSA has been previously shown to improve OSA symptomology. However, a survey of orchestra members did not indicate a difference in OSA risk between wind and non-wind instrumentalist. The present study examines whether playing of different wind instrument types may affect the risk of OSA. METHODS: A national sample of active musicians (n = 906) was surveyed through the internet. Participants' risk for OSA was determined by the Berlin Questionnaire. Additional survey items included questions about general health and musical experience. RESULTS: A binary logistic regression was conducted to determine if OSA risk was predicted by gender, age, number of years playing instrument, number of hours per week playing instrument, and instrument type. Musicians who played a double reed instrument had a lower risk of OSA (p = 0.047) than non-wind instrumentalists. Additionally, in double reed instrumentalists, the number of hours spent playing the instrument predicted lower OSA risk (p = 0.020). The risk for OSA in other wind instruments (i.e., single reed, high brass, and low brass) was not significantly different from non-wind musicians. CONCLUSIONS: Playing a double reed musical instrument was associated with a lower risk of OSA.

Usefulness of peripheral arterial tonometry in the detection of mental stress-induced myocardial ischemia.

BACKGROUND: Mental stress-induced myocardial ischemia (MSIMI) identifies a subset of coronary arterial disease (CAD) patients at increased risk for adverse cardiovascular events. Peripheral arterial vasoconstriction has been consistently reported as an underlying mechanism for ischemia development in this setting and as such affords a unique opportunity for the noninvasive detection of this phenomenon. HYPOTHESIS: We studied the usefulness of a peripheral arterial tonometry (PAT) technique in the detection of MSIMI. We sought to identify response patterns that would predict the development of MSIMI. METHODS: Participants were 211 patients with documented CAD. Mental stress testing was performed using a public speaking task. Rest-stress myocardial perfusion imaging was the gold standard for ischemia detection. PAT responses were assessed during the 2 phases of the stressful task (stress anticipation and the task performance) and were calculated as a ratio of stress to the resting pulse wave amplitude. RESULTS: Vascular response during the stress anticipation period (speech preparation) was more pronounced than during the actual speaking task (the mean preparation index was 0.64 +/- 0.53; the mean speech index was 0.72 +/- 0.60; P < 0.001). PAT response during speech preparation had modest accuracy for predicting MSIMI (area under the curve [AUC] was 0.63; 95% confidence interval [CI]: 0.53-0.74, P = 0.015). A PAT index < or = 0.52 was identified as the best cut off value for detecting MSIMI with a sensitivity of 76% and a specificity of 56%. CONCLUSION: We identified a pattern of peripheral arterial response to mental stress that has a relatively modest accuracy in predicting MSIMI. Further research is needed to validate the findings of this study.