Defining Major Depressive Disorder Cohorts Using the EHR: Multiple Phenotypes Based on ICD-9 Codes and Medication Orders.

BACKGROUND: Major Depressive Disorder (MDD) is one of the most common mental illnesses and a leading cause of disability worldwide. Electronic Health Records (EHR) allow researchers to conduct unprecedented large-scale observational studies investigating MDD, its disease development and its interaction with other health outcomes. While there exist methods to classify patients as clear cases or controls, given specific data requirements, there are presently no simple, generalizable, and validated methods to classify an entire patient population into varying groups of depression likelihood and severity. METHODS: We have tested a simple, pragmatic electronic phenotype algorithm that classifies patients into one of five mutually exclusive, ordinal groups, varying in depression phenotype. Using data from an integrated health system on 278,026 patients from a 10-year study period we have tested the convergent validity of these constructs using measures of external validation, including patterns of psychiatric prescriptions, symptom severity, indicators of suicidality, comorbidity, mortality, health care utilization, and polygenic risk scores for MDD. RESULTS: We found consistent patterns of increasing morbidity and/or adverse outcomes across the five groups, providing evidence for convergent validity. LIMITATIONS: The study population is from a single rural integrated health system which is predominantly white, possibly limiting its generalizability. CONCLUSION: Our study provides initial evidence that a simple algorithm, generalizable to most EHR data sets, provides categories with meaningful face and convergent validity that can be used for stratification of an entire patient population.

Daily Pain, Physical Activity, and Home Fluid Intake in Pediatric Sickle Cell Disease.

Objectives: This study examined the temporal relationship between physical activity, fluid intake, and daily pain in children with sickle cell disease (SCD) with frequent pain. Methods: A total of 30 African American children ( M age = 13.9; 53% female; 76.3% type SS) who reported pain more than or equal to once every 2 weeks and their parents completed measures of pain and anxiety/depressive symptoms. Children then completed a daily pain diary and wore a physical activity Actiwatch for 14 days at home. Results: Contrary to physiological theory-based hypotheses, lower physical activity was associated with greater pain during the same day and the next day. Less pain was associated with greater physical activity the next day. There was no relationship between self-reported home fluid intake and daily pain ( p 's < .05). Conclusions: Results lend support for a complex bidirectional relationship between physical activity and daily pain in pediatric SCD, and identify physical activity as a target for future research.

Psychosocial functioning and adjustment to university settings: comparing students with chronic illnesses to healthy peers.

Purpose: College students with chronic illnesses are vulnerable to poor adjustment, but it remains unclear how these students differ from healthy peers. This study compares psychosocial adjustment and risky behavior between students with and without chronic illnesses. Participants: Participants (N = 629, 78% Caucasian, 77% Female) were recruited from universities. Methods: Participants completed measures of illness history, anxiety, depression, stressful life events, social support, and risky behavior. Results: College students with chronic illnesses demonstrated significantly greater symptoms of anxiety F(1,620) = 8.742, p < .003, depression F(1,614) = 26.947, p < .001, more stressful life events F(1,476) = 23.671, p < .001, and lower social support F(1,613) = 15.645, p < .001. No differences in risky behaviors between groups emerged F(1,601) = 3.432, p = .064. An indirect effect of health status on risk-taking behavior was observed [b = .677, 95% CI (.351, 1.072)] partially mediated by depression. Conclusion: College students with chronic illnesses demonstrated worse psychosocial outcomes than healthy students, warranting programs to support these students. Depressive symptoms partially mediated risky behavior.

Evaluating clinical and demographic influences on health perception: A translation of the SF-12 for use with NHANES.

Improving public health depends on an intricate understanding of the factors that influence how individuals perceive and self-report their personal health. Self-perceived health is an independent predictor of future health-related outcomes, but capturing self-perception of health is complex due to the intricate relationship between clinical and perceived health. A commonly used measure of self-perceived health is the Short Form 12 (SF-12), developed in the 1990s. In this study, we aim to evaluate clinical and demographic influences on self-perceived health among American adults using the National Health and Nutrition Examination Survey (NHANES). While NHANES captures information on a number of domains of health, including clinical assessments, it does not include SF-12 items necessary to measure self-perceived health. Therefore, to assess self-perceived health for our study, we constructed and validated a novel SF-12-equivalent measure for use with NHANES using analogous items from the 2015-2016 NHANES interview questionnaires. The developed measure reflects established knowledge of population health patterns and closely parallels the behavior of the original SF-12. An analysis of the clinical and demographic influences on this novel measure of health perception revealed that both clinical and demographic factors, such as depression status and race, influence how healthy individuals perceive themselves to be. Importantly, our analysis indicated that among American adults, while controlling for clinical and demographic covariates, an increase in low-density lipoprotein (i.e., "bad") cholesterol level was associated with an improvement in self-perceived health. This study contributes significantly in two domains: it provides a novel measure of self-perceived health compatible for use with the widely used NHANES data (as well as details on how the process was developed), and it identifies a critical area in need of improved clinical education regarding the apparent confusion around cholesterol health.

Association of mild cognitive impairment and characteristic of COPD and overall health status in a cohort study.

Introduction: We evaluated risk factors and demographic characteristics of associated with mild cognitive impairment (MCI) in patients with COPD. Methods: 220 individuals with COPD enrolled in a cohort study designed to evaluate anxiety conducted at 16 clinical centers. Cognitive impairment was assessed with the Montreal Cognitive Assessment (MoCA), a cutoff score of <26 defined as MCI. Data were collected including spirometry, 6-minute walk test, symptom burden by COPD Assessment Test and dyspnea by Modified Medical Research Council, anxiety measured by Anxiety Inventory of Respiratory Disease, Generalized Anxiety Disorder-7 and Hospital Anxiety Depression Scale, depression by Patient Health Questionnaire-9 and health status by Patient Reported Outcomes Measurement Information System and sleep quality by the Pittsburg Sleep Quality Index. Results: The median age was 65 years and 54% of participants were male. 119(54%) of participants had MCI as classified by MoCA. In multivariable logistic regression, higher odds ratios (OR) (95% confidence interval) for MCI (MoCA) <26 were associated with increased years of age, 1.06 (1.02 -1-09, p<0.003); African-American race, 3.68(1.67-8.11, p<0.001); persistent phlegm, 2 (1.12-3.57, p<0.01) and sleep disturbance, 1.04(1.01-1.08, p<0.01). Conclusions: COPD patients commonly screen positive for MCI. Characteristics associated with MCI included age, African-American race, sleep disturbance and persistent phlegm.

Test Performance Characteristics of the AIR, GAD-7, and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease.

Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR).Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the "gold standard."Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2-4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses.Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69-0.87), followed by the HADS-A (0.74; 95% CI, 0.64-0.84) and the AIR (0.66; 95% CI, 0.56-0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P < 0.001) and the AIR (65%; P < 0.001); GAD-7 specificity was higher than AIR specificity (P < 0.001).Conclusions: Symptoms of anxiety among patients with COPD as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting DSM-V criteria. The GAD-7, the HADS-A and the AIR questionnaires had fair to moderate psychometric properties as screening tools for anxiety in individuals with COPD, indicating the need for improved measures for this patient population.

CF RISE: Implementing a Clinic-Based Transition Program.

During the period of healthcare transition, adolescents should increase responsibility for managing their health. Transition services are associated with improved outcomes; however, many youth with chronic conditions such as cystic fibrosis (CF) are not receiving guideline-based transition services. Individual CF centers have transition programs, yet no specific program is widely disseminated. A transition program CF: Responsibility, Independence, Self-care, Education CF RISE was recently developed and implemented at 10 CF centers. We conducted a process evaluation of CF RISE implementation based on the Consolidated Framework of Implementation Research (CFIR). CF healthcare providers (23/25 [95%]) from the 10 sites completed an online survey about their experiences 6 months after initiating the program. Open-ended survey questions were coded into central themes addressing domains of implementation. Providers reported that CF RISE facilitated communication with the family, particularly the knowledge and skills assessments. All providers rated the program as valuable with 60% finding the program very or extremely valuable. Time was the biggest implementation barrier (96%) followed by planning for the visit (61%). Ninety-five percent felt the program could become a sustainable part of the clinic, and 91% felt that it was somewhat or completely likely that they would be using the program 1 year from now. Providers also appreciated the flexibility of the program. CF healthcare providers positively evaluated CF RISE during its initial implementation period. The feedback provides insight into the sustainability and challenges that must be considered as wider implementation plans are developed. It is critical to evaluate the effectiveness of programs such as CF RISE on the outcomes during the transition period.