Depression and Uptake of Oral Anticoagulation Therapy in Patients With Atrial Fibrillation: A Danish Nationwide Cohort Study.

BACKGROUND: Oral anticoagulation therapy (OAT) in patients with atrial fibrillation (AF) is a highly important preventive intervention, perhaps especially in those with comorbid depression, who have a worse prognosis. However, OAT may pose particular challenges in depressed patients. OBJECTIVES: To assess whether AF patients with depression have lower OAT uptake. METHODS: This nationwide register-based 2005-2016 cohort study of all Danes with AF and OAT indication (CHA2DS2VASc stroke risk score ≥2) assessed OAT initiation within 90 days in those with incident AF (N=147,162) and OAT prevalence in those with prevalent AF (N=192,656). The associations of depression with both outcomes were estimated in regression analyses with successive adjustment for socioeconomic characteristics and somatic and psychiatric comorbidity. RESULTS: Comorbid depression was significantly associated with lower frequency of OAT initiation in incident AF patients {adjusted proportion differences (aPDs): -6.6% [95% confidence interval (CI), -7.4 to -5.9]} and lower prevalence of OAT [aPD: -4.2% (95% CI, -4.7 to -3.8)] in prevalent AF patients. Yet, the OAT uptake increased substantially during the period, particularly in depressed patients [aPD for OAT prevalence in 2016: -0.8% (95% CI, -1.6 to -0.0)]. CONCLUSIONS: Comorbid depression was associated with a significantly lower OAT uptake in patients with AF, which questions whether depressed patients receive sufficient support to manage this consequential cardiac condition. However, a substantial increase in the overall OAT uptake and a decrease of the depression-associated deficit in OAT were seen over the period during which OAT was developed through the introduction of new oral anticoagulation therapy.

Perceived Stress, Multimorbidity, and Risk for Hospitalizations for Ambulatory Care-sensitive Conditions: A Population-based Cohort Study.

BACKGROUND: Psychiatric disorders are associated with an increased risk for ambulatory care-sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population. OBJECTIVES: To determine whether perceived stress is associated with ACSC-related hospitalizations and rehospitalizations, and posthospitalization 30-day mortality. RESEARCH DESIGN AND MEASURES: Population-based cohort study with 118,410 participants from the Danish National Health Survey 2010, which included data on Cohen's Perceived Stress Scale, followed from 2010 to 2014, combined with individual-level national register data on hospitalizations and mortality. Multimorbidity was assessed using health register information on diagnoses and drug prescriptions within 39 condition categories. RESULTS: Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91, 2.38) versus being in the lowest stress quintile after adjusting for age, sex, follow-up time, and predisposing conditions. The associated risk attenuated to 1.48 (95% CI, 1.32, 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless of multimorbidity status. Being in the highest stress quintile was associated with a 1.26-times insignificantly increased adjusted risk (95% CI, 0.79, 2.00) for ACSC rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13, 1.81) of mortality within 30 days of admission. CONCLUSIONS: Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis.

Serious Mental Illness and Risk for Hospitalizations and Rehospitalizations for Ambulatory Care-sensitive Conditions in Denmark: A Nationwide Population-based Cohort Study.

BACKGROUND: Hospitalizations for ambulatory care-sensitive conditions (ACSCs) and early rehospitalizations increase health care costs. OBJECTIVES: To determine if individuals with serious mental illnesses (SMIs) (eg, schizophrenia or bipolar disorder) are at increased risk for hospitalizations for ACSCs, and rehospitalization for the same or another ACSC, within 30 days. RESEARCH DESIGN: Population-based cohort study. PARTICIPANTS: A total of 5.9 million Danish persons aged 18 years and older between January 1, 1999 and December 31, 2013. MEASURES: The Danish Psychiatric Central Register provided information on SMI diagnoses and the Danish National Patient Register on hospitalizations for ACSCs and 30-day rehospitalizations. RESULTS: SMI was associated with increased risk for having any ACSC-related hospitalization after adjusting for demographics, socioeconomic factors, comorbidities, and prior primary care utilization [incidence rate ratio (IRR): 1.41; 95% confidence interval (95% CI), 1.37-1.45]. Among individual ACSCs, SMI was associated with increased risk for hospitalizations for angina (IRR: 1.14, 95% CI, 1.04-1.25), chronic obstructive pulmonary disease/asthma exacerbation (IRR: 1.87; 95% CI, 1.74-2.00), congestive heart failure exacerbation (IRR: 1.25; 95% CI, 1.16-1.35), and diabetes (IRR: 1.43; 95% CI, 1.31-1.57), appendiceal perforation (IRR: 1.49; 95% CI, 1.30-1.71), pneumonia (IRR: 1.72; 95% CI, 1.66-1.79), and urinary tract infection (IRR: 1.70; 95% CI, 1.62-1.78). SMI was also associated with increased risk for rehospitalization within 30 days for the same (IRR: 1.28; 95% CI, 1.18-1.40) or for another ACSC (IRR: 1.62; 95% CI, 1.49-1.76). CONCLUSION: Persons with SMI are at increased risk for hospitalizations for ACSCs, and after discharge, are at increased risk for rehospitalizations for ACSCs within 30 days.

Antidepressant Medication Treatment and Risk of Death.

OBJECTIVE: Although previous studies have assessed whether depression is a mortality risk factor, few have examined whether antidepressant medications (ADMs) influence mortality risk. METHODS: We estimated hazards of 1-year all-cause mortality associated with ADMs, with use occurring within 90 days of depression diagnosis among 720 821 patients who received treatment in a Veterans Health Administration facility during fiscal year 2006. We addressed treatment selection biases using conventional Cox regression, propensity-stratified Cox regression (propensity score), and 2 forms of marginal structural models. Models accounted for multiple potential clinical and demographic confounders, and sensitivity analyses compared findings by antidepressant class. RESULTS: Antidepressant medication use compared with no use was associated with significantly lower hazards of 1-year mortality risk in Cox (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.90-0.97) and propensity score estimates (HR, 0.94; 95% CI, 0.91-0.98), whereas marginal structural model-based estimates showed no difference in mortality risk when the exposure was specified as "as-treated" in every 90-day intervals of the 1-year follow-up (HR, 0.91; 95% CI, 0.66-1.26) but showed increased risk when specified as "intent-to-treat" (HR, 1.07; 95% CI, 1.02-1.13). CONCLUSIONS: Among patients treated with ADMs belonging to a single class in the first 90 days, there were no significant differences in 1-year all-cause mortality risks. When accounting for clinical and demographic characteristics and treatment selection bias, ADM use was associated with no excess harm.

The association of depression, cognitive impairment without dementia, and dementia with risk of ischemic stroke: a cohort study.

OBJECTIVE: To determine if depression, cognitive impairment without dementia (CIND), and/or dementia are each independently associated with risk of ischemic stroke and to identify characteristics that could modify these associations. METHODS: This retrospective-cohort study examined a population-based sample of 7031 Americans older than 50 years participating in the Health and Retirement Study (1998-2008) who consented to have their interviews linked to their Medicare claims. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Hospitalizations for ischemic stroke were identified via ICD-9-CM diagnoses. RESULTS: After adjusting for demographics, medical comorbidities, and health-risk behaviors, CIND alone (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.11-1.69) and co-occurring depression and CIND (OR = 1.65, 95% CI = 1.24-2.18) were independently associated with increased odds of ischemic stroke. Depression alone was not associated with odds of ischemic stroke (OR = 1.11, 95% CI = 0.88-1.40) in unadjusted analyses. Neither dementia alone (OR = 1.09, 95% CI = 0.82-1.45) nor co-occurring depression and dementia (OR = 1.25, 95% CI = 0.89-1.76) were associated with odds of ischemic stroke after adjusting for demographics. CONCLUSIONS: CIND and co-occurring depression and CIND are independently associated with increased risk of ischemic stroke. Individuals with co-occurring depression and CIND represent a high-risk group that may benefit from targeted interventions to prevent stroke.

Psychiatric symptoms and acute care service utilization over the course of the year following medical-surgical ICU admission: a longitudinal investigation*.

OBJECTIVE: To determine if the presence of in-hospital substantial acute stress symptoms, as well as substantial depressive or posttraumatic stress disorder symptoms at 3 months post-ICU, are associated with increased acute care service utilization over the course of the year following medical-surgical ICU admission. DESIGN: Longitudinal cohort study. SETTING: Academic medical center. PATIENTS: One hundred fifty patients who are 18 years old or older admitted to medical-surgical ICUs for over 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participants were interviewed in-hospital to ascertain substantial acute stress symptoms using the Posttraumatic Stress Disorder Checklist-Civilian version. Substantial depressive and posttraumatic stress disorder symptoms were assessed using the Patient Health Questionnaire-9 and the Posttraumatic Stress Disorder Checklist-Civilian version, respectively, at 3 months post-ICU. The number of rehospitalizations and emergency department visits were ascertained at 3 and 12 months post-ICU using the Cornell Services Index. After adjusting for participant and clinical characteristics, in-hospital substantial acute stress symptoms were independently associated with greater risk of an additional hospitalization (relative risk, 3.00; 95% CI, 1.80-4.99) over the year post-ICU. Substantial posttraumatic stress disorder symptoms at 3 months post-ICU were independently associated with greater risk of an additional emergency department visit during the subsequent 9 months (relative risk, 2.29; 95% CI, 1.09-4.84) even after adjusting for both rehospitalizations and emergency department visits between the index hospitalization and 3 months post-ICU. CONCLUSIONS: Post-ICU psychiatric morbidity is associated with increased acute care service utilization during the year after a medical-surgical ICU admission. Early interventions for at-risk ICU survivors may improve long-term outcomes and reduce subsequent acute care utilization.

Neuropsychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans.

BACKGROUND: The relative contributions of depression, cognitive impairment without dementia (CIND), and dementia to the risk of potentially preventable hospitalizations in older adults are not well understood. OBJECTIVE(S): To determine if depression, CIND, and/or dementia are each independently associated with hospitalizations for ambulatory care-sensitive conditions (ACSCs) and rehospitalizations within 30 days after hospitalization for pneumonia, congestive heart failure (CHF), or myocardial infarction (MI). DESIGN: Prospective cohort study. PARTICIPANTS: Population-based sample of 7,031 Americans > 50 years old participating in the Health and Retirement Study (1998-2008). MAIN MEASURES: The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Primary outcomes were time to hospitalization for an ACSC and presence of a hospitalization within 30 days after hospitalization for pneumonia, CHF, or MI. KEY RESULTS: All five categories of baseline neuropsychiatric disorder status were independently associated with increased risk of hospitalization for an ACSC (depression alone: Hazard Ratio [HR]: 1.33, 95% Confidence Interval [95%CI]: 1.18, 1.52; CIND alone: HR: 1.25, 95%CI: 1.10, 1.41; dementia alone: HR: 1.32, 95%CI: 1.12, 1.55; comorbid depression and CIND: HR: 1.43, 95%CI: 1.20, 1.69; comorbid depression and dementia: HR: 1.66, 95%CI: 1.38, 2.00). Depression (Odds Ratio [OR]: 1.37, 95%CI: 1.01, 1.84), comorbid depression and CIND (OR: 1.98, 95%CI: 1.40, 2.81), or comorbid depression and dementia (OR: 1.58, 95%CI: 1.06, 2.35) were independently associated with increased odds of rehospitalization within 30 days after hospitalization for pneumonia, CHF, or MI. CONCLUSIONS: Depression, CIND, and dementia are each independently associated with potentially preventable hospitalizations in older Americans. Older adults with comorbid depression and cognitive impairment represent a particularly at-risk group that could benefit from targeted interventions.

The effect of serious mental illness on the risk of rehospitalization among patients with diabetes.

BACKGROUND: Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system. OBJECTIVE: The study's aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization. METHODS: This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period. RESULTS: After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 mo). CONCLUSIONS: Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population.

Depression and risk of hospitalizations for ambulatory care-sensitive conditions in patients with diabetes.

BACKGROUND: Hospitalizations for ambulatory care-sensitive conditions (ACSCs), conditions that should not require inpatient treatment if timely and appropriate ambulatory care is provided, may be an important contributor to rising healthcare costs and public health burden. OBJECTIVE: To examine if probable major depression is independently associated with hospitalization for an ACSC in patients with diabetes. DESIGN: Secondary analysis of data from a prospective cohort study. PARTICIPANTS: Population-based cohort of 4,128 patients with diabetes ≥ 18 years old seen in primary care, who were enrolled between 2000 and 2002 and followed for 5 years (through 2007). MAIN MEASURES: Depressive symptoms were assessed with the Patient Health Questionnaire-9. Outcomes of interest included time to initial hospitalization for an ACSC and total number of ACSC-related hospitalizations. We used Cox proportional hazards regression models to ascertain an association between probable major depression and time to ACSC-related hospitalization, as well as Poisson regression for models examining probable major depression and number of ACSC-related hospitalizations. KEY RESULTS: Patients' mean age at study enrollment was 63.4 years (Standard Deviation: 13.4 years). Over the 5-year follow-up period, 981 patients in the study were hospitalized a total of 1,721 times for an ACSC, comprising 45.1 % of all hospitalizations. After adjusting for baseline demographic, clinical and health-risk behavioral factors, probable major depression was associated with initial ACSC-related hospitalization (Hazard Ratio: 1.41, 95 % Confidence Interval [95 % CI]: 1.15, 1.72) and number of ACSC-related hospitalizations (Relative Risk: 1.37, 95 % CI: 1.12, 1.68). CONCLUSIONS: Probable major depression in patients with diabetes is independently associated with hospitalization for an ACSC. Additional research is warranted to ascertain if effective interventions for depression in patients with diabetes could reduce the risk of hospitalizations for ACSCs and their associated adverse outcomes.

Symptoms of depression in survivors of severe sepsis: a prospective cohort study of older Americans.

OBJECTIVES: To examine if incident severe sepsis is associated with increased risk of subsequent depressive symptoms and to assess which patient characteristics are associated with increased risk of depressive symptoms. DESIGN: Prospective longitudinal cohort study. SETTING: Population-based cohort of older U.S. adults interviewed as part of the Health and Retirement Study (1998-2006). PARTICIPANTS: A total of 439 patients who survived 471 hospitalizations for severe sepsis and completed at least one follow-up interview. MEASUREMENTS: Depressive symptoms were assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. Severe sepsis was identified using a validated algorithm in Medicare claims. RESULTS: The point prevalence of substantial depressive symptoms was 28% at a median of 1.2 years before sepsis, and remained 28% at a median of 0.9 years after sepsis. Neither incident severe sepsis (relative risk [RR]: 1.00; 95% confidence interval [CI]: 0.73, 1.34) nor severe sepsis-related clinical characteristics were significantly associated with subsequent depressive symptoms. These results were robust to potential threats from missing data or alternative outcome definitions. After adjustment, presepsis substantial depressive symptoms (RR: 2.20; 95% CI: 1.66, 2.90) and worse postsepsis functional impairment (RR: 1.08 per new limitation; 95% CI: 1.03, 1.13) were independently associated with substantial depressive symptoms after sepsis. CONCLUSIONS: The prevalence of substantial depressive symptoms in severe sepsis survivors is high but is not increased relative to their presepsis levels. Identifying this large subset of severe sepsis survivors at increased risk for major depression, and beginning interventions before hospital discharge, may improve outcomes.

A longitudinal investigation of alcohol use over the course of the year following medical-surgical intensive care unit admission.

BACKGROUND: There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors. OBJECTIVE: To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission. METHOD: This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Post-traumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use. RESULTS: There was a significant decline in the mean AUDIT score from baseline (3.9, 95% confidence interval [95% CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95% CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95% CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95% CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95% CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use. CONCLUSIONS: Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed.

Depressive symptoms in spouses of older patients with severe sepsis.

OBJECTIVE: To examine whether spouses of patients with severe sepsis are at increased risk for depression independent of the spouse's presepsis history, whether this risk differs by sex, and is associated with a sepsis patient's disability after hospitalization. DESIGN: Prospective longitudinal cohort study. SETTING: Population-based cohort of U.S. adults over 50 yrs old interviewed as part of the Health and Retirement Study (1993-2008). PATIENTS: Nine hundred twenty-nine patient-spouse dyads comprising 1,212 hospitalizations for severe sepsis. MEASUREMENTS AND MAIN RESULTS: Severe sepsis was identified using a validated algorithm in Medicare claims. Depression was assessed with a modified version of the Center for Epidemiologic Studies Depression Scale. All analyses were stratified by gender. The prevalence of substantial depressive symptoms in wives of patients with severe sepsis increased by 14 percentage points at the time of severe sepsis (from 20% at a median of 1.1 yrs presepsis to 34% at a median of 1 yr postsepsis) with an odds ratio of 3.74 (95% confidence interval: 2.20, 6.37), in multivariable regression. Husbands had an 8 percentage point increase in the prevalence of substantial depressive symptoms, which was not significant in multivariable regression (odds ratio 1.90, 95% confidence interval 0.75, 4.71). The increase in depression was not explained by bereavement; women had greater odds of substantial depressive symptoms even when their spouse survived a severe sepsis hospitalization (odds ratio 2.86, 95% confidence interval 1.06, 7.73). Wives of sepsis survivors who were disabled were more likely to be depressed (odds ratio 1.35 per activities of daily living limitation of sepsis survivor, 95% confidence interval 1.12, 1.64); however, controlling for patient disability only slightly attenuated the association between sepsis and wives' depression (odds ratio 2.61, 95% confidence interval 0.93, 7.38). CONCLUSIONS: Older women may be at greater risk for depression if their spouse is hospitalized for severe sepsis. Spouses of patients with severe sepsis may benefit from greater support and depression screening, both when their loved one dies and when their loved one survives.

The association between intensive care unit admission and subsequent depression in patients with diabetes.

OBJECTIVE: To examine whether intensive care unit (ICU) admission is independently associated with increased risk of major depression in patients with diabetes. METHODS: This prospective cohort study included 3596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study, of whom 193 had at least one ICU admission over a 3-year period. We controlled for baseline depressive symptoms, demographics, and clinical characteristics. We examined associations between ICU admission and subsequent major depression using logistic regression. RESULTS: There were 2624 eligible patients who survived to complete follow-up; 98 had at least one ICU admission. Follow-up assessments occurred at a mean of 16.4 months post-ICU for those who had an ICU admission. At baseline, patients who had an ICU admission tended to be depressed, older, had greater medical comorbidity, and had more diabetic complications. At follow-up, the point prevalence of probable major depression among patients who had an ICU admission was 14% versus 6% among patients without an ICU admission. After multivariate adjustment, ICU admission was independently associated with subsequent probable major depression (Odds Ratio 2.07, 95% confidence interval (1.06-4.06)). Additionally, baseline probable major depression was significantly associated with post-ICU probable major depression. CONCLUSIONS: ICU admission in patients with diabetes is independently associated with subsequent probable major depression. Additional research is needed to identify at-risk patients and potentially modifiable ICU exposures in order to inform future interventional studies with the goal of decreasing the burden of comorbid depression in older patients with diabetes who survive critical illnesses.

The association of comorbid depression with intensive care unit admission in patients with diabetes: a prospective cohort study.

BACKGROUND: It is unknown if comorbid depression in patients with diabetes mellitus increases the risk of intensive care unit (ICU) admission. OBJECTIVE: This study examined whether comorbid depression in patients with diabetes increased risk of ICU admission, coronary care unit (CCU) admission, and general medical-surgical unit hospitalization, as well as total days hospitalized, after controlling for demographics, clinical characteristics, and health risk behaviors. METHOD: This prospective cohort study included 3,596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study. We assessed baseline depression with the Patient Health Questionnaire-9. We controlled for baseline demographics, smoking, BMI, exercise, hemoglobin A(1c), medical comorbidities, diabetes complications, type 1 diabetes, diabetes duration, and insulin treatment. We assessed time to any ICU, CCU, and/or general medical-surgical unit admission using Cox proportional-hazards regression. We used Poisson regression with robust standard errors to examine associations between depression and total days hospitalized. RESULTS: Unadjusted analyses revealed that baseline probable major depression was associated with increased risk of ICU admission [hazard ratio (HR) 1.94, 95% confidence interval (95% CI)(1.34-2.81)], but was not associated with CCU or general medical-surgical unit admission. Fully adjusted analyses revealed probable major depression remained associated with increased risk of ICU admission [HR 2.23, 95% CI(1.45-3.45)]. Probable major depression was also associated with more total days hospitalized (Incremental Relative Risk 1.64, 95%CI(1.26-2.12)). CONCLUSIONS: Patients with diabetes and comorbid depression have a greater risk of ICU admission. Improving depression treatment in patients with diabetes could potentially prevent hospitalizations for critical illnesses and lower healthcare costs.

Association Between Bipolar Disorder or Schizophrenia and Oral Anticoagulation Use in Danish Adults With Incident or Prevalent Atrial Fibrillation.

Importance: Individuals with bipolar disorder or schizophrenia have a higher risk of adverse outcomes from cardiovascular diseases. Oral anticoagulation therapy (OAT) for patients with atrial fibrillation (AF) is needed for stroke prevention, but whether patients with bipolar disorder or schizophrenia face disparities in receiving this therapy is unknown. Objective: To assess whether bipolar disorder or schizophrenia is associated with a lower rate of OAT initiation in patients with incident AF and lower prevalence of OAT in those with prevalent AF. Design, Setting, and Participants: A nationwide cohort study of Danish patients with AF was conducted from January 1, 2005, to December 31, 2016, and data were analyzed from January 1 to June 15, 2020. Data from national registries included information on all redeemed prescriptions and all hospital contacts of all patients with incident or prevalent AF (age, 18-100 years) and increased risk status, defined by a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) risk score greater than or equal to 2. Exposures: Hospital diagnosis of bipolar disorder or schizophrenia. Main Outcomes and Measures: Adjusted proportion differences for OAT initiation and OAT prevalence, comparing individuals with and without bipolar disorder or schizophrenia. Results: Patients included with incident AF (n = 147 810) had a mean (SD) age of 76.9 (10.1) years, 78 577 (53.2%) were women, 1208 (0.8%) had bipolar disorder, and 572 (0.4%) had schizophrenia. Accounting for age, sex, and calendar time, bipolar disorder and schizophrenia were associated with significantly lower frequency of OAT initiation within 90 days after incident AF (bipolar disorder: -12.7%; 95% CI, -15.3% to -10.0%; schizophrenia: -24.5%; 95% CI, -28.3% to -20.7%) and lower OAT prevalence in patients with prevalent AF (bipolar disorder: -11.6%; 95% CI, -13.9% to -9.3% schizophrenia: -21.6%; 95% CI, -24.8% to -18.4%). Adjusting for socioeconomic factors and other comorbid conditions attenuated these associations, particularly for patients with bipolar disorder. However, schizophrenia continued to be associated with a with a lower rate of OAT initiation (-15.5%, 95% CI, -19.3% to -11.7%) and a -12.8% (95% CI, -15.9% to -9.7%) lower OAT prevalence. These associations were also present after the introduction of non-vitamin K antagonists (adjusted proportion difference in 2013-2016: -12.4%; 95% CI, -18.7% to -6.1% for initiation and -10.1%; 95% CI, -13.8% to -6.4% for prevalence). Conclusions and Relevance: In this study, patients with bipolar disorder or schizophrenia were less likely to receive OAT in the setting of AF. For patients with bipolar disorder, this deficit was largely associated with socioeconomic factors and comorbidities, especially toward the end of the study period. For patients with schizophrenia, disparities in this stroke prevention therapy persistently exceeded what could be explained by other patient characteristics.

The burden of adverse mental health outcomes in critical illness survivors.

Survivors of critical illnesses are at increased risk for posttraumatic stress disorder and major depression. In the present issue of Critical Care, Myhren and colleagues report on an investigation of predictors of posttraumatic stress, general anxiety, and depressive symptoms up to 1 year following intensive care unit admission for critical illnesses. The present study found that an endogenous patient characteristic, the personality trait pessimism, was associated with posttraumatic stress and depressive symptoms. Myhren and colleagues' study sheds light on potential predictors of psychopathology in critical illness survivors as well as stimulating directions for future research to address these complex problems.

Death of a Partner and Risks of Ischemic Stroke and Intracerebral Hemorrhage: A Nationwide Danish Matched Cohort Study.

Background Stress has been reported to trigger stroke, and the death of a loved one is a potentially extremely stressful experience. Yet, previous studies have yielded conflicting findings of whether bereavement is associated with stroke risk, possibly because of insufficient distinction between ischemic stroke (IS) and intracerebral hemorrhage (ICH). We therefore examined the associations between bereavement and IS and ICH separately in contemporary care settings using nationwide high-quality register resources. Methods and Results The study cohort included all Danish individuals whose partner died between 2002 and 2016 and a reference group of cohabiting individuals matched 1:2 on sex, age, and calendar time. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) and corresponding 95% CIs during up to 5 years follow-up. During the study period, 278 758 individuals experienced partner bereavement, of whom 7684 had an IS within the subsequent 5 years (aHR, 1.11; CI, 1.08-1.14 when compared with nonbereaved referents) and 1139 experienced an ICH (aHR, 1.13; CI, 1.04-1.23). For ICH, the estimated association tended to be stronger within the initial 30 days after partner death (aHR, 1.66; CI, 1.06-2.61), especially in women (aHR, 1.99; CI, 1.06-3.75), but the statistical precision was low. In absolute numbers, the cumulative incidence of IS at 30 days was 0.73 per 1000 in bereaved individuals versus 0.63 in their referents, and the corresponding figures for ICH were 0.13 versus 0.08. Conclusions Statistically significant positive associations with partner bereavement were documented for both IS and ICH risk, for ICH particularly in the short term. However, absolute risk differences were small.

Symptoms of depression and anxiety after delirium.

BACKGROUND: Delirium is a common problem in hospitalized patients. OBJECTIVE: The author investigated the relationship between in-hospital delirium and subsequent depressive and anxiety symptoms. METHOD: A literature search and review using MEDLINE, EMBASE, Cochrane Library, CINAHL, and PsycINFO was performed. RESULTS: Eight studies were eligible. Five studies found significant associations between delirium episodes and subsequent symptoms of depression and/or anxiety. CONCLUSION: Psychological distress is common after delirium, warranting comprehensive evaluation and treatment.

Psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: a review of the literature.

Severe burns, traumatic injuries and other critical illnesses are a substantial source of morbidity in the United States. As more patients survive these conditions, there has been increasing interest in psychiatric and functional outcomes of these individuals. In this article, we reviewed the literature on the prevalence of psychiatric conditions, with particular emphasis on posttraumatic stress disorder (PTSD) and depression, as well as functional impairments, in adult and pediatric survivors of burns, trauma and intensive care unit stays for other critical illnesses. We found that PTSD and depressive symptoms are quite prevalent in these patient groups. We also examined potential risk factors for psychiatric morbidity and impaired function in all three patient groups, and conclude that patient-specific and acute care factors, in addition to early post-acute care psychiatric symptoms, may convey risk for subsequent psychopathology and diminished function. Finally, we discussed limitations in the literature as well as possible directions for future research, particularly in clarifying risk factors for psychiatric disorders as well as potential preventative and treatment interventions that may improve outcomes.