Trends in obstructive sleep apnea disease severity over nearly two decades: update on the VA San Diego experience.

Study Objectives: The Sleep Program at the VA San Diego Healthcare System (VASDHS) started a patient database over twenty years ago for its home sleep apnea testing (HSAT) program. An analysis of ten years of diagnostic HSAT data was reported on over 12 500 patients in 2014. Over this time period, severe obstructive sleep apnea (OSA) decreased in frequency. In contrast, mild OSA increased in frequency and was the most frequently reported severity in our analysis. In more recent times, the 2021 continuous positive airway pressure (CPAP) crisis created difficulties in dispersing CPAP therapies to individuals including Veterans with OSA, prompting our group to reexamine the HSAT database. Methods: A retrospective review was performed of the local clinical database of HSAT diagnostic testing of 8,928 sleep studies from 2018 to 2022. Results: The overall mean apnea-hypopnea index (AHI) decreased from 40.4/hour (2004) to 24.3/hour (2022) (p < .001). The two time periods were examined separately. For 2004-2013, it was found that the mean AHI in 2004 was not significantly different from the mean AHI in 2005, 2006, or 2007 but was significantly different from the mean AHI in each year from 2008 (mean AHI = 30.7/h) to 2013 (mean AHI = 26.1/hour). For 2019-2022, the mean AHI did not significantly differ between the 4 years. Conclusions: These findings have implications for OSA therapies. Additionally, the high prevalence of mild sleep apnea, which is typically associated with lesser adherence to PAP therapy, further highlights the importance of non-PAP alternatives to improve treatment effectiveness.

A tale of two veterans: homeless vs domiciled veterans presenting to a psychiatric urgent care clinic.

BACKGROUND: The relationship between homelessness among veterans and mental illness and suicidality has not been clearly defined. To further examine this relationship, we compared rates of mental illness and suicidality among homeless and domiciled veterans seeking urgent psychiatric care at a US Department of Veterans Affairs (VA) facility. METHODS: Information was collected by survey from 482 consecutive veterans seeking care at the Psychiatric Emergency Clinic (PEC) at the VA San Diego Healthcare System. A total of 73 homeless veterans were designated the homeless group and 73 domiciled veterans were randomly selected as the domiciled group. Suicidality and mental illnesses were assessed by self-assessment questionnaires and chart review of diagnoses. RESULTS: The homeless group had significantly higher rates of past suicide attempts (47% vs 27%) and recent reckless or self-harming behavior (33% vs 18%) compared with the domiciled group but significantly lower rates of depressive disorder (25% vs 44%), as diagnosed by a PEC physician. There were no differences between groups on the questionnaires for posttraumatic stress disorder (PTSD), depression, or alcohol abuse. Nor were there differences in diagnoses of bipolar disorder, PTSD, anxiety disorder, schizophrenia/schizoaffective disorder, or alcohol abuse. CONCLUSIONS: Veterans seeking help from a VA-based urgent psychiatric care clinic often are burdened by substantial depression, alcohol use disorders, PTSD, and both past and present suicide risk.

Burnout in premedical undergraduate students.

BACKGROUND: There has been growing recognition that medical students, interns, residents and practicing physicians across many specialties are prone to burnout, with recent studies linking high rates of burnout to adverse mental health issues. Little is known about the trajectory and origins of burnout or whether its roots may be traced to earlier in medical training, specifically, during undergraduate studies. Here, the authors surveyed undergraduates at UC San Diego (UCSD) to assess the relationship of burnout to premedical status while controlling for depression severity. METHODS: Undergraduate students at UCSD were invited to participate in a web-based survey, consisting of demographic questions; the Maslach Burnout Inventory Student Survey (MBI-SS), which gauged the three dimensions of burnout; and the nine-item Patient Health Questionnaire (PHQ-9), to assess depression severity. RESULTS: A total of 618 premedical students and 1,441 non-premedical students completed the questionnaire. Premedical students had greater depression severity and emotional exhaustion than non-premedical students, but they also exhibited a greater sense of personal efficacy. The burnout differences were persistent even after adjusting for depression. Also, premedical women and Hispanic students had especially high levels of burnout, although differences between groups became nonsignificant after accounting for depression. CONCLUSIONS: Despite the limitations of using a burnout questionnaire not specifically normed for undergraduates, the unique ethnic characteristics of the sample, and the uncertain response rate, the findings highlight the importance of recognizing the unique strains and mental health disturbances that may be more common among premedical students than non-premedical students. Results also underscore the close relationship between depression and burnout, and point the way for subsequent longitudinal, multi-institutional studies that could help identify opportunities for prevention and intervention.

The relationship of marital status and clinical characteristics in middle-aged and older patients with schizophrenia and depressive symptoms.

BACKGROUND: This study examines the relationship of marital status to depression, positive and negative symptoms, quality of life, and suicidal ideation among 211 patients with schizophrenia-spectrum disorders and subsyndromal depressive symptoms. We hypothesized that single participants would have more severe symptomatology than married and cohabitating participants. METHODS: Outpatients, age 40 or older, were diagnosed with schizophrenia or schizoaffective disorders using the MINI Structured Clinical Interview for DSM-IV Axis 1 Disorders. Participants exhibited a score of >8 on the Hamilton Rating Scale for Depression but did not meet criteria for a major depressive episode. RESULTS: Participants who were married or cohabitating had a later age of onset of first psychotic episode or hospitalization than those who were single (age, 29.35 vs 24.21). Married participants rated their quality of life higher than those who were single (mean Quality of Life Scale scores, 72.28 vs 53.87) and had less suicidal ideation than those who were divorced, widowed, or separated (7.4% vs 29.2%). CONCLUSIONS: In middle-aged and older individuals with schizophrenia or schizoaffective disorder and depressive symptoms, marriage appeared to enhance quality of life and protect against suicidal ideation. Efforts that focus on providing additional support for those who are experiencing divorce or separation could prove to be lifesaving for these individuals.

Prevalence and longitudinal stability of negative symptoms in healthy participants.

OBJECTIVE: Although negative symptoms are prominent in older patients with schizophrenia, it is unknown whether this pattern is prevalent in healthy participants. The objective of this study was to evaluate whether negative symptoms are present in healthy populations and to determine whether they are linked to illness-related processes or normal aging. METHODS: A systemic review of 26 studies that have administered negative symptom assessments to healthy participants was conducted. In addition, 213 (age > 40 years old) healthy participants completed PANSS and SANS ratings at both baseline and 1-year follow-up. One-hundred participants also completed ratings after 3 years. RESULTS: Across all reviewed studies, negative symptoms were absent in the majority of participants. Comparable results were found in the current study's large longitudinal evaluation with middle-aged to older adults. CONCLUSIONS: Taken together, the data suggest that healthy volunteers do not suffer from prominent negative symptoms. This finding is consistent with the hypothesis that the greater prevalence and severity of negative symptoms in older patients is not related to normal aging but to illness-related processes.

Depressive symptom patterns in patients with chronic schizophrenia and subsyndromal depression.

BACKGROUND: Since subsyndromal depressive symptoms (SDS) are prevalent, under-recognized and clinically important problems in patients with schizophrenia, as well as in the elderly, the association and correlates of SDS in mid-life and older age patients with schizophrenia deserves more investigation. The purpose of this study is to learn more about the occurrence, pattern of symptoms and associated features of subsyndromal depressive symptoms in patients with chronic schizophrenia or schizoaffective disorder. METHOD: The first 165 participants from the "Citalopram Augmentation in Older Adults with Psychoses" (NIH RO1 # 63931) study comprised the sample. Inclusion criteria included: age > or =40, DSM-IV diagnosis of schizophrenia or schizoaffective disorder, outpatient status, >2 DSM-IV symptoms of MDE and Hamilton Depression Rating Scale (HAM-D) score > or =8. Depressive symptoms were assessed using the 17-item version of the HAM-D and the Calgary Depression Rating Scale (CDRS). RESULTS: The most prevalent symptoms cut across several domains of the depressive syndrome: psychological (e.g., depressed mood, depressed appearance, psychic anxiety); cognitive (e.g., guilt, hopelessness, self depreciation, loss of insight); somatic (insomnia, anorexia, loss of libido, somatic anxiety); psychomotor (e.g., retardation and agitation) and functional (diminished work and activities). Participants diagnosed with schizoaffective disorder appeared more depressed, endorsed more intense "guilty ideas of reference" and had higher total CDRS scores than patients diagnosed with schizophrenia. CONCLUSION: This study confirms the high prevalence of depressive symptoms in middle-aged and older persons with schizophrenia and schizoaffective disorder who were selected on the basis of having subsyndromal symptoms of depression.

Increased Framingham 10-year risk of coronary heart disease in middle-aged and older patients with psychotic symptoms.

OBJECTIVE: The Framingham 10-risk of coronary heart disease (CHD) has been a widely studied estimate of cardiovascular risk in the general population. However, few studies have compared the relative risk of developing CHD in antipsychotic-treated patients with different psychiatric disorders, especially in older patients with psychotic symptoms. In this study, we compared the 10-year risk of developing CHD among middle-aged and older patients with psychotic symptoms to that in the general population. METHOD: We analyzed baseline data from a study examining metabolic and cardiovascular effects of atypical antipsychotics in patients over age 40 with psychotic symptoms. After excluding patients with prior history of CHD and stroke, 179 subjects were included in this study. Among them, 68 had a diagnosis of schizophrenia, 42 mood disorder, 38 dementia, and 31 PTSD. Clinical evaluations included medical and pharmacologic treatment history, physical examination, and clinical labs for metabolic profiles. Using the Framingham 10-year risk of developing CHD based on the Framingham Heart Study (FHS), we calculated the risk CHD risk for each patient, and then compared relative risk in each psychiatric diagnosis to the risks reported in the FHS. RESULTS: The mean age of entire sample was 63 (range 40-94) years, 68% were men. The Framingham 10-year risk of CHD was increased by 79% in schizophrenia, 72% in PTSD, 61% in mood disorder with psychosis, and 11% in dementia relative to the risk in general population from the FHS. CONCLUSIONS: In this sample of middle-aged and older patients with psychotic symptoms, we found a significantly increased 10-year risk of CHD relative to the estimated risk from FHS, with the greatest increased risk for patients with schizophrenia and PTSD. Development of optimally tailored prevention and intervention efforts to decrease different risk components in these patients could be an important step to help decrease the risks of CHD and overall mortality in this vulnerable population.

Comparison of two enhanced consent procedures for patients with mild Alzheimer disease or mild cognitive impairment.

OBJECTIVE: The objective of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of two enhanced consent procedures provided to patients with Alzheimer disease or mild cognitive impairment that used either a PowerPoint presentation or an enhanced printed consent form. METHODS: Patients randomly assigned to an enhanced written consent procedure or slideshow presentation were assessed with the MacArthur Competence Assessment Tool for Clinical Research. RESULTS: Verbal reexplanation was associated with improved understanding in both conditions. Level of understanding did not significantly differ between the two consent groups, but administration time for slideshow presentation was less than that for an enhanced written consent procedure. CONCLUSION: Enhanced consent procedures are feasible and useful for consent to research among patients with mild cognitive impairment or mild Alzheimer disease.