Psychiatric comorbidity in the Baltimore ECA follow-up study: the matrix approach.

BACKGROUND: Psychiatric comorbidity is defined as the joint occurrence of two or more mental or substance use disorders. Widespread psychiatric comorbidity has been reported in treatment and population-based studies. The aim of this study was to measure the extent and impact of psychiatric comorbidity in a cohort of the Baltimore Epidemiologic Catchment Area study. METHODS: We examined the comorbidity burden of 16 mental disorders in a cohort of 847 participants using both established and novel analytical approaches The Comorbidity to Diagnosis Inflation Ratio (CDIR), is a statistical instrument that quantifies impact of pairwise comorbid associations, both on the whole sample, as well as on each specific disorder. RESULTS: Most anxiety disorders had substantial co-occurrence with each other, as well as with Major Depressive Disorder (MDD). In addition, mood disorders had a high degree of comorbidity with Alcohol Dependence (AD). The CDIR for the whole sample was 1.32, indicating a ratio of 132 comorbidities per 100 diagnoses. The conditions with high sample prevalence were relatively less comorbid than the low prevalence conditions. Obsessive Compulsive Disorder had a comorbidity burden that was 89% greater than the overall sample. CONCLUSION: Anxiety disorders are highly interrelated, as well as highly comorbid with depression. The comorbidity phenomenon is linked to the differential prevalence of the analyzed conditions. Comorbidity frequency (most prevalent comorbid condition) appears mutually exclusive to comorbidity burden (most widely interrelated condition). While AD and MDD were the most frequently diagnosed disorders; low prevalence conditions as OCD and GAD were the most widely interrelated.

The serotonin transporter gene polymorphism (SLC6A4) and risk for psychiatric morbidity and comorbidity in the Baltimore ECA follow-up study.

BACKGROUND: The human serotonin transporter (SERT) gene polymorphism (5HTTLPR) has been associated with multiple psychiatric disorders, including major depression, anxiety disorders, and substance use disorders. This study investigated the association between 5HTTLPR and psychiatric morbidity and comorbidity in a psychiatrist-examined population sample. METHODS: 628 participants, mean age 48.3 years old, were assessed by psychiatrists using the Schedules for Clinical Assessment in Neuropsychiatry. Associations between 5HTTLPR and the prevalence, comorbidity, and time-to-diagnoses for 16 psychiatric conditions were evaluated, using several analytical approaches. RESULTS: The SERT S allele was significantly associated with an increased lifetime prevalence of panic disorder. There was a "protective" association between SERT gene S allele carrier status and the risk of obsessive-compulsive disorder (OCD) in time-to-event analysis. Carriers of the S allele had a significant increased risk of two specific comorbid disorder pairs: major depressive disorder (MDD) and social phobia, and MDD and agoraphobia. Overall, there was no increased risk of receiving an initial or an additional diagnosis for a mental disorder in the SERT S allele carriers CONCLUSIONS: The findings suggest that the S allele carrier status is associated with an increased prevalence of panic disorder in a community sample. There was an increased risk for comorbidity in a more homogeneous subgroup of cases with MDD and social phobia, as well as or agoraphobia. Our findings suggest a specific effect of the SERT promoter gene polymorphism on a subgroup of individuals identifiable by their comorbidity.

Short and medium-term outcomes in individuals hospitalized with acute myocardial infarction and multiple chronic conditions: The Worcester heart attack study.

Background: Multiple chronic conditions (MCCs) are common in patients hospitalized with acute myocardial infarction (AMI). We examined the association of 12 MCCs with the risk of a 30-day hospital readmission and/or dying within one year among those discharged from the hospital after an AMI. We also examined the five most prevalent pairs of chronic conditions in this population and their association with the principal study endpoints. Methods: The study population consisted of 3,294 adults hospitalized with a confirmed AMI at the three major medical centers in central Massachusetts on an approximate biennial basis between 2005 and 2015. Patients were categorized as ≤1, 2-3, and ≥4 chronic conditions. Results: The median age of the study population was 67.9 years, 41.6% were women, and 15% had ≤1, 32% had 2-3, and 53% had ≥4 chronic conditions. Patients with ≥4 conditions tended to be older, had a longer hospital stay, and received fewer cardiac interventional procedures. There was an increased risk for being rehospitalized during the subsequent 30 days according to the presence of MCCs, with the highest risk for those with ≥4 conditions. There was an increased, but attenuated, risk for dying during the next year according to the presence of MCCs. Individuals with diabetes/hypertension and those with heart failure/chronic kidney disease were at particularly high risk for developing the principal study outcomes. Conclusion: Development of guidelines that include complex patients, particularly those with MCCs and those at high risk for adverse short/medium term outcomes, remain needed to inform best treatment practices.

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction.

BACKGROUND: Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities. METHODS AND RESULTS: Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years. CONCLUSIONS: Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population.

Temporal Trends and Patient Characteristics Associated with 30-Day Hospital Readmission Rates after a First Acute Myocardial Infarction.

BACKGROUND: Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction. METHODS: We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts. RESULTS: The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient's hospitalization for a first acute myocardial infarction. CONCLUSIONS: We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed.

Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior.

BACKGROUND: This study set out to describe age differences in patient's chief complaint related to a first myocardial infarction and how the "typicality" of patient's acute symptoms relates to extent of prehospital delay. METHODS: The medical records of 2586 residents of central Massachusetts hospitalized at 11 greater Worcester medical centers with a first myocardial infarction on a biennial basis between 2001 and 2011 were reviewed. RESULTS: The average age of the study population was 66.4 years, 39.6% were women, 40.2% were diagnosed with a ST-elevation myocardial infarction (STEMI), and 72.0 % presented with typical symptoms of myocardial infarction, namely acute chest pain or pressure. Patients were categorized into 5 age strata: >55 years (23%), 55-64 years (20%), 65-74 years (19%), 75-84 years (22%), and ≥85 years (16%). The lowest proportion (11%) of atypical symptoms of myocardial infarction was observed in patients <55 years, increasing to 17%, 28%, 40%, and 51% across the respective age groups. The most prevalent chief complaint reported at the time of hospitalization was chest pain, but the proportion of patients reporting this symptom decreased from the youngest (83%) to the oldest patient groups (45%). There was a slightly increased risk of prehospital delay across the different age groups (higher in the oldest old) in those who presented with atypical, rather than typical, symptoms of myocardial infarction. CONCLUSIONS: The present results provide insights to the presenting chief complaint of patients hospitalized with a first myocardial infarction according to age and the relation of symptom presentation to patient's care-seeking behavior.

Advancing cross-national planning and partnership: Proceedings from the International Multimorbidity Symposium 2019.

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward.

Impact of cardiac- and noncardiac-related conditions on adverse outcomes in patients hospitalized with acute myocardial infarction.

BACKGROUND: To examine the impact of cardiac- and noncardiac-related conditions on the risk of hospital complications and 7- and 30-day rehospitalizations in older adult patients with an acute myocardial infarction (AMI). METHODS AND RESULTS: The study population consisted of 3863 adults aged 65 years and older hospitalized with AMI in Worcester, Massachusetts, during six annual periods between 2001 and 2011. Individuals were categorized into four groups based on the presence of 11 previously diagnosed cardiac and noncardiac conditions. The median age of the study population was 79 years and 49% were men. Twenty-eight percent of patients had two or less cardiac- and no noncardiac-related conditions, 21% had two or less cardiac and one or more noncardiac conditions, 20% had three or more cardiac and no noncardiac conditions, and 31% had three or more cardiac and one or more noncardiac conditions. Individuals who presented with one or more noncardiac-related conditions were less likely to have been prescribed evidence-based medications and/or to have undergone coronary revascularization procedures than patients without any noncardiac condition. After multivariable adjustment, individuals with three or more cardiac and one or more noncardiac conditions were at greatest risk for all adverse outcomes. CONCLUSIONS: Older patients hospitalized with AMI carry a significant burden of cardiac- and noncardiac-related conditions. Older adults who presented with multiple cardiac and noncardiac conditions experienced the worse short-term outcomes and treatment strategies should be developed to improve their in-hospital and post-discharge care and outcomes.

Characteristics, Management, and Short-Term Outcomes of Adults ≥65 Years Hospitalized With Acute Myocardial Infarction With Prior Anemia and Heart Failure.

Our study objectives were to examine the impact of anemia and heart failure (HF) on in-hospital complications, and postdischarge outcomes (7 and 30-day rehospitalizations and mortality) in adults ≥65 years hospitalized with acute myocardial infarction (AMI). We used multivariable-adjusted logistic regression models to examine the association between the presence of anemia and/or HF, and the examined outcomes. The study population consisted of 3,863 patients ≥65 years hospitalized with AMI at the 3 major medical centers in Worcester, MA, during 6 annual periods between 2001 and 2011. Individuals were categorized into 4 groups based on the presence of previously diagnosed anemia (hemoglobin ≤10 mg/dl) and/or HF: Those without these conditions (n = 2,300), those with anemia only (n = 382), those with HF only (n = 837), and those with both conditions (n = 344). The median age of the study population was 79 years and 49% were men. Individuals who had been previously diagnosed with anemia and HF had the highest proportion of older adults (≥85 years) and the lowest proportion of those who had received any cardiac interventional procedure during hospitalization. After multivariable adjustment, individuals who presented with both previously diagnosed conditions were at the greatest risk for experiencing adverse events. Patients who presented with HF only were at higher risk for developing several clinical complications during hospitalization, whereas those with anemia only were at slightly higher risk of being rehospitalized within 7-days of their index hospitalization. In conclusion, anemia and HF are prevalent chronic conditions that increased the risk of adverse events in older adults hospitalized with AMI.

Decade-long trends (1999-2009) in the characteristics, management, and hospital outcomes of patients hospitalized with acute myocardial infarction with prior diabetes and chronic kidney disease.

BACKGROUND: Despite the increasing magnitude and impact, there are limited data available on the clinical management and in-hospital outcomes of patients who have diabetes mellitus (DM) and chronic kidney disease (CKD) at the time of hospitalization for acute myocardial infarction (AMI). The objectives of our population-based observational study in residents of central Massachusetts were to describe decade-long trends (1999-2009) in the characteristics, in-hospital management, and hospital outcomes of AMI patients with and without these comorbidities. METHODS: We reviewed the medical records of 6,018 persons who were hospitalized for AMI on a biennial basis between 1999 and 2009 at all eleven medical centers in central Massachusetts. Our sample consisted of the following four groups: DM with CKD (n=587), CKD without DM (n=524), DM without CKD (n=1,442), and non-DM/non-CKD (n=3,465). RESULTS: Diabetic patients with CKD were more likely to have a higher prevalence of previously diagnosed comorbidities, to have developed heart failure acutely, and to have a longer hospital stay compared with non-DM/non-CKD patients. Between 1999 and 2009, there were marked increases in the prescribing of beta-blockers, statins, and aspirin for patients with CKD and DM as compared to those without these comorbidities. In-hospital death rates remained unchanged in patients with DM and CKD, while they declined markedly in patients with CKD without DM (20.2% dying in 1999; 11.3% dying in 2009). CONCLUSION: Despite increases in the prescribing of effective cardiac medications, AMI patients with DM and CKD continue to experience high in-hospital death rates.

Caudate and putamen volumes in good and poor outcome patients with schizophrenia.

Magnetic resonance images of 37 patients with schizophrenia and 37 age- and sex-matched volunteers were acquired. The caudate nucleus and putamen were traced on axial slices from the most superior extent of the caudate to the most inferior point where the caudate and putamen merge. Two subtypes of schizophrenia were compared, the Kraepelinian subtype (n=13), characterized by an unremitting and severe course, and the non-Kraepelinian subtype (n=24), characterized by a remitting course and some periods of self-care. Patients with good outcome schizophrenia had larger relative mean putamen size (0.0129) than poor outcome patients (0.0123) or normal controls (0.0121), but not caudate size. This enlargement was most marked for the dorsal putamen and right hemisphere. Striatal size was not related to whether patients were currently being treated with atypical or typical neuroleptics or whether they had been predominantly treated with typical or atypical neuroleptics over the past 3 years. This suggests the possibility that the expansion of putamen size may be a physiological correlate of neuroleptic responsiveness or that small putamen size at disease onset may be a predictor of outcome.

Citalopram in the treatment of dysthymic disorder.

This study aimed to provide preliminary data on the tolerability and effectiveness of citalopram for patients with dysthymic disorder. Twenty-one adult subjects meeting DSM-IV criteria for dysthymic disorder were enrolled in this 12-week open-label study, of whom 15 had pure dysthymia (e.g. no major depression in the past 2 years). Citalopram was initiated at 20 mg/day, and increased to a maximum of 60 mg/day. Response was defined as 50% or greater drop in score on the Hamilton Depression Rating Scale (HDRS) and a Clinical Global Impressions-I score of 1 ('very much improved') or 2 ('much improved'). Of these 15 pure dysthymic disorder subjects, all completed the trial, and 11 (73.3%) were treatment responders. All paired sample t-tests were highly significant, demonstrating significant average improvement on all measures of symptomatology and functioning. Scores on the 24-item HDRS decreased from 22.3+/-4.3 at baseline to 9.1+/-7.8 at week 12 [t(14)=6.1, P<0.001]. In addition, improvement was noted in self-reported measures of temperament and social functioning. The average final dose of citalopram was 39 mg/day. Side-effects were reported by nine of 15 subjects (60%), most frequently gastrointestinal symptoms (n=5), dry mouth (n=5) and sexual side-effects (n=3). These findings suggest the effectiveness and tolerability of citalopram in treating dysthymic disorder. Double-blind prospective studies are needed comparing citalopram both to placebo and to other medications, assessing both initial and sustained response to treatment.

Classes of depression, anxiety, and functioning in acute coronary syndrome patients.

OBJECTIVES: To describe change in subgroups characterized by patterns of depression, anxiety, and functional impairment; examine treatment effects on subgroup membership; examine effects of sex and age on subgroup membership. METHODS: Latent class models were used to meet the first 2 objectives using 79 patients with depression/anxiety. Generalized estimating equations were used to meet the third objective. RESULTS: Three subgroups characterized by different combinations of psychiatric disorders and functioning were identified. Patients who received treatment were more likely to transition to a less impaired subgroup. CONCLUSIONS: Unique information about holistic treatment effects can be gained when multiple outcomes are considered simultaneously.

Identifying symptom profiles of depression and anxiety in patients with an acute coronary syndrome using latent class and latent transition analysis.

OBJECTIVE: To identify symptom profiles of depression and anxiety in patients with an acute coronary syndrome (ACS), to examine changes in symptom profiles over time, and finally, to examine the effects of age and sex on patients' symptom profiles. METHODS: One hundred ACS patients with mild to severe symptoms of depression and/or anxiety at 1 month post-hospital discharge were enrolled in a randomized trial of cognitive behavioral therapy. Latent class and latent transition analyses were used to identify symptom profiles and describe change over the time in profile membership. RESULTS: A two-class solution was selected to describe depression and anxiety symptom profiles. Class I (76% of patients at baseline) was labeled "depression and some anxiety symptoms." Class II (24% of patients at baseline) was labeled "anxiety and some depression symptoms." Approximately 25% of patients in the treatment condition transitioned from the depression and some anxiety symptoms class to the anxiety and some depression symptoms class at follow-up compared to 10% of patients in the control condition at follow-up; nearly 50% of patients in the control condition showed worsening of symptoms as compared to 28% in the treatment condition. Results suggested age differences in the probabilities of transitioning between the classes; older patients were more likely to continue having depression and some anxiety symptoms at the time of follow-up. CONCLUSIONS: Identifying symptom profiles of depression and anxiety in patients with an ACS may improve diagnostic practices and help to design tailored interventions.