Maternal mental health: a key area for future research among women with congenital heart disease.

In this viewpoint, we respond to the recently published national priorities for research in congenital heart disease (CHD) among adults, established through the James Lind Alliance Priority Setting Partnership, with specific attention to priority 3 (mental health) and priority 5 (maternal health). Our recent policy impact project explored how maternal mental health is currently addressed in adult congenital heart disease (ACHD) services in the National Health Service, identified gaps and discussed possible ways forward. Our multidisciplinary discussion groups, which included women with lived experience of CHD and pregnancy, cardiology and obstetrics clinicians and medical anthropologists, found that while pregnancy and the postnatal period increase the mental health challenges faced by women with CHD, current services are not yet equipped to address them. Based on this work, we welcome the prioritisation of both mental health and maternal health in ACHD, and suggest that future research should focus on the overlaps between these two priority areas.

Randomized controlled trial of interpersonal psychotherapy versus enhanced treatment as usual for women with co-occurring depression and pelvic pain.

OBJECTIVE: Our study assessed the effectiveness of Interpersonal Psychotherapy (IPT) tailored for biomedical patients with depression and pain. IPT was compared to enhanced treatment as usual (E-TAU) among women with co-occurring depression and chronic pain presenting for care at a women's health or family medicine practice. We hypothesized that women presenting to urban medical practices with depression and chronic pain would benefit from IPT tailored to address their needs to a greater degree than from E-TAU. METHODS: We conducted a randomized controlled psychotherapy trial of 61 women from 2 urban medical practices who met criteria for major depressive disorder and chronic pelvic pain. Participants were assigned to receive either 8 sessions of IPT or a facilitated psychotherapy referral to a community mental health center, and assessed for depression, social interactions, and pain at 0-, 12-, 24-, and 36-weeks, with score on the Hamilton Rating Scale for Depression as the primary outcome. Both intent-to-treat (ITT) and causal modeling analyses correcting for treatment attendance were conducted. RESULTS: ITT analyses were not significant. In causal modeling analyses, participants assigned to IPT showed significantly more improvement for depression and social interactions, but not for pain. CONCLUSION: IPT may be a viable option as part of a comprehensive treatment program for women in medical practices with depression and chronic pain. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov, NCT00895999.

Interpersonal Psychotherapy for Co-occurring Depression and Chronic Pain.

Up to 37% of individuals experience chronic pain during their lifetimes. Approximately one-fourth of primary care patients with chronic pain also meet criteria for major depression. Many of these individuals fail to receive psychotherapy or other treatment for their depression; moreover when they do, physical pain is often not addressed directly. Women, socioeconomically disadvantaged individuals, African Americans and Latinos all report higher rates of pain and depression compared to other groups. This article describes a version of Interpersonal Psychotherapy tailored for patients with comorbid depression and chronic pain, Interpersonal Psychotherapy for Depression and Pain (IPT-P). While IPT-P potentially could be delivered to many different patient populations in a range of clinical settings, this article focuses on its delivery within primary care settings for socioeconomically disadvantaged women. Adaptations include a brief 8-session protocol that incorporates strategies for anticipating barriers to psychotherapy, accepting patients' conceptualization of their difficulties, encouraging patients to consider the impact of their pain on their roles and relationships, emphasizing self-care, incorporating pain management techniques, and flexible scheduling. In addition, IPT-P is designed as an adjunct to usual medical pain treatment, and seeks to engage non-treatment seeking patients in psychotherapy by focusing on accessibility and relevance of the intervention to concerns common among patients with pain. Identifying patients with comorbid depression and chronic pain and offering IPT-P as a treatment option has the potential to improve clinical outcomes for individuals with depression and chronic pain.

Interpersonal psychotherapy for women with comorbid depression and chronic pain.

Chronic pain is prevalent among patients with depression and a risk factor for poor depression treatment outcomes. No known psychotherapy approaches have been developed to target the needs of patients with comorbid depression and chronic pain. This study's goals were to evaluate feasibility, acceptability, and initial effects of interpersonal psychotherapy adapted for women with depression and chronic pain. Seventeen women with major depression and chronic pelvic pain were offered 8 sessions of individual treatment, interpersonal psychotherapy for depression and pain (IPT-P). Participants were recruited from a women's health clinic, were predominantly low-income and minority, and generally did not initially self-identify as depressed. Large effect sizes with significant improvements were found for depression severity and social adjustment; pain interference remained unchanged. Most enrolled patients reported a high level of satisfaction with IPT-P. This pilot study provides preliminary support for the use of IPT-P for patients with comorbid depression and chronic pain.

Pain and depression in gynecology patients.

BACKGROUND: The prevalence and consequences of comorbid pain and depression in gynecology patients are understudied. OBJECTIVE: The purpose of the study was to determine the prevalence of pain, depression, and their co-occurrence among gynecology patients, and to examine how pain and depression are associated with additional comorbid mental disorders. METHOD: Self-reported pain, depressive symptoms, other mental-disorder symptoms, functional status, interpersonal distress, and abuse were assessed in 1,647 gynecology patients by use of the Patient Health Questionnaire and the Medical Outcomes Study (SF-20). RESULTS: Moderate-to-severe pain was reported by 29% of patients; depression, by 21%; with both present in 10.3%. Comorbid pain and depression was associated with anxiety, suicidal or death ideation, functional impairment, interpersonal distress, and physical or sexual abuse. DISCUSSION: Innovative approaches are needed to assess and treat gynecology patients with comorbid pain and depression, given the degree of overlap between them.

Pain as a predictor of depression treatment outcomes in women with childhood sexual abuse.

OBJECTIVES: Childhood sexual abuse (CSA) increases risk for both depression and pain in women. Pain is associated with worse depression treatment response. The contribution of pain to depression treatment outcomes in women with histories of CSA is unknown. This study examined whether clinically significant pain would be associated with worse depression and functioning outcomes among women with CSA histories treated with interpersonal psychotherapy. METHOD: Participants were 66 women with major depression and CSA who presented to a community mental health center. An interpersonal psychotherapy protocol planned for 14 weekly sessions followed by 2 biweekly sessions. Patients were classified as experiencing high pain or low pain based on reported pain severity and interference with functioning. Generalized estimating equations were used to assess change over time in intent-to-treat analyses. RESULTS: High pain patients entered treatment with greater depression symptom severity than low pain patients. Although both high and low pain patients demonstrated improvement in mood, high-pain patients continued to report more depressive symptoms posttreatment. Furthermore, high pain patients demonstrated less change in their emotion-related role functioning over the course of treatment than low pain patients. LIMITATIONS: Small sample size, secondary analyses, lack of a control group, and limited assessment of pain all limit confidence in the findings of this study. CONCLUSION: Findings support the evidence that depression is particularly severe and difficult to treat in patients with CSA and pain. Clinicians should evaluate pain in depressed patients with CSA histories. Role functioning may prove to be a particularly important target in the treatment of patients with pain.

Psychosocial stress and anxiety in musculoskeletal pain patients with and without depression.

OBJECTIVE: The objective of this study was to determine if psychosocial stress and anxiety were associated with depression severity in primary care patients with chronic musculoskeletal pain. METHODS: A cross-sectional sample of 500 primary care patients with musculoskeletal pain (250 with depression and 250 without depression) was assessed for anxiety, psychosocial stress, depression severity and demographics. The depressed and nondepressed participants were compared using t test and chi(2) analyses. Multiple linear regression analyses were used to evaluate the respective associations of psychosocial stressors and anxiety with depression severity based on the 20-item Symptoms Check List across all 500 participants. RESULTS: Compared with nondepressed patients, the depressed patients reported significantly more psychosocial stressors and more severe anxiety. Depressed patients reported a higher frequency of difficulties with every psychosocial stressor assessed. After controlling for covariates, both anxiety and psychosocial stressors were found to be associated with depression severity. CONCLUSIONS: Both anxiety and psychosocial stress should be considered in the assessment and treatment of patients with musculoskeletal pain and depression. Psychosocial stressors among patients with pain may have an impact on depression beyond that of anxiety. Tailored, integrated treatments that target the psychosocial needs of patients with pain and depression are needed. In addition to pharmacotherapy, psychotherapy and other behavioral treatments may be especially important for depression complicated by anxiety or psychosocial stress.

What makes our hospitals different: the nursing role in a specialty hospital.

MedCath, Inc. is the largest provider of cardiovascular services in the United States; therefore, tremendous opportunities present themselves to us in regard to improving and redesigning care for this patient population. With that in mind, we actively address the nursing model of care specifically for a specialty hospital. This article illustrates why we believe our nursing delivery model is different and better than traditional health care models in the country. We believe that our approach to patient-focused care offers the resources and tools that nurses require to adequately care for the complex patients that present to our hospitals. A key part of our strategy is the commitment we have to education, training, adequate staffing ratios, safety, and collaborative care processes. We consider our model to be dynamic in nature, and we rely on the input from nurses, physicians, and other caregivers to continuously improve our model of care. Data and analysis are provided daily through our balanced scorecard initiatives and from our clinical metrics, clinical best practice teams, and throughput efforts. We seek to be a learning organization and recognize that knowledge is enhanced by the collective ideas and actions of our key stakeholders, which include the nursing staff.

Pain and depressive symptoms among financially disadvantaged women's health patients.

OBJECTIVES: Women are at greater risk than men for both pain and depression, yet little is known about the frequency and implications of comorbid pain and depression among women in women's health settings. This study aimed to determine the frequency of comorbid depressive symptoms and pain among a sample of gynecology outpatients and to evaluate the associations of comorbid pain and depressive symptoms with physical, emotional, and social functioning and abuse experiences. METHODS: A total of 242 low-income, primarily African American women presenting at an urban women's health clinic for routine gynecological care consented to participate. Subjects completed the Beck Depression Inventory, Brief Symptom Inventory, Graded Chronic Pain Scale, SF-36, Physical and Sexual Abuse Questionnaire, and Duke Social Support Index. Multivariate analyses were used to test pain and depressive symptoms in their associations with emotional, physical, and social functioning and abuse experience. Age, race, income, and education were controlled in all analyses. RESULTS: Nearly 20% of participants reported comorbid high depressive symptoms and pain. Both depressive symptoms and pain were independently associated with emotional, physical, and social functioning domains. Depressive symptoms, but not pain, were associated with increased likelihood of history of abuse. CONCLUSIONS: Comorbid depressive symptoms and pain are a substantial problem, with pervasive implications among financially disadvantaged women seeking routine gynecological care. Subsequent research will determine if psychosocial treatment can be adapted effectively to the needs of this patient population.

Contributions of physical and sexual abuse to women's experiences with chronic pelvic pain.

OBJECTIVE: To examine the roles of physical and sexual abuse in women with chronic pelvic pain using multi-dimensional pain assessment and to compare the chronic pelvic pain experiences of women with physical abuse to those of women with sexual abuse. STUDY DESIGN: Structured questionnaires were used to measure self-reported abuse, pain severity, psychological distress, physical functioning, interpersonalfunctioning, and coping in 63 women attending a tertiary care gynecologic clinic for diagnosis and treatment of chronic pelvic pain. RESULTS: Women with chronic pelvic pain who reported abuse demonstrated significantly more psychological distress than did women who reported no abuse, but there were no differences in pain severity, physical functioning, interpersonal functioning or coping. Women with physical abuse reported more overall psychological distress, depression, anxiety and somatization than women who reported no physical abuse. Women who reported sexual abuse showed more overall psychological distress and anxiety than women who reported no sexual abuse. While physical abuse was more consistently associated with psychological distress than was sexual abuse, both types of abuse were risk factors for distress. CONCLUSION: These results suggest that both physical and sexual abuse are associated with psychological distress in women with chronic pelvic pain but not with other domains of pain experience. Additional research to improve identification and treatment of women with both chronic pelvic pain and abuse is indicated.

Personality traits and symptom reduction in a group treatment for women with histories of childhood sexual abuse.

The influence of personality on symptom reduction has not been examined in research on treatments for women with childhood sexual abuse histories, although personality has demonstrated predictive value in other treatment contexts. This study examined personality variables associated with symptom reduction in group therapy for hospitalized women with histories of sexual abuse. Personality was measured with the NEO-Five-Factor Inventory (NEO-FFI), which yields scores on neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Among 86 women who participated in either the Women's Safety in Recovery (WSIR) group therapy or treatment as usual, 43 completed assessments of symptom reduction at discharge and 6-month follow-up. We hypothesized that extraversion, agreeableness, and openness to experience would be associated with treatment outcome. Our results showed that agreeableness and extraversion moderated the effect of treatment on symptom reduction. WSIR participants who were less agreeable improved more at discharge and 6-month follow-up than more agreeable WSIR participants. Moreover, women in the WSIR group who were more introverted showed greater symptom improvement at discharge than more extraverted women. Our findings suggest that more introverted, less agreeable patients with sexual abuse histories may indeed benefit from structured group treatments.

Neuropsychological changes and treatment compliance in older adults with sleep apnea.

INTRODUCTION: Apnea is a common disorder in older adults and has been shown to affect cognition. Some studies suggest that treatment for apnea improves certain cognitive deficits, but few studies have examined the relationship between compliance and cognitive improvement. We designed a study to answer the following questions about sleep apnea, cognition and treatment in older adults: (1) Which neuropsychological (NP) variables are differentially associated with measures of sleep fragmentation and oxygen desaturation? (2) Does compliant use of CPAP provide a cognitive advantage over noncompliant use? (3) Does NP performance at baseline predict compliance at 3 months? METHOD: Twelve participants were recruited for the study. All had polysomnographically defined sleep apnea with an RDI of 10 or greater. All were also at least 55 years of age, had no other diagnosable sleep disorder and had no previous treatment for sleep apnea syndrome (SAS). Participants were administered a full NP battery before and 3 months after treatment with CPAP. RDI at baseline was associated with delayed verbal recall, while oxygen desaturation was associated with both delayed recall and constructional abilities. Compliant use of CPAP at 3 months was associated with greater improvements in attention, psychomotor speed, executive functioning and nonverbal delayed recall. Finally, attention measures predicted compliance at 3 months suggesting that those who were least vigilant at baseline were more likely to comply with treatment. DISCUSSION: Results are discussed in terms of the relevance to targeting special populations for compliance interventions, the ways that treatment may specifically affect older adults and the possible dose-response relationship of CPAP.

Neuroimaging of NREM sleep in primary insomnia: a Tc-99-HMPAO single photon emission computed tomography study.

STUDY OBJECTIVES: The objectives of this study were to: 1) demonstrate the feasibility of combining polysomnography and SPECT neuroimaging to study NREM sleep in primary insomnia and 2) evaluate possible functional CNS abnormalities associated with insomnia. DESIGN: Patients with insomnia and good sleeper controls were studied polysomnographically for three nights with a whole brain SPECT Scan of NREM sleep on Night 3. Groups were screened for medical/psychiatric history, substance use, and matched on age, body mass index, and education. SETTING: Sleep Research Laboratory and Nuclear Medicine Center PARTICIPANTS: Nine females, 5 patients with chronic psychophysiologic insomnia and 4 healthy good sleepers (mean age 36 years, SD 12, range 27-55). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Tomographs of regional cerebral blood flow during the 1st NREM sleep cycle were successfully obtained. Contrary to our expectations, patients with insomnia showed a consistent pattern of hypoperfusion across all 8 pre-selected regions of interest, with particular deactivation in the basal ganglia (p=.006). The frontal medial, occipital, and parietal cortices also showed significant decreases in blood flow compared to good sleepers (p<.05). Subjects with insomnia had decreased activity in the basal ganglia relative to the frontal lateral cortex, frontal medial cortex, thalamus, occipital and parietal cortices (p<.05). CONCLUSIONS: This study demonstrated the feasibility of combining neuroimaging and polysomnography to study cerebral activity in chronic insomnia. These preliminary results suggest that primary insomnia may be associated with abnormal central nervous system activity during NREM sleep that is particularly linked to basal ganglia dysfunction.

The effects of an orally administered cholinergic agonist on REM sleep in major depression.

BACKGROUND: Centrally active cholinergic agents such as arecoline and physostigmine shorten rapid eye movement (REM) latency, reduce REM interval times, or both and do so preferentially in patients with depression. We tested an orally administered cholinergic agonist (donepezil HCL 10 mg [Aricept]) to determine whether this agent also alters REM timing in depressed patients (n = 8) compared with age- and gender-matched control subjects (n = 8). METHODS: All subjects were studied for 3 consecutive nights in the sleep laboratory. The design was a fixed-order placebo-donepezil protocol to accommodate the long half-life of donepezil. Night 1 served as an adaptation night. On night 2, placebo was administered at 8:00 PM. On night 3, donepezil was administered at 8:00 PM. RESULTS: The cholinergic challenge distinguished the groups. In depressed patients REM latency was reduced compared with baseline (47.6 vs. 64.4, p =.04) following administration of donepezil. Control subjects showed no response: REM latency after donepezil was virtually identical to baseline REM latency (71.7 vs. 69.3). CONCLUSIONS: These data indicate that donepezil is likely to be useful in testing hypotheses related to cholinergic function in mood disorders.

Genetic segregation analysis of recurrent, early-onset major depression: evidence for single major locus transmission.

Coordinated efforts are now underway to identify susceptibility genes for unipolar major depressive disorder (MDD) and related disorders. These studies have focused on recurrent, early-onset MDD (RE-MDD), thought to be the most familial form of this disorder. The goal of this study was to conduct a complex segregation analysis of recurrent MDD and other major mood disorders aggregating in families identified by probands with RE-MDD. Eighty-one families were identified through probands over the age of 18 who met criteria for recurrent (> or =2 episodes), early-onset (< or =25 years), nonpsychotic, unipolar MDD (RE-MDD) and included 407 first-degree relatives and 835 extended relatives. Psychiatric diagnoses for probands and their family members who provided blood samples were formulated from structured personal interviews, structured family history assessments, and available medical records. The remaining family members who participated and those who were deceased were evaluated through the family history method augmented by available medical records. Best-estimate diagnoses were made during a consensus conference according to established diagnostic criteria. Segregation analyses were performed using the REGD routine in S.A.G.E. release 4.0. The segregation analysis of recurrent MDD supported a sex-independent Mendelian codominant model. Analysis of major mood disorders supported a sex-independent Mendelian dominant model. Interestingly, inclusion of spousal residual correlations provided better fitting models for recurrent MDD but not the broader phenotype of major mood disorders. Unlike unipolar MDD, the lifetime prevalence of bipolar I disorder in this sample of families did not exceed the reported population prevalence [Zubenko et al., 2001]. Our results suggest that a major locus contributes to the expression of recurrent MDD and possibly other major mood disorders within families identified by probands with RE-MDD. Due to the limitations of the segregation analysis model, our results cannot address whether the same major locus is segregating across families in our sample or whether multiple major loci are involved (genetic heterogeneity). The absence of aggregation of bipolar I disorder in these families strongly suggests that while the genetic determinants of unipolar and bipolar disorders may overlap, they are not identical. Our findings illustrate the advantage of employing families identified by probands with RE-MDD in studies designed to detect susceptibility loci for unipolar MDD and related disorders.

Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia.

OBJECTIVE: Although four meta-analytic reviews support the efficacy of pharmacotherapy and behavior therapy for the treatment of insomnia, no meta-analysis has evaluated whether these treatment modalities yield comparable outcomes during acute treatment. The authors conducted a quantitative review of the literature on the outcome of the two treatments to compare the short-term efficacy of pharmacotherapy and behavioral therapy in primary insomnia. METHOD: They identified studies from 1966 through 2000 using MEDLINE, psycINFO, and bibliographies. Investigations were limited to studies using prospective measures and within-subject designs to assess the efficacy of benzodiazepines or benzodiazepine receptor agonists or behavioral treatments for primary insomnia. Benzodiazepine receptor agonists included zolpidem, zopiclone, and zaleplon. Behavioral treatments included stimulus control and sleep restriction therapies. Twenty-one studies summarizing outcomes for 470 subjects met inclusion criteria. RESULTS: Weighted effect sizes for subjective measures of sleep latency, number of awakenings, wake time after sleep onset, total sleep time, and sleep quality before and after treatment were moderate to large. There were no differences in magnitude between pharmacological and behavioral treatments in any measures except latency to sleep onset. Behavior therapy resulted in a greater reduction in sleep latency than pharmacotherapy. CONCLUSIONS: Overall, behavior therapy and pharmacotherapy produce similar short-term treatment outcomes in primary insomnia.

Beta EEG activity and insomnia.

To date there have been seven studies which find that beta EEG is elevated at around sleep onset and during polysomnographic sleep in patients with insomnia. These findings suggest that insomnia may be characterized by central nervous system (CNS) hyperarousal. In this article, the seven studies are critically reviewed, two theoretical perspectives on beta EEG are presented, and the concept of hyperarousal as a three component process is discussed.