Predictors of Use and Drop Out From a Web-Based Cognitive Behavioral Therapy Program and Health Community for Depression and Anxiety in Primary Care Patients: Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: A previously reported study examined the treatment of primary care patients with at least moderate severity depressive or anxiety symptoms via an evidence-based computerized cognitive behavioral therapy (CCBT) program (Beating the Blues) and an online health community (OHC) that included a moderated internet support group. The 2 treatment arms proved to be equally successful at 6-month follow-up. OBJECTIVE: Although highly promising, e-mental health treatment programs have encountered high rates of noninitiation, poor adherence, and discontinuation. Identifying ways to counter these tendencies is critical for their success. To further explore these issues, this study identified the primary care patient characteristics that increased the chances patients would not initiate the use of an intervention, (ie, not try it even once), initiate use, and go on to discontinue or continue to use an intervention. METHODS: The study had 3 arms: one received access to CCBT (n=301); another received CCBT plus OHC (n=302), which included a moderated internet support group; and the third received usual care (n=101). Participants in the 2 active intervention arms of the study were grouped together for analyses of CCBT use (n=603) because both arms had access to CCBT, and there were no differences in outcomes between the 2 arms. Analyses of OHC use were based on 302 participants who were randomized to that arm. RESULTS: Several baseline patient characteristics were associated with failure to initiate the use of CCBT, including having worse physical health (measured by the Short Form Health Survey Physical Components Score, P=.01), more interference from pain (by the Patient-Reported Outcomes Measurement Information System Pain Interference score, P=.048), less formal education (P=.02), and being African American or another US minority group (P=.006). Characteristics associated with failure to initiate use of the OHC were better mental health (by the Short Form Health Survey Mental Components Score, P=.04), lower use of the internet (P=.005), and less formal education (P=.001). Those who initiated the use of the CCBT program but went on to complete less of the program had less formal education (P=.01) and lower severity of anxiety symptoms (P=.03). CONCLUSIONS: This study found that several patient characteristics predicted whether a patient was likely to not initiate use or discontinue the use of CCBT or OHC. These findings have clear implications for actionable areas that can be targeted during initial and ongoing engagement activities designed to increase patient buy-in, as well as increase subsequent use and the resulting success of eHealth programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/study/NCT01482806.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients.

BACKGROUND: Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems. METHODS: Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE. DISCUSSION: The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT. TRIAL REGISTRATION: ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Prognostic implications of a one-item health literacy screen on health status outcomes among heart failure patients with depression.

Background: Health literacy (HL) is the degree to which individuals can obtain, process, and understand basic health information and services. Although low HL portends greater risk for clinical events, its association with heart failure (HF)-specific health status- patients' symptoms, function and quality of life- is poorly understood. We thus explored the association of low HL with health status outcomes in depressed patients with HF, for whom treatment regimens can be complex. Methods: Participants with HF with reduced ejection fraction and depression, from the Hopeful Heart trial, were categorized as having low or adequate HL at baseline using a validated, 1-item HL screen. HF-specific health status was measured at baseline, 3, 6, and 12 months using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Using serial risk-adjusted linear regression models, we assessed the association of HL with baseline, 12-month and 12-month change in the KCCQ Overall Summary (OS) scores (range 0-100; lower scores = worse health status). Results: Among 629 participants, 35 % had low HL. Those with low HL had lower health status at all time points, including at 12 months after discharge (-9.8 points, 95%CI [-14.3, -5.3], p < 0.001), with poorer improvements in KCCQ-OS scores after accounting for baseline health status (-6.4 points, 95%CI [-10.5, -2.3], p = 0.002). Conclusions: In those with HF and depression, low HL was common and associated with worse HF-specific health status and poorer improvement over time. A brief HL screen can identify patients at risk for poorer health status outcomes and for whom additional interventions may be warranted.

The Relationship Between Objectively Measured Step Count, Clinical Characteristics, and Quality of Life Among Depressed Patients Recently Hospitalized With Systolic Heart Failure.

OBJECTIVE: Physical activity (PA) can improve symptoms of both depression and heart failure (HF), but objective activity data among recently hospitalized HF patients with comorbid depression are lacking. We examined PA and the relationship between daily step counts and mood, health-related quality of life (HRQoL), and heart health among patients enrolled in a clinical trial treating HF and comorbid depression. METHODS: We screened hospitalized patients with systolic HF (left ventricular ejection fraction [LVEF] ≤45%) and New York Heart Association class II-IV symptoms for depression using the two-item Patient Health Questionnaire (PHQ-2) and telephoned screen-positive patients to administer the PHQ-9 2 weeks after discharge. If the patient scored PHQ-9 ≥10 and agreed to continue in our study, we administered our baseline assessment and mailed them an armband accelerometer. We instructed patients to wear the armbands for 7 days before returning them and classified their data as "usable" if they wore it ≥10 hours per day on ≥4 separate days. RESULTS: We mailed accelerometers to 531 depressed HF patients, and 222 (42%) returned them with usable data. Their median age was 64 years, 54% were women, 23% were non-White, and they walked a median of 1170 steps daily. Higher median daily step counts were associated with lower New York Heart Association class and better physical- and HF-specific HRQoL, but not mood symptoms, mental HRQoL, or LVEF. CONCLUSIONS: Patients with HF and comorbid depression are generally sedentary after hospital discharge. Although mood symptoms and LVEF were unrelated to objective PA, patients with higher step counts self-reported better HRQoL.Trial Registration:ClinicalTrials.gov identifier NCT02044211.

Perceptions of Need for Palliative Care in Recently Hospitalized Patients With Systolic Heart Failure.

CONTEXT: The symptom burden associated with heart failure (HF) remains high despite improvements in therapy and calls for the integration of palliative care into traditional HF care. Little is also known about how patients with HF perceive palliative care and patient-level characteristics associated with the need for palliative care, which could influence the utilization of palliative care in HF management. OBJECTIVES: To identify characteristics of HF patients associated with perceived need for palliative care. METHODS: We analyzed data from the Hopeful Heart Trial, which studied the efficacy of a collaborative care intervention for treating both systolic HF and depression. Palliative care preferences were collected during routine study follow-up. We assessed the association of perceived need for palliative care during study follow-up and baseline data on sociodemographics, clinical measures, and patient-centered outcomes. We then used descriptive statistics and logistic regression to analyze our data. RESULTS: Participants were on average 64 years old, male, and reported severe HF symptoms and poor to below average quality of life (. Most had unfavorable impressions of palliative care, but many still perceived a need for palliative care. Factors associated with perceived need for palliative care included depression, non-white race, more severe HF symptoms, and lower mental & physical health-related quality of life. CONCLUSION: HF patients' beliefs about palliative care may affect utilization of palliative care. Specific characteristics can help identify patients with HF who may benefit from palliative care involvement. Education targeted towards patients with selected attributes may help incorporate palliative care into HF management.

Bypassing the blues: Insomnia in the depressed post-CABG population.

BACKGROUND: BACKGROUND: Recovery from coronary artery bypass graft (CABG) surgery often is complicated by depression and insomnia, resulting in poorer health-related quality of life and clinical outcomes. We explored the relationships among depression, insomnia, quality of life, and the impact of a collaborative care strategy on reducing insomnia in patients after CABG surgery. METHODS: METHODS: Patients with a Patient Health Questionnaire score ≥10 were randomized to nurse-delivered collaborative care for depression (n = 150) or their physician's usual care (n = 152). A convenience sample of patients without depression (n = 151) served as the control group. Using the Hamilton Depression Rating Scale sleep questions, we created an "insomnia index." RESULTS: RESULTS: At baseline, 63% of participants who were depressed vs 12% of those who were not depressed reported insomnia. Compared with usual care, fewer collaborative care participants reported insomnia at 8 months, and they tended to have a lower insomnia score (insomnia index change score −0.95 and −1.47, respectively; P = .05) with no time-by- randomization interaction, Cohen's d = 0.22 (95% confidence interval, −0.001 to 0.43). Participants with baseline insomnia reported greater improvements in mental health­related quality of life (Medical Outcomes Survey 36-item Short Form Mental Component Summary score; −3.32, P = .02), but insomnia was not a significant moderator of the effect of collaborative care. CONCLUSIONS: CONCLUSIONS: This is the first study to examine the long-term impact on insomnia among post-CABG patients treated for depression. Future collaborative care studies could consider including a therapeutic focus for insomnia.

Racial Differences in the Effectiveness of Internet-Delivered Mental Health Care.

BACKGROUND: Computerized cognitive behavioral therapy (cCBT) can improve mental health outcomes in White populations; however, it is unknown whether racial and ethnic minority populations receive clinical benefits from cCBT. OBJECTIVE: To study race differences in the impact of cCBT use on mental health outcomes among White and African American primary care patients. DESIGN: Secondary analysis of a three-arm randomized controlled clinical trial. PARTICIPANTS: Primary care physicians (PCPs) referred 2,884 patients aged 18-75; 954 met eligibility criteria (including elevated mood and/or anxiety symptoms indicated as a score ≥ 10 on Patient Health Questionnaire or Generalized Anxiety Disorder scale); 704 were randomized in 3:3:1 ratio to receive either (1) the cCBT program (cCBT-only), (2) cCBT plus access to an Internet Support Group (cCBT+ISG), or (3) their PCP's usual care (UC). After exclusions, this study analyzed 689 patients: 590 receiving cCBT, in the combined cCBT-only and cCBT+ISG groups (91 African American, 499 White), and 99 receiving UC (22 African American, 77 White). INTERVENTION(S): We used the Beating the Blues cCBT program that consisted of eight 50-min Internet-delivered interactive sessions and "homework" assignments to complete between weekly sessions. College graduate-level care coaches provided six months of remote support. MAIN MEASURE(S): After prior analyses demonstrated no effect of the ISG program, we combined the cCBT-only and cCBT+ISG groups (cCBT) to compare to UC at 6-month follow-up. Controlling for sociodemographic factors, baseline symptoms, and treatment arm, we examined race differences for impact of cCBT versus UC on the mental health-related quality-of-life (Short-form 12 Health Survey), and Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety, and depression. RESULTS: Compared to UC, cCBT had no effect on quality of life (d = 0.10; p = 0.40), depression (d = - 0.19; p = 0.10), or anxiety (d = - 0.16; p = 0.18) for Whites. However, for African American patients, cCBT was associated with significant 6-month decrease in depression (d = - 0.47, p < 0.01) and anxiety scores (d = - 0.54, p < 0.01). CONCLUSIONS: cCBT may be an efficient and scalable first step to eliminating disparities in mental health care. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01482806. https://www.clinicaltrials.gov/ct2/show/NCT01482806?term=rollman&rank=4.

Engagement and outcomes for a computerised cognitive-behavioural therapy intervention for anxiety and depression in African Americans.

BACKGROUND: Computerised cognitive-behavioural therapy (CCBT) helps improve mental health outcomes in White populations. However, no studies have examined whether CCBT is acceptable and beneficial for African Americans. AIMS: We studied differences in CCBT use and self-reported change in depression and anxiety symptoms among 91 African Americans and 499 White primary care patients aged 18-75, enrolled in a randomised clinical trial of collaborative care embedded with an online treatment for depression and anxiety. METHOD: Patients with moderate levels of mood and/or anxiety symptoms (PHQ-9 or GAD-7≥10) were randomised to receive either care-manager-guided access to the proven-effective Beating the Blues® CCBT programme or usual care from their primary care doctor. RESULTS: Compared with White participants, African Americans were less likely to start the CCBT programme (P=0.01), and those who did completed fewer sessions and were less likely to complete the full programme (P=0.03). Despite lower engagement, however, African Americans who started the CCBT programme experienced a greater decrease in self-reported depressive symptoms (estimated 8-session change: -6.6 v. -5.5; P=0.06) and similar decrease in anxiety symptoms (-5.3 v. -5.6; P=0.80) compared with White participants. CONCLUSIONS: CCBT may be an efficient and scalable first-step to improving minority mental health and reducing disparities in access to evidence-based healthcare. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Telephone-Delivered Stepped Collaborative Care for Treating Anxiety in Primary Care: A Randomized Controlled Trial.

BACKGROUND: Collaborative care for depression is more effective in improving treatment outcomes than primary care physicians' (PCPs) usual care (UC). However, few trials of collaborative care have targeted anxiety. OBJECTIVE: To examine the impact and 12-month durability of a centralized, telephone-delivered, stepped collaborative care intervention (CC) for treating anxiety disorders across a network of primary care practices. DESIGN: Randomized controlled trial with blinded outcome assessments. PARTICIPANTS: A total of 329 patients aged 18-64 referred by their PCPs in response to an electronic medical record (EMR) prompt. They include 250 highly anxious patients randomized to either CC or to UC, and 79 moderately anxious patients who were triaged to a watchful waiting (WW) cohort and later randomized if their conditions clinically deteriorated. INTERVENTION: Twelve months of telephone-delivered CC involving non-mental health professionals who provided patients with basic psycho-education, assessed preferences for guideline-based pharmacotherapy, monitored treatment responses, and informed PCPs of their patients' care preferences and progress via the EMR. MAIN MEASURES: Mental health-related quality of life ([HRQoL]; SF-36 MCS); secondary outcomes: anxiety (Hamilton Anxiety Rating Scale [SIGH-A], Panic Disorder Severity Scale) and mood (PHQ-9). KEY RESULTS: At 12-month follow-up, highly anxious patients randomized to CC reported improved mental HRQoL (effect size [ES]: 0.38 [95 % CI: 0.13-0.63]; P = 0.003), anxiety (SIGH-A ES: 0.30 [0.05-0.55]; P = 0.02), and mood (ES: 0.45 [0.19-0.71] P = 0.001) versus UC. These improvements were sustained for 12 months among African-Americans (ES: 0.70-1.14) and men (ES: 0.43-0.93). Of the 79 WW patients, 29 % met severity criteria for randomization, and regardless of treatment assignment, WW patients reported fewer anxiety and mood symptoms and better mental HRQoL over the full 24-month follow-up period than highly anxious patients who were randomized at baseline. CONCLUSIONS: Telephone-delivered, centralized, stepped CC improves mental HRQoL, anxiety and mood symptoms. These improvements were durable and particularly evident among those most anxious at baseline, and among African-Americans and men.

The prognostic impact and optimal timing of the Patient Health Questionnaire depression screen on 4-year mortality among hospitalized patients with systolic heart failure.

OBJECTIVE: An American Heart Association (AHA) Science Advisory recommends patients with coronary heart disease undergo routine screening for depressive symptoms with the two-stage Patient Health Questionnaire (PHQ). However, little is known on the prognostic impact of a positive PHQ screen on heart failure (HF) mortality. METHODS: We screened hospitalized patients with systolic HF (left ventricle ejection fraction≤40%) for depression with the two-item Patient Health Questionnaire (PHQ-2) and administered the follow-up nine-item Patient Health Questionnaire (PHQ-9) both immediately following the PHQ-2 and by telephone 1 month after discharge. Later, we ascertained vital status at 4-year follow-up on all patients who completed the inpatient PHQ-9 and calculated mortality incidence and risk by baseline PHQ. RESULTS: Of the 520 HF patients we enrolled, 371 screened positive for depressive symptoms on the PHQ-2. Of these, 63% scored PHQ-9≥10 versus 24% of those who completed the PHQ-9 1 month later (P<.001). PHQ-2 positive status was an independent predictor of 4-year all-cause mortality (HR: 1.50; P=.04), and mortality incidence was similar by baseline PHQ-9 score. CONCLUSIONS: Among hospitalized patients with systolic HF, a positive PHQ-2 screen for depressive symptoms is an independent risk factor for increased 4-year all-cause mortality. Our findings extend the AHA's Science Advisory for depression to hospitalized patients with systolic HF.

Twelve-month cost-effectiveness of telephone-delivered collaborative care for treating depression following CABG surgery: a randomized controlled trial.

OBJECTIVE: To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians' usual care (UC). METHODS: We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone 2 weeks following hospitalization (nine-item Patient Health Questionnaire ≥10) and were randomized to either an 8-month centralized, nurse-provided and telephone-delivered CC intervention for depression or to their physicians' UC. RESULTS: At 12 months following randomization, CC patients had $2068 lower but statistically similar estimated median costs compared to UC (P=.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost-effectiveness ratio of CC was -$9889 (-$11,940 to -$7838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC "dominating" UC (more QALYs at lower cost). CONCLUSIONS: Centralized, nurse-provided and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

Benefits of collaborative care for post-CABG depression are not related to adjustments in antidepressant pharmacotherapy.

OBJECTIVE: To determine whether the use and adjustment of antidepressant pharmacotherapy accounted for the beneficial effects of collaborative care treatment on the improvement of mood symptoms and health-related quality of life (HRQoL) after coronary artery bypass graft (CABG) surgery. METHODS: In a post-hoc analysis of data from the Bypassing the Blues (BtB) trial we tested the impact of antidepressant medication on changes in depression and HRQoL from the early postoperative period to 8-month follow-up. Two hundred fifty-nine depressed post-CABG patients scoring ≥10 on the Patient Health Questionnaire-9 were classified in four groups according to whether or not they received antidepressants at baseline and 8-months following randomization. RESULTS: Patients using antidepressant pharmacotherapy at baseline and follow-up tended to be younger and female (p≤0.01), but were similar in various clinical characteristics. Just 24% (63/259) of patients were on an antidepressant at baseline which increased to 36% at follow-up (94/259). Compared to other groups, patients on antidepressants at both baseline and follow-up assessment showed the smallest improvement in mood symptoms and HRQoL. While multivariate analyses confirmed that randomization to collaborative care was associated with greater improvement in mood symptoms (odds ratio [OR]=3.1; 95%-confidence interval [CI]=1.8-5.4, p<0.0001) and mental HRQoL (OR=3.6, CI=1.4-9.3, p=0.01), use of antidepressant medication had no differential impact on either measure (p=0.06 and p=0.92, respectively). CONCLUSION: The beneficial effects of collaborative care for post-CABG depression were not generated by adjustments in antidepressant medication. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00091962. (http://clinicaltrials.gov/ct2/show/NCT00091962?term=rollman+cabg&rank=1).

Pain adversely affects outcomes to a collaborative care intervention for anxiety in primary care.

BACKGROUND: Primary care patients with Panic Disorder (PD) and Generalized Anxiety Disorder (GAD) experience poorer than expected clinical outcomes, despite the availability of efficacious pharmacologic and non-pharmacologic treatments. A barrier to recovery from PD/GAD may be the co-occurrence of pain. OBJECTIVE: To evaluate whether pain intensity interfered with treatment response for PD and/or GAD in primary care patients who had received collaborative care for anxiety disorders. DESIGN: A secondary data analysis of a randomized, controlled effectiveness trial comparing a telephone-delivered collaborative care intervention for primary care patients with severe PD and/or GAD to their doctor's "usual" care. PARTICIPANTS: Patients had to have a diagnosis of PD and/or GAD and a severe level of anxiety symptoms. The 124 patients randomized at baseline to the collaborative care intervention were analyzed. Participants were divided into two pain intensity groups based on their response to the SF-36 Bodily Pain scale (none or mild pain vs. at least moderate pain). MAIN MEASURES: Pain was assessed using the Bodily Pain scale of the SF-36. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HRS-A), Panic Disorder Severity Scale (PDSS) and Generalized Anxiety Disorder Severity Scale (GADSS). Measures were collected over 12 months. KEY RESULTS: At baseline, patients with at least moderate pain were significantly more likely to endorse more anxiety symptoms on the HRS-A than patients with no pain or mild pain (P < .001). Among patients with severe anxiety symptoms, 65 % (80/124) endorsed experiencing at least moderate pain in the previous month. A significantly lesser number of patients achieved a 50 % improvement at 12 months on the HRS-A and GADSS if they had at least moderate pain as compared to patients with little or no pain (P = 0.01 and P = 0.04, respectively). CONCLUSIONS: Coexisting pain was common in a sample of primary care patients with severe PD/GAD, and appeared to negatively affect response to anxiety treatment.

Alcohol consumption trajectory patterns in adult women with HIV infection.

HIV-infected women with excessive alcohol consumption are at risk for adverse health outcomes, but little is known about their long-term drinking trajectories. This analysis included longitudinal data, obtained from 1996 to 2006, from 2,791 women with HIV from the Women's Interagency HIV Study. Among these women, the proportion in each of five distinct drinking trajectories was: continued heavy drinking (3 %), reduction from heavy to non-heavy drinking (4 %), increase from non-heavy to heavy drinking (8 %), continued non-heavy drinking (36 %), and continued non-drinking (49 %). Depressive symptoms, other substance use (crack/cocaine, marijuana, and tobacco), co-infection with hepatitis C virus (HCV), and heavy drinking prior to enrollment were associated with trajectories involving future heavy drinking. In conclusion, many women with HIV change their drinking patterns over time. Clinicians and those providing alcohol-related interventions might target those with depression, current use of tobacco or illicit drugs, HCV infection, or a previous history of drinking problems.

Prevalence and correlates of complicated grief in adults who have undergone a coronary artery bypass graft.

BACKGROUND: Complicated grief (CG) is a recently described mental health condition that follows bereavement. CG is often comorbid with depression and may also be associated with poor health outcomes. However, CG has not been studied in depressed medically ill populations. This study examined the prevalence, correlates, and impact of CG in depressed post-coronary artery bypass graft surgery (CABG) patients. METHODS: A 5-item CG screen was administered to 302 depressed post-CABG patients participating in a comparative effectiveness intervention trial at 7 Pittsburgh-area hospitals from March 2004 to September 2007. Eligible patients were randomly assigned to either a telephone-delivered collaborative care intervention for depression or their primary care physicians' usual care. Measures examined depression, physical and mental health-related quality of life, and physical functioning over 8 months. RESULTS: Compared to CG screen-negative patients, CG screen-positive patients were younger, more likely to: be female, non-White, have lost a partner or child, and to have used tobacco or antidepressants. At baseline, they had significantly higher depression and lower mental health scores. At 8 months, screen-positives had poorer physical functioning and marginally higher depression scores. LIMITATIONS: The study lacked a definitive measure of CG. Moreover, the CG-positive group was relatively small, reducing the power to detect differences between groups or control for the possible influence of other variables on identified results. CONCLUSIONS: CG in depressed post-CABG patients is associated with negative health and mental health outcomes. These results underscore the importance of identifying and treating CG in depressed medically ill populations.

Optimism, response to treatment of depression, and rehospitalization after coronary artery bypass graft surgery.

OBJECTIVE: Optimism has been associated with a lower risk of rehospitalization after coronary artery bypass graft (CABG) surgery, but little is known about how optimism affects treatment of depression in post-CABG patients. METHODS: Using data from a collaborative care intervention trial for post-CABG depression, we conducted exploratory post hoc analyses of 284 depressed post-CABG patients (2-week posthospitalization score in the 9-item Patient Health Questionnaire ≥ 10) and 146 controls without depression who completed the Life Orientation Test - Revised (full scale and subscale) to assess dispositional optimism. We classified patients as optimists and pessimists based on the sample-specific Life Orientation Test - Revised distributions in each cohort (full sample, depressed, nondepressed). For 8 months, we assessed health-related quality of life (using the 36-item Short-Form Health Survey) and mood symptoms (using the Hamilton Rating Scale for Depression [HRS-D]) and adjudicated all-cause rehospitalization. We defined treatment response as a 50% or higher decline in HRS-D score from baseline. RESULTS: Compared with pessimists, optimists had lower baseline mean HRS-D scores (8 versus 15, p = .001). Among depressed patients, optimists were more likely to respond to treatment at 8 months (58% versus 27%, odds ratio = 3.02, 95% confidence interval = 1.28-7.13, p = .01), a finding that was not sustained in the intervention group. The optimism subscale, but not the pessimism subscale, predicted treatment response. By 8 months, optimists were less likely to be rehospitalized (odds ratio = 0.54, 95% confidence interval = 0.32-0.93, p = .03). CONCLUSIONS: Among depressed post-CABG patients, optimists responded to depression treatment at higher rates. Independent of depression, optimists were less likely to be rehospitalized by 8 months after CABG. Further research should explore the impact of optimism on these and other important long-term post-CABG outcomes.

The Bypassing the Blues trial: collaborative care for post-CABG depression and implications for future research.

Depressive symptoms are reported by up to one-half of patients following coronary artery bypass graft (CABG) surgery, and are associated with numerous adverse outcomes, including poorer health-related quality of life, worse functional status, and delayed recovery. Strategies to detect and then manage depression in CABG patients and in cardiac populations are of great interest given the potential for depression treatment to reduce cardiovascular morbidity. Yet, many tested interventions have had little or no effect on mood symptoms in cardiac patients. "Collaborative care" is a safe and proven-effective strategy for treating depression in concert with patients' primary care physicians; however, it had not been tested previously in patients with cardiac disease. This article presents the design and main outcome findings from the National Institutes of Health-funded Bypassing the Blues study, the first trial to examine the impact of a collaborative care strategy for treating depression among patients with cardiac disease, and our efforts to improve upon and expand the model for testing in other cardiac conditions.

Treating post-CABG depression with telephone-delivered collaborative care: does patient age affect treatment and outcome?

OBJECTIVE: To determine the nature of telephone-delivered collaborative care intervention provided to patients younger than and older than 60 years experiencing clinically significant depressive symptoms after coronary artery bypass graft (CABG) surgery and whether patient age is related to response and remission rates and delivery of care at 8-month follow-up. DESIGN: : Exploratory post-hoc analysis of data collected in a randomized controlled trial (RCT). SETTING: Seven Pittsburgh-area general hospitals. PARTICIPANTS: Fifty-eight depressed post-CABG patients younger than 60 and 92 comparable patients age 60 years and older randomized to the RCT's intervention arm. MEASUREMENTS: : Components of collaborative care provided to patients over the 8-month study period and Hamilton Rating Scale for Depression scores at 8-month follow-up to determine response and remission status. RESULTS: There were no differences in the cumulative 8-month rates at which the components of collaborative care were delivered to the two age groups. Similar response and remission rates were also achieved by these groups. CONCLUSION: Older and younger patients experiencing clinical depression after CABG surgery can be treated with comparable components of collaborative care, and both age groups will achieve clinical outcomes that do not differ significantly from each other.

The impact of pain and depression on recovery after coronary artery bypass grafting.

OBJECTIVE: To describe the relationship between pain and depression on recovery after coronary artery bypass grafting (CABG). METHODS: A secondary data analysis on 453 depressed and nondepressed post-CABG patients enrolled in a randomized, controlled, effectiveness trial of telephone-delivered collaborative care for depression. Outcome measures were collected from March 2004 to September 2007 and included pain, physical function, and mood symptoms. RESULTS: Depressed patients (baseline Patient Health Questionnaire-9 score ≥10) versus those without depression reported significantly worse pain scores on the 36-Item Short Form Health Survey Bodily Pain Scale at baseline and up to 12 months post-CABG, p < .05. Among patients with depression, those who received collaborative care reported significantly better pain scores at each time point between 2 and 12 months post-CABG versus depressed patients randomized to the usual care control group, p < .05. Regardless of intervention status, depressed participants with at least moderate pain at baseline reported significantly lower functional status (measured by the Duke Activity Status Index) at 8 and 12 months versus depressed patients with none or mild pain, p < .05. Depressed patients with at least moderate pain at baseline were also significantly less likely to show improvement of depressive symptoms throughout the course of follow-up versus depressed patients with little or no pain, p < .05. These findings controlled for age, gender, education, race, comorbid conditions, and baseline pain diagnosis. CONCLUSIONS: Depression and pain seem to influence functional recovery post-CABG. The relationship between these two conditions and 12-month outcomes should be considered by clinicians when planning treatment.