Outcome of a randomized study of a mental health peer education and support group in the VA.

OBJECTIVES: Study objectives were to compare mental health outcomes of a peer-led recovery group, a clinician-led recovery group, and usual treatment and to examine the effect of group attendance on outcomes. METHODS: The study used a randomized design with three groups: a recovery-oriented peer-led group (Vet-to-Vet), a clinician-led recovery group, and usual treatment. The sample included 240 veterans. Recovery and mental health assessments were obtained at enrollment and three months later. Intention-to-treat analysis using mixed-model regression was performed to examine the effect of the intervention. "As treated" analysis was performed to examine the effect of group attendance. RESULTS: There were no statistically significant differences in improvement among the groups. Across groups, depression and functioning, psychotic symptoms, and overall mental health improved significantly. Better group attendance was associated with more improvement. CONCLUSIONS: This study adds to the evidence suggesting no short-term incremental benefit (or harm) from peer services beyond usual care.

Correlates of antiretroviral and antidepressant adherence among depressed HIV-infected patients.

Although crucial for efficacy of pharmacotherapy, adherence to prescribed medication regimens for both antiretrovirals and antidepressants is often suboptimal. As many depressed HIV-infected individuals are prescribed both antiretrovirals and antidepressants, it is important to know whether correlates of nonadherence are similar or different across type of regimen. The HIV Translating Initiatives for Depression into Effective Solutions (HI-TIDES) study was a single-blinded, longitudinal, randomized controlled effectiveness trial comparing collaborative care to usual depression care at three Veterans Affairs HIV clinics. The current investigation utilized self-report baseline interview and chart-abstracted data. Participants were 225 depressed HIV-infected patients who were prescribed an antidepressant (n=146), an antiretroviral (n=192), or both (n=113). Treatment adherence over the last 4 days was dichotomized as "less than 90% adherence" or "90% or greater adherence." After identifying potential correlates of nonadherence, we used a seemingly unrelated regression (SUR) bivariate probit model, in which the probability of adherence to HIV medications and the probability of adherence to antidepressant medications are modeled jointly. Results indicated that 75.5% (n=146) of those prescribed antiretrovirals reported 90%-plus adherence to their antiretroviral prescription and 76.7% (n=112) of those prescribed antidepressants reported 90%-plus adherence to their antidepressant prescription, while 67% of those prescribed both (n=113) reported more than 90% adherence to both regimens. SUR results indicated that education, age, and HIV symptom severity were significant correlates of antiretroviral medication adherence while gender and generalized anxiety disorder diagnosis were significant correlates of adherence to antidepressant medications. In addition, antiretroviral adherence did not predict antidepressant adherence (ß=1.62, p=0.17), however, antidepressant adherence did predict antiretroviral adherence (ß=2.30, p<0.05).

Enhancing self-report assessment of PTSD: development of an item bank.

The authors report results of work to enhance self-report posttraumatic stress disorder (PTSD) assessment by developing an item bank for use in a computer-adapted test. Computer-adapted tests have great potential to decrease the burden of PTSD assessment and outcomes monitoring. The authors conducted a systematic literature review of PTSD instruments, created a database of items, performed qualitative review and readability analysis, and conducted cognitive interviews with veterans diagnosed with PTSD. The systematic review yielded 480 studies in which 41 PTSD instruments comprising 993 items met inclusion criteria. The final PTSD item bank includes 104 items representing each of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994), PTSD symptom clusters (reexperiencing, avoidance, and hyperarousal), and 3 additional subdomains (depersonalization, guilt, and sexual problems) that expanded the assessment item pool.

Effectiveness of collaborative care for depression in human immunodeficiency virus clinics.

BACKGROUND: Depression is common among persons with the human immunodeficiency virus (HIV) and is associated with unfavorable outcomes. METHODS: A single-blind randomized controlled effectiveness trial at 3 Veterans Affairs HIV clinics (HIV Translating Initiatives for Depression Into Effective Solutions [HITIDES]). The HITIDES intervention consisted of an off-site HIV depression care team (a registered nurse depression care manager, pharmacist, and psychiatrist) that delivered up to 12 months of collaborative care backed by a Web-based decision support system. Participants who completed the baseline telephone interview were 249 HIV-infected patients with depression, of whom 123 were randomized to the intervention and 126 to usual care. Participant interview data were collected at baseline and at the 6- and 12-month follow-up visits. The primary outcome was depression severity measured using the 20-item Hopkins Symptom Checklist (SCL-20) and reported as treatment response (≥50% decrease in SCL-20 item score), remission (mean SCL-20 item score, <0.5), and depression-free days. Secondary outcomes were health-related quality of life, health status, HIV symptom severity, and antidepressant or HIV medication regimen adherence. RESULTS: Intervention participants were more likely to report treatment response (33.3% vs 17.5%) (odds ratio, 2.50; 95% confidence interval [CI], 1.37-4.56) and remission (22.0% vs 11.9%) (2.25; 1.11-4.54) at 6 months but not 12 months. Intervention participants reported more depression-free days during the 12 months (ß = 19.3; 95% CI, 10.9-27.6; P < .001). Significant intervention effects were observed for lowering HIV symptom severity at 6 months (ß = -2.6; 95% CI, -3.5 to -1.8; P < .001) and 12 months (ß = -0.82; -1.6 to -0.07; P = .03). Intervention effects were not significant for other secondary outcomes. CONCLUSION: The HITIDES intervention improved depression and HIV symptom outcomes and may serve as a model for collaborative care interventions in HIV and other specialty physical health care settings where patients find their "medical home." TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00304915.

The incremental value of self-reported mental health measures in predicting functional outcomes of veterans.

Research on patient-centered care supports use of patient/consumer self-report measures in monitoring health outcomes. This study examined the incremental value of self-report mental health measures relative to a clinician-rated measure in predicting functional outcomes among mental health service recipients. Participants (n = 446) completed the Behavior and Symptom Identification Scale, the Brief Symptom Inventory, and the Veterans/Rand Short Form-36 at enrollment in the study (T1) and 3 months later (T2). Global Assessment of Functioning (GAF) ratings, mental health service utilization, and psychiatric diagnoses were obtained from administrative data files. Controlling for demographic and clinical variables, results indicated that improvement based on the self-report measures significantly predicted one or more functional outcomes (i.e., decreased likelihood of post-enrollment psychiatric hospitalization and increased likelihood of paid employment), above and beyond the predictive value of the GAF. Inclusion of self-report measures may be a useful addition to performance measurement efforts.

A longitudinal investigation of the impact of life stress on HIV treatment adherence.

Suboptimal antiretroviral adherence is associated with poorer HIV outcomes. Psychosocial factors, including life stress, depression and coping, may influence adherence behavior. This prospective investigation sought to examine the impact of life stress (acute life events, chronic stress, and perceived stress), depression, and coping style on adherence to HIV treatment regimes over time. Participants were 87 treatment-seeking HIV-infected individuals recruited from an urban HIV clinic. They completed clinician-administered interviews and self-report questionnaires at baseline and 3-month follow-up. Acute life events and chronic stress prospectively predicted decreases in treatment adherence more strongly among individuals in a major depressive episode (n = 21) compared to non-depressed individuals (n = 66). Coping style did not appear to be the mechanism by which life stress influenced adherence among depressed HIV-infected individuals. These findings demonstrate that life stress has toxic effects for depressed individuals and suggest that treatment adherence interventions with depressed individuals could be enhanced via development of stress management skills.

Improving access to mental health services via a clinic-wide mental health intervention in a Southeastern US infectious disease clinic.

Stepleman, Hann, Santos, and House (2006) described a brief psychological consultation model, which aims to improve integration of mental health services into HIV primary care. This retrospective chart review sought to examine which patients in our adult Infectious Disease clinic were served by this model in a one-year period. Furthermore, we examined whether the patients who subsequently engage in mental health care differ demographically from the consult population. Results indicated that 26.1% (n=252) of the patients at our Infectious Disease clinic (n=963; 36% female, 75% racial minority) received a mental health consultation. We observed no statistically significant differences between the consult and clinic populations with respect to gender, age, or race. Moreover, 43.3% (n=109) of those patients served by the consult model received specialized psychiatric care. There were statistically significant racial differences between those patients who engaged specialty psychiatric care and those who did not after receiving a consultation (chi(2)(1)=16.65, p<0.001; 70% racial minority in consult vs. 47.7% racial minority in psychiatric care). While our in-clinic consultation service reached a representative population, we had less success recruiting this diverse patient population into traditional psychiatric care. Future efforts will need to examine how mental health consultation and traditional psychiatric services can best reduce barriers to engagement and retention in care.

Factors associated with psychotherapy longevity among HIV-positive patients.

Mental health concerns are salient to many HIV-positive individuals, yet, there are also numerous challenges with regard to access and retention in care. The present study sought to investigate factors that are associated with longevity in outpatient psychological care for HIV-positive patients. We aimed to better understand what factors (e.g., race, gender, age, history of mental health service utilization) are associated with the length of participation in psychotherapy in our clinic. This is an archival study consisting of chart review of our clinical documentation related to the psychological services provided in our clinic from January 2005 through December 2007. Eligible charts included all HIV-positive individuals seeking psychotherapy in the Department of Psychiatry and Health Behavior at the Medical College of Georgia (n = 87 records; 33.3% female; 52.9% ethnic minority, 57% sexual minority, middle-aged (42.0 years +/- 9.6 years). Results indicated that the presence of cohabitating social support distinguished between those who continued or terminated after the intake session, with social support being associated with continuation after intake. Furthermore, shorter distance from clinic, history of previous psychotherapy, concurrent pharmacotherapy, comorbid personality disorder diagnosis, and having an ethnic minority provider were associated with greater longevity in treatment. As a result of modest sample size relative to the number of predictor variables, analyses utilized multiple bivariate analyses and thus, results must be considered preliminary and should be replicated in a larger investigation. However, treatment providers may utilize these initial findings to improve retention in care and to improve the quality of mental health care provided to HIV-positive outpatients.

Non-treatment-related sudden gains in depression: the role of self-evaluation.

A number of studies have demonstrated that recovery from depression is often marked by precipitous improvements during the course of treatment. The present research examined sudden gains occurring outside of the context of treatment in a sample of college students with current major depressive disorder (n=60), and tested whether variables pertaining to cognitive style, hope, self-evaluation, and life events would be associated with these gains. Results indicated that 60% of the sample experienced sudden gains, with over half of those sudden gains reversing before the end of the 9-week observation period. Sudden gainers were significantly less depressed at the end of the observation period but were no more likely to have achieved remission compared to non-sudden gainers. Although changes in cognitive style did not precede sudden gains, individuals with sudden gains had significantly higher self-esteem at baseline compared to non-sudden gainers. Furthermore, decreases in the frequency of social comparison occurred in the week prior to sudden gains. These results suggest that sudden gains do occur outside of the context of treatment and that self-evaluation processes may play an important role in recovery from depression.

A prospective investigation of the impact of attachment style on stress generation among clinically depressed individuals.

The present study sought to determine if attachment style contributed to the generation of stressful life events among clinically depressed individuals during the course of treatment. Participants (N=68) were interviewed about life stressors experienced during a 3-month treatment protocol using a contextual approach (Life Events and Difficulties Schedule; [Brown, G. W., & Harris, T. O. (1978). Social origins of depression: A study of psychiatric disorder in women. New York: Free Press]). Results suggested interactive effects between severity of depression and attachment style on stress associated with future sociotropic and dependent life events. Mildly depressed individuals who reported a dismissing attachment style (higher levels of avoidant attachment and lower levels of anxious attachment) or preoccupied style (lower levels of avoidant attachment and higher levels of anxious attachment) experienced higher levels of stress associated with sociotropic events. Likewise, a dismissing attachment style predicted stress associated with dependent events among mildly depressed individuals. These effects were not present among our more severely depressed participants.

Life stress and adherence to antiretroviral therapy among HIV-positive individuals: a preliminary investigation.

The present study sought to investigate the impact of life stress on treatment adherence and viral load of HIV-positive individuals. Three different aspects of life stress were examined in this investigation (perceived stress, acute life events unrelated to the HIV illness, and HIV-related acute life events). Furthermore, we examined whether these relationships were moderated by depressive severity, self-esteem, and neuroticism. Participants (n = 24) were treatment- seeking HIV-positive individuals who completed a series of questionnaires for this investigation. The majority of the participants in this sample were middle-aged, Caucasian males who identified themselves as either homosexual or bisexual, had contracted HIV via sexual contact, and met criteria for AIDS (mean CD4 count = 324). This sample was highly self-selected and varied from the county HIV-positive population in terms of gender, ethnicity, and HIV risk factor. Information on their adherence and viral load was collected from their medical records 6 to 9 months after completion of the psychological measurements. Results indicated that perceived stress, but not acute events, prospectively predicted adherence. Moreover, marginal trends suggested that depressive symptoms and neuroticism moderated the effect of perceived stress on adherence. Neither perceived stress nor acute life events were associated with viral load.

An open pilot study of nefazodone in depression with anger attacks: relationship between clinical response and receptor binding.

Nefazodone has been widely used as an antidepressant, but it has not been tested for depression with anger attacks. In an open study, we administered nefazodone (maximum 600 mg/day) for 12 weeks to 16 outpatients who had major depression with anger attacks. Assessment instruments comprised the Structured Clinical Interview for DSM-IV (SCID), Anger Attacks Questionnaire (AAQ), 17-item Hamilton Rating Scale for Depression (HAM-D-17), Clinician Global Impression Scale (CGI), Symptom Questionnaire (SQ), Modified Overt Aggression Scale (MOAS), and MOAS-Self-Rated. Three subjects underwent positron emission tomography (PET) with [18F]-setoperone for 5-HT2 binding potential (BP) and [11C]-SCH-23,390 for D1 BP, both at baseline and after 6 weeks of treatment. Eight subjects underwent PET with [18F]-setoperone and with [11C]-SCH-23,390 at baseline only. In an examination of whether D1 and 5HT2 (data available in six subjects) receptor BP predicted treatment response, we found significant decreases in the HAM-D-17, CGI-S, weighted MOAS, MOAS verbal scale, OAS Self-Rated verbal, SQ Depression and Anger/Hostility scales after nefazodone; 50% responded to nefazodone (defined as >or=50% decrease in HAM-D-17 score), and 44% reported disappearance of anger attacks. A statistically significant percentage decrease in 5HT2 BP was observed for the right mesial frontal and left parietal regions after 6 weeks of treatment. No significant change was observed in D1 BP in any region. Although CGI-I scores correlated significantly with D1 BP in the left thalamic region, the correlation was not significant after Bonferroni correction. The effectiveness of nefazodone for depression with anger attacks may be related to widespread changes in 5HT2 receptor BP.

An open study of olanzapine and fluoxetine for psychotic major depressive disorder: interim analyses.

BACKGROUND: Although atypical antipsychotic agents are commonly used in the treatment of psychotic depression, there are no published prospective studies on their use in this condition. The aim of this study was to assess, by interim analyses, the efficacy of the atypical antipsychotic agent olanzapine in combination with the selective serotonin reuptake inhibitor antidepressant agent fluoxetine. METHOD: We enrolled 27 patients (17 women [63.0%] and 10 men [37.0%]; mean +/- SD age: 41.2 +/- 14.7 years) with DSM-IV-defined major depressive disorder with psychotic features into an open trial of olanzapine, 5 to 20 mg/day, plus fluoxetine, 20 to 80 mg/day. Patients were assessed at each visit with the 17-item Hamilton Rating Scale for Depression and both the psychotic and mood modules of the Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition. We are reporting the results of the first 6 weeks of treatment. RESULTS: Twenty-two (81.5%) of the 27 enrolled patients completed the 6-week open trial, and 5 (18.5%) dropped out, with only 2 (7.4%) dropping out due to side effects. Of the 27 patients, 74.1% (N = 20) met criteria for melancholic features, 14.8% (N = 4) had delusions alone, 18.5% (N = 5) had hallucinations alone, and 66.7% (N = 18) reported both delusions and hallucinations. In addition, the overall rates of response for the intent-to-treat group were as follows: depression response rate, 66.7% (N = 18); psychosis response rate, 59.3% (N = 16); psychotic depression response rate, 55.6% (N = 15); and psychotic depression remission rate, 40.7% (N = 11). CONCLUSION: The combination of olanzapine and fluoxetine appears to be a promising, safe, and effective treatment for psychotic depression. Double-blind studies are needed to confirm this impression.