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1.
J Clin Psychiatry ; 82(6)2021 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-34610227

RESUMO

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD) in randomized clinical trials. Two prior studies using Department of Veterans Affairs (VA) medical records data show these medications are also effective in routine practice. Using an expanded retrospective cohort, we assessed the possibility of differential patterns of response based on patient and clinical factors.Methods: We identified 6,839 VA outpatients with clinical diagnoses of PTSD between October 1999 and September 2019 who initiated one of the medications and met pre-specified criteria for treatment duration and dose, combined with baseline and endpoint PTSD checklist (PCL) measurements. We compared 12-week changes in PCL score within clinical subgroups defined by sex, race and ethnicity, and military exposures, as well as comorbidities. Comorbidities were identified using International Classification of Diseases diagnostic codes and grouped according to major diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (eg, Psychotic Disorders, Depressive Disorders). We used a propensity score weighting approach to balance covariates among medication arms within each clinical subgroup. In our exploratory analyses using unweighted data for the overall cohort, we built penalized logistic regression models to identify covariates that predicted meaningful improvement.Results: There were no significant differences between medications in our weighted subgroup analyses. In unweighted exploratory analyses, higher baseline PCL scores and concurrent receipt of evidence-based psychotherapy predicted meaningful improvement, while high levels of disability predicted not realizing meaningful improvement.Conclusions: In the largest real-world study of medications for PTSD to date, we did not observe a pattern of differential response among clinical subgroups. All patients taking medications for PTSD, especially those with the highest levels of disability, should consider combined treatment with evidence-based psychotherapy.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34360101

RESUMO

Suicide is a significant public health concern worldwide and in the United States. Despite the far-reaching impact of suicide, risk factors are still not well understood and efforts to accurately assess risk have fallen short. Current research has highlighted how potentially modifiable environmental exposures (i.e., meteorological, pollution, and geographic exposures) can affect suicide risk. A scoping review was conducted to evaluate the strength of the historical and current literature on the environment's effect on suicide and suicide risk. Three databases (i.e., Medline, Embase, and PsychInfo) were reviewed to identify relevant studies and two authors independently reviewed studies considering pre-determined inclusion criteria. A total of 46 meteorological studies were included as well as 23 pollution studies and 12 geographic studies. Descriptive statistics, including counts, percentages, review of studies' sample size (minimum, maximum, median, and interquartile range), were calculated using Excel and SAS 9.4. Overall, strong evidence supports that exposure to sunlight, temperature, air pollution, pesticides, and high altitude increases suicide risk, although effect sizes range from very small to small.


Assuntos
Poluentes Atmosféricos , Poluição do Ar , Suicídio , Poluentes Atmosféricos/análise , Poluentes Atmosféricos/toxicidade , Poluição do Ar/efeitos adversos , Poluição do Ar/análise , Gerenciamento de Dados , Exposição Ambiental/efeitos adversos , Exposição Ambiental/análise , Humanos
3.
J Rural Health ; 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33900641

RESUMO

PURPOSE: To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users). METHODS: We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans. FINDINGS: Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.52.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users. CONCLUSIONS: A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

4.
J Clin Psychiatry ; 81(6)2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33049805

RESUMO

OBJECTIVE: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD). One prior study using US Department of Veterans Affairs (VA) medical records data to compare these agents found no differences in symptom reduction in clinical practice. The current study addresses several weaknesses in that study, including limited standardization of treatment duration, inability to account for prior treatment receipt, use of an outdated symptomatic assessment for PTSD, and lack of functional outcome. METHODS: A total of 834 VA outpatients were identified with DSM-5 clinical diagnoses of PTSD between October 2016 and March 2018 who initiated one of the medications and met prespecified criteria for treatment duration and dose, combined with baseline and endpoint DSM-5 PTSD Checklist (PCL-5) measurements. Twelve-week acute-phase changes in PCL-5 score and remission of PTSD symptoms were compared among patients receiving the different medications, as was use of acute psychiatric services in the subsequent 6-month continuation phase. RESULTS: In the acute phase, patients improved by a mean of 6.8-10.1 points on the PCL-5 and 0.0%-10.9% achieved remission of PTSD symptoms. Those taking venlafaxine were significantly more likely to achieve remission (P = .008 vs fluoxetine and P < .0001 vs paroxetine, sertraline, and topiramate). In the continuation phase, there were no differences in acute psychiatric care use between medications. Those who continued their medication were less likely to use acute psychiatric services (HR = 0.55; P = .03). CONCLUSIONS: There may be an advantage to venlafaxine over other agents in achieving acute-phase remission for DSM-5 PTSD in routine clinical practice, but this finding requires further study. Regardless of the agent chosen, medication cessation during the continuation phase is associated with a higher risk of acute psychiatric care use.


Assuntos
Inibidores da Anidrase Carbônica/farmacologia , Fluoxetina/farmacologia , Avaliação de Resultados em Cuidados de Saúde , Paroxetina/farmacologia , Inibidores de Captação de Serotonina/farmacologia , Inibidores da Recaptação de Serotonina e Norepinefrina/farmacologia , Sertralina/farmacologia , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Topiramato/farmacologia , Cloridrato de Venlafaxina/farmacologia , Doença Aguda , Adulto , Inibidores da Anidrase Carbônica/administração & dosagem , Feminino , Fluoxetina/administração & dosagem , Humanos , Masculino , Adesão à Medicação , Paroxetina/administração & dosagem , Indução de Remissão , Inibidores de Captação de Serotonina/administração & dosagem , Inibidores da Recaptação de Serotonina e Norepinefrina/administração & dosagem , Sertralina/administração & dosagem , Topiramato/administração & dosagem , Estados Unidos , United States Department of Veterans Affairs , Cloridrato de Venlafaxina/administração & dosagem
5.
J Behav Med ; 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32915350

RESUMO

There is an elevated risk of suicide among people living in rural areas, and the rural-urban disparity in death by suicide is growing in the general United States population. The department of Veterans Affairs (VA) implemented programs targeting rural health in 2007 and suicide prevention in 2008. Rural-urban differences in suicide rates among VA users have not been examined since 2010. We sought to understand whether the rural-urban disparity in suicide risk among VA users decreased during a time of contemporaneous VA efforts to improve access to mental health care for rural Veterans and to improve the effectiveness of mental health services at preventing suicide. We performed a retrospective cohort study examining differences in the raw and adjusted annual suicide rate among rural and urban VA users between 2003 and 2017. All VHA users 2003-2017. Descriptive statistics are presented for all VHA users in 2017. This includes 6,120,355 unique VA users, 32.0% (n = 1,955,935) of whom lived at a rural address. Raw rates of death by suicide were higher in rural VA users than urban VA users overall (33.3 vs. 29.1 deaths per 100,000 population) and across years, but the age, sex, and race-adjusted rates converged in 2005. White VA users had over triple the rate of death by suicide as black VA users, and lived disproportionally in rural areas. The rural-urban suicide disparity among VA users persists. However, the disparity appears to be driven by differences in the racial composition of rural and urban patients, which were not accounted for in prior studies.

6.
J Dual Diagn ; 16(2): 228-238, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31852392

RESUMO

Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.


Assuntos
Causas de Morte , Overdose de Drogas/mortalidade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/terapia , Cooperação do Paciente/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Suicídio Consumado/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Comorbidade , Diagnóstico Duplo (Psiquiatria) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estudos Retrospectivos , Estados Unidos/epidemiologia
7.
J Eval Clin Pract ; 25(4): 689-699, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31115137

RESUMO

RATIONALE: Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement. METHOD: Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks. We obtained PCL data as well as demographic, diagnostic, and health services use information from the VA corporate data warehouse. We used latent trajectory analysis to identify classes of patients based on PCL scores, then determined demographic, diagnostic, and treatment predictors of membership in each class. RESULTS: Patients who met our PCL-based inclusion criteria were far more likely than those who did not receive EBTs. We identified two latent trajectories of PTSD symptoms. Patients in the substantial improvement group (25.9%) had a mean decrease in PCL score of 16.24, whereas patients in the modest improvement group improved by a mean of 8.09 points. However, there were few differences between the groups, and our model to predict group membership was only slightly better than chance (area under the curve [AUC] = 0.55). Of the 64 covariates we tested, the only robust individual predictor of improvement was gender, with men having lower odds of being in the substantial improvement group compared with women (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.58-0.96). CONCLUSION: VA patients with PTSD can realize significant improvement in routine clinical practice. Although available medical records-based variables were generally insufficient to predict improvement trajectory, this study did indicate that men have lower odds of substantial improvement than women.


Assuntos
Medicina Baseada em Evidências , Serviços de Saúde Mental/normas , Administração dos Cuidados ao Paciente , Guias de Prática Clínica como Assunto , Transtornos de Estresse Pós-Traumáticos , Adulto , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Preferência do Paciente , Medidas de Resultados Relatados pelo Paciente , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/terapia , Resultado do Tratamento , Estados Unidos , Saúde dos Veteranos/estatística & dados numéricos
8.
Psychiatry Res ; 273: 247-251, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30658209

RESUMO

The relationship between three markers of chronic hypoxia (altitude, smoking and chronic obstructive pulmonary disease (COPD)) and suicide risk has not been well-studied. We conducted a population-based cohort study evaluating the association between chronic hypoxia and suicide risk. Patients entered the cohort in their first year with a documented healthcare encounter and remained in the cohort until their death or the end of the study period. Generalized estimating equation (GEE) methodology was used to assess the association between suicide and three risk markers of chronic hypoxia. Findings were summarized using odds ratio (OR) and 95% confidence intervals (CI). Among the 9,620,944 patients in the cohort, there were 22,403 suicide deaths. There was a statistically significant progression of suicide risk as altitude rose in increments of 1000 m (OR: 1.22). There was a strong association between the number of hypoxic conditions and the odds of suicide. Patients with three markers of chronic hypoxia was nearly four times more likely to die by suicide than patients with no markers (OR: 3.96). Chronic hypoxia is a risk factor for suicide and having multiple indicators of hypoxia confers a greater risk for suicide, indicating a dose-response relationship.


Assuntos
Hipóxia/psicologia , Suicídio/psicologia , Adulto , Altitude , Doença Crônica , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Doença Pulmonar Obstrutiva Crônica/psicologia , Fatores de Risco , Fumar/psicologia
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