The association of health literacy with adherence and outcomes in moderate-severe asthma.

BACKGROUND: Low health literacy is associated with poor outcomes in asthma and other diseases, but the mechanisms governing this relationship are not well defined. OBJECTIVE: We sought to assess whether literacy is related to subsequent asthma self-management, measured as adherence to inhaled steroids, and asthma outcomes. METHODS: In a prospective longitudinal cohort study, numeric (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults) were assessed at baseline in adults with moderate or severe asthma for their impact on subsequent electronically monitored adherence and asthma outcomes (asthma control, asthma-related quality of life, and FEV1) over 26 weeks, using mixed-effects linear regression models. RESULTS: A total of 284 adults participated: age, 48 ± 14 years, 71% females, 70% African American, 6% Latino, mean FEV1 66% ± 19%, 86 (30%) with hospitalizations, and 148 (52%) with emergency department visits for asthma in the prior year. Mean Asthma Numeracy Questionnaire score was 2.3 ± 1.2 (range, 0-4); mean Short Test of Functional Health Literacy in Adults score was 31 ± 8 (range, 0-36). In unadjusted analyses, numeric and print literacy were associated with better adherence (P = .01 and P = .08, respectively), asthma control (P = .005 and P < .001, respectively), and quality of life (P < .001 and P < .001, respectively). After controlling for age, sex, and race/ethnicity, the associations diminished and only quality of life (numeric P = .03, print P = .006) and asthma control (print P = .005) remained significantly associated with literacy. Race/ethnicity, income, and educational attainment were correlated (P < .001). CONCLUSION: While the relationship between literacy and health is complex, interventions that account for and address the literacy needs of patients may improve asthma outcomes.

The wish to die and 5-year mortality in elderly primary care patients.

OBJECTIVES: The authors examined the impact of the wish to die on mortality over a 5-year period, stratified by baseline depressive status (i.e., major, minor, and no depression diagnosis). The authors also examined whether a depression care management intervention would minimize these relationships. DESIGN: Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). SETTING: Twenty primary care practices from New York City, Philadelphia, and Pittsburgh. PARTICIPANTS: One thousand two hundred two participants were identified through two-stage, age-stratified (60-74 years; 75 years and older) depression screening of randomly sampled participants. INTERVENTION: Practices randomized to Care Management Intervention or Usual Care conditions. MEASUREMENTS: Vital status at 5 years using the National Death Index. RESULTS: Rates of the wish to die were 29% (major depression), 11% (minor depression), and 7% (no depression). In Usual Care, the wish to die was associated with an increased risk of 5-year mortality across depressive status (adjusted hazard ratios ranging from 1.62 to 1.71). In intervention practices, this association was greater among the no depression (adjusted hazard ratio 1.64) compared with major depression group (adjusted hazard ratio 0.68). CONCLUSIONS: The wish to die was associated with mortality in the usual care of elderly primary care patients, suggesting that the wish to die has clinical significance and may be worth assessing even in patients without other evidence of depression. This association was not observed among depressed patients located in primary care practices that implemented the PROSPECT intervention, suggesting potential long-term benefits of treatment and management of depression.

Association of resolution of major depression with increased natural killer cell activity among HIV-seropositive women.

OBJECTIVE: Depression is a potential risk factor for morbidity and mortality among patients with numerous medical conditions, including HIV disease, and it is also associated with decrements in immune function, such as natural killer (NK) cell activity. This study examined whether improvements in the diagnostic status of major depression are related to increases in NK cell activity among HIV-seropositive women. METHOD: HIV-seropositive women were recruited as part of a longitudinal cohort study and underwent comprehensive medical and psychiatric evaluations during a 2-year period. Fifty-seven women had complete NK cell activity and depression data measured at two time points and were examined for associations between changes in depression status and alterations in NK cell activity over time. RESULTS: Among the 57 HIV-seropositive women, improvements in the diagnostic status of depression and decreases in scores on the 17-item Hamilton Depression Rating Scale were significantly associated with increases in NK cell activity over time, as measured in lytic units. Eleven women (19.3%) had a major depression diagnosis that resolved over time, and this group also had a significant increase in cell activity measured in lytic units during this period. CONCLUSIONS: This study suggests that depression may impair certain aspects of innate cellular immunity relevant to delaying the progression of HIV disease and that these alterations are reversible with the resolution of a depressive episode. These findings support an examination of NK cell activity in assessments of the relationship between depression and morbidity and mortality in HIV disease.

Probing for affective side effects of drugs used in geriatric practice: use of daily diaries to test for effects of metoclopramide and naproxen.

The aim of this study was to develop the use of daily diaries of affects and events as measures of pharmacological effects on affective processes and to apply them to evaluate the possible affective toxicity of metoclopramide and naproxen, two medications commonly used in geriatric practice. In all, 105 adults aged 65 years or older were randomized to receive metoclopramide (up to 40 mg/day), naproxen (up to 1000 mg/day), or placebo under double-blind conditions for a period of 5 weeks. Patients were seen weekly for evaluations of affective and cognitive outcomes as well as safety. In addition, patients kept diaries with daily records of positive and negative affect and reports of significant daily events. Findings included mixed model analyses of drug assignment, time, events, and interactions for both positive affect and days with significant negative affect. Subjects exhibited high levels of adherence in completing daily diaries. Neither the pattern of dropouts nor the weekly assessments demonstrated significant drug effects on mood or affect. However, diary data demonstrated that metoclopramide increased the apparent impact of negative events on both positive and negative affect relative to placebo, and that naproxen increased the apparent impact of positive events on positive affect and, possibly, of negative events on negative affect relative to placebo. The findings confirm the utility of diary methods for studying drug effects on affective processes in normal elderly subjects. They suggest that both metoclopramide and naproxen can affect the associations between daily events and affects. If replicated, they would demonstrate that drug effects can extend beyond the intensity of affect and/or the emergence of full-fledged psychiatric disorders to include moderation of the interactions between daily events and affect.

Racial differences in medical mistrust among men diagnosed with prostate cancer.

BACKGROUND: Mistrust of healthcare providers and systems is a significant barrier to quality healthcare. However, limited empirical data are available on perceptions of medical mistrust among individuals who are diagnosed with cancer. The objective of this study was to identify sociodemographic, clinical, and cultural determinants of mistrust among men diagnosed with prostate cancer. METHODS: The authors conducted an observational study among 196 African-American men (n = 71) and white men (n = 125) who were newly diagnosed with prostate cancer during 2003 through 2007. RESULTS: Race, education, healthcare experiences, and cultural factors had significant effects on mistrust. African-American men (P = .01) and men who had fewer years of formal education (P = .001) reported significantly greater levels of mistrust compared with white men and men who had more education. Mistrust also was greater among men who had been seeing their healthcare provider for a longer period (P = .01) and among men with lower perceptions of interdependence (P = .01). CONCLUSIONS: The current findings suggested that efforts to enhance trust among men who are diagnosed with prostate cancer should target African-American men, men with fewer socioeconomic resources, and men with lower perceptions of interdependence. Reasons for deterioration in trust associated with greater experience with specialty providers should be explored along with the effects of interventions that are designed to address the concerns of individuals who have greater mistrust.

Treating late-life depression with interpersonal psychotherapy in the primary care sector.

BACKGROUND: Interpersonal psychotherapy (IPT) is an empirically-validated intervention for treating late-life depression. OBJECTIVE: To determine the manner in which IPT is utilized by primary care physicians in relation to antidepressant medications. METHODS: The authors reviewed treatment logs prepared by care managers during the first 12 months of a patient's participation in the PROSPECT clinical trial to determine initial and longitudinal treatment patterns utilized by physicians, and clinical outcomes associated with initial treatment assignment. RESULTS: Primary care physicians in practices randomized to PROSPECT's intervention arm initially prescribed an antidepressant medication for 58% of eligible patients and referred only 11% of them to IPT. Over time, however, 27% of patients participated in IPT as monotherapy or augmentation therapy. Initial treatment assignment was not associated with depressive status at 4 and 12 months nor with suicidal ideation at 4, 8, and 12 months. CONCLUSION: IPT is an effective treatment for late-life depression whose greater use by primary care physicians should be encouraged.

A daily diary study of late-life depression.

OBJECTIVE: The objective of this study was to use data from daily diaries to characterize the day-to-day variability in positive and negative affects, and the relationship between daily events and daily affects in primary care patients with late-life depression. METHOD: Daily diary data were obtained from primary care patients with major depression (N = 25) and other depressive disorders (N = 33); data from a two-week period were compared with those from elderly normal volunteer comparison subjects (N = 70) who participated in other studies. RESULTS: There was significant day-to-day variability in negative affect in patients with major depression and other depressive disorders. Dysphoric days (days with a negative affect ratings that occurred once every two weeks in normal subjects) represented 65.3% (standard deviation [SD]: 37.1) of days in those with major depression and 50.6% (SD: 37.6) in those with other depression versus 7.7% (SD: 16.3) in normal subjects (F = 36.0, p <0.001). The groups did not differ significantly in the number of positive and negative events reported, but the proportion of dysphoric days that occurred in association with negative events was greater in normal subjects than in those with major depression. Mixed-effects analyses demonstrated that patients with major depression had blunted positive affective responses to positive events, consistent with impairments in hedonic processes, and that patients with other depressions exhibited heightened negative affective responses to negative events, greater than those in normal subjects and patients with major depression. CONCLUSIONS: Diary methods demonstrated characteristics of late-life depression that have not been identified with assessment methods that have lower time resolution.

Importance of subsyndromal symptoms of depression in elderly patients.

OBJECTIVE: There is a debate about the importance of subsyndromal symptoms of depression (SSD). The current study examined the cross-sectional and longitudinal significance of SSD in geriatric subjects both with and without a past history of major depression. METHODS: Elderly primary-care subjects with SSD, both with (SSD+; N=54) and without (SSD-; N=204) a history of major depression, were compared with subjects with major depression (MDD; N=111), minor depression (MinD; N=74), and symptom-free comparison subjects (N=59). Assessment domains included physical and psychological disability, health-care utilization, hopelessness, death and suicidal ideation, and a diagnostic evaluation at a 3-month follow-up. RESULTS: Both subjects with SSD+ and SSD- differed from the symptom-free comparison subjects on measures of psychological disability, hopelessness, and death ideation, with SSD+ subjects being more severely psychologically disabled than SSD- subjects. There were few differences between SSD+ and MinD subjects or those with MDD, except on measures of psychological disability. Finally, more than 24% of SSD+ subjects progressed to meet criteria of MDD, MinD, or dysthymia over a 3-month period. Utilization of outpatient services did not differ among any of the depression groups or comparison subjects. CONCLUSIONS: SSD (with or without a past history of MDD) is associated with significant disability. Moreover, the risk of developing a diagnosis of MDD, MinD, or dysthymia is substantially elevated in subjects with a past history of MDD.

SSRIs do not cause affective blunting in healthy elderly volunteers.

OBJECTIVE: This study was undertaken to evaluate the effects of selective serotonin reuptake inhibitors (SSRIs) on affective experience in healthy older adults. METHODS: After 1 week of observation, normal elderly volunteers (age range: 65-84 years) were given placebo, paroxetine (10 mg-40 mg/day), or sertraline (50 mg-150 mg/day) for 3 weeks in a double-blind study. Paroxetine- and sertraline-treated subjects were analyzed together as the SSRI group (N=30). Volunteers were assessed weekly and recorded mood and events in a daily diary each evening. All data were analyzed with mixed-effects random-regression models. RESULTS: There were significant relationships between daily affect and events reported in the daily diary for the sample as a whole, with no differences between groups in mean slopes of positive or negative affect across the length of the study. There were no differences between groups in affective variability. However, the SSRI group, but not the placebo group, demonstrated a significant drug-dependent decrease in negative affect related to negative events. There were no other observed group differences on any other measure. CONCLUSION: Interpreting the results conservatively, they demonstrate that SSRIs are not associated with affective toxicity in elderly persons.