Antidepressant Use by Class: Association with Major Adverse Cardiac Events in Patients with Coronary Artery Disease.

BACKGROUND: To assess use of antidepressants by class in relation to cardiology practice recommendations, and the association of antidepressant use with the occurrence of major adverse cardiovascular events (MACE) including death. METHODS: This is a historical cohort study of all patients who completed cardiac rehabilitation (CR) between 2002 and 2012 in a major CR center. Participants completed the Patient Health Questionnaire (PHQ-9) at the start and end of the program. A linkage system enabled ascertainment of antidepressant use and MACE through 2014. RESULTS: There were 1,694 CR participants, 1,266 (74.7%) of whom completed the PHQ-9 after the program. Depressive symptoms decreased significantly from pre- (4.98 ± 5.20) to postprogram (3.57 ± 4.43) (p < 0.001). Overall, 433 (34.2%) participants were on antidepressants, most often selective serotonin reuptake inhibitors (SSRI; n = 299; 23.6%). The proportion of days covered was approximately 70% for all 4 major antidepressant classes; discontinuation rates ranged from 37.3% for tricyclics to 53.2% for serotonin-norepinephrine reuptake inhibitors (SNRI). Antidepressant use was significantly associated with lower depressive symptoms after CR (before, 7.33 ± 5.94 vs. after, 4.69 ± 4.87; p < 0.001). After a median follow-up of 4.7 years, 264 (20.9%) participants had a MACE. After propensity matching based on pre-CR depressive symptoms among other variables, participants taking tricyclics had significantly more MACE than those not taking tricyclics (HR = 2.46; 95% CI 1.37-4.42), as well as those taking atypicals versus not (HR = 1.59; 95% CI 1.05-2.41) and those on SSRI (HR = 1.45; 95% CI 1.07-1.97). There was no increased risk with use of SNRI (HR = 0.89; 95% CI 0.43-1.82). CONCLUSION: The use of antidepressants was associated with lower depression, but the use of all antidepressants except SNRI was associated with more adverse events.

Validation of a Teaching Effectiveness Assessment in Psychiatry Continuing Medical Education.

OBJECTIVE: Little is known about factors associated with effective continuing medical education (CME) in psychiatry. The authors aimed to validate a method to assess psychiatry CME teaching effectiveness and to determine associations between teaching effectiveness scores and characteristics of presentations, presenters, and participants. METHODS: This cross-sectional study was conducted at the Mayo Clinic Psychiatry Clinical Reviews and Psychiatry in Medical Settings. Presentations were evaluated using an eight-item CME teaching effectiveness instrument, its content based on previously published instruments. Factor analysis, internal consistency and interrater reliabilities, and temporal stability reliability were calculated. Associations were determined between teaching effectiveness scores and characteristics of presentations, presenters, and participants. RESULTS: In total, 364 participants returned 246 completed surveys (response rate, 67.6%). Factor analysis revealed a unidimensional model of psychiatry CME teaching effectiveness. Cronbach α for the instrument was excellent at 0.94. Item mean score (SD) ranged from 4.33 (0.92) to 4.71 (0.59) on a 5-point scale. Overall interrater reliability was 0.84 (95% CI, 0.75-0.91), and temporal stability was 0.89 (95% CI, 0.77-0.97). No associations were found between teaching effectiveness scores and characteristics of presentations, presenters, and participants. CONCLUSIONS: This study provides a new, validated measure of CME teaching effectiveness that could be used to improve psychiatry CME. In contrast to prior research in other medical specialties, CME teaching effectiveness scores were not associated with use of case-based or interactive presentations. This outcome suggests the need for distinctive considerations regarding psychiatry CME; a singular approach to CME teaching may not apply to all medical specialties.

Supervised, Vigorous Intensity Exercise Intervention for Depressed Female Smokers: A Pilot Study.

INTRODUCTION: Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females. METHODS: Thirty adult women with moderate-severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12. RESULTS: Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040). CONCLUSIONS: Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy. IMPLICATIONS: This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.

A qualitative study of traditional healing practices among American Indians with chronic pain.

OBJECTIVE: Although chronic pain is prevalent among American Indian (AI) populations, the use of traditional healing practices has not been widely investigated. The aim of this qualitative study was to solicit information from adult AIs with chronic pain regarding use of traditional health practices (THPs) for chronic pain and pain reduction. DESIGN: Prospective qualitative design. SETTING: The Min No Aya Win Human Services Center, Fond du Lac Band Reservation in Cloquet, MN, and the Center for American Indian Resources, Duluth, MN. PATIENTS: The cohort included 21 (10 women and 11 men) AI patients with chronic pain. INTERVENTION: A semi-structured interview guide was developed, and audiotaped interviews were conducted with all patients. OUTCOME MEASURE: Audiotaped interviews were transcribed, and thematic analysis strategies were used to identify core concepts and categories for coding interview data. A qualitative software analysis program was used to facilitate data coding. RESULTS: A range of THP were described including smudging (burning sage), sweat lodge (ceremonial sauna), sema (ceremonial tobacco), feasting (strengthening process), pipes (ceremonial herb and tobacco), storytelling (nonhierarchical environment for verbal communication), and contact with a traditional healer (elder spiritual leader). The majority of individuals from the Reservation described prior exposure to THP; however, the majority of urban individuals reported limited exposure. Although the majority of individuals endorsed inclusion of THP in ambulatory-based pain treatment programs, recommendations for inclusion of specific practices were not systematically identified. CONCLUSIONS: The findings of this qualitative study suggest AIs from this tribal community utilize THP, but which specific THPs should be included in an ambulatory-based pain treatment program will require further research.

Impact of Musculoskeletal Limitations on Cardiac Rehabilitation Participation.

Background: To help clarify a potential barrier to cardiac rehabilitation (CR) participation we sought to examine the association between musculoskeletal limitations (MSLs) and CR enrollment and participation. Methods: Consecutive CR eligible individuals hospitalized for a cardiac event (myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass graft) between the months of November 2007 and May 2008, were asked to complete a mailed survey within 2 weeks after hospital discharge, assessing demographic factors, Patient Health Questionnaire (PHQ-9), participation in CR and MSLs through a validated MSLs screening tool. CR enrollment rates were compared between patients with and without MSLs. Results: Three hundred and twenty-one (37%) of patients contacted responded to our survey, including 228 males (71%), with a mean age 68 ± 10.8 years, of whom 98% were Caucasian. Eighty-two percent of responders reported a musculoskeletal disorder at the time of hospital discharge. Arthritis was the most frequent diagnosis (45%). Muscle or joint pain sufficient to limit the ability to do moderate exercise was reported in 52% of the respondents. Problems with balance affected 37%, of whom 45% reported a fall within the previous year. No significant difference in CR enrollment was observed in respondents with and without MSLs [OR = 0.98, 95% CI (0.88-1.09), p = 0.750]. Similar results were found when severity and number of MSLs were taken into account. However, we found that when compared to those without MSLs, the presence of MSLs was associated with lower CR participation (OR = 0.80, 95%, CI: 0.65-0.97, p = 0.0252). Conclusion: Despite a high prevalence of MSLs among CR-eligible patients, we found no association between MSLs and CR enrollment. However, patients with MSLs attended significantly fewer CR sessions as compared to patients without them. CR programs should consider providing additional support and interventions to patients with MSLs in order to optimize their adherence to prescribed CR sessions.

Is a videotape to change beliefs and behaviors superior to a standard videotape in acute low back pain? A randomized controlled trial.

BACKGROUND CONTEXT: Cognitive behavioral therapy has been used successfully in acute low back pain (LBP) treatment, but the use of a cognitive behavioral videotape as an adjunct to treatment has not been studied. PURPOSE: To determine outcomes for patients with acute LBP receiving a videotape designed to change beliefs and behaviors compared with a standard instructional videotape. STUDY DESIGN/SETTING: Randomized controlled trial; multidisciplinary clinic in an academic setting. PATIENT SAMPLE: Consecutive subjects with less than 3 months of LBP. Of 224 eligible subjects, 138 participated and completed the initial questionnaires. OUTCOME MEASURES: Oswestry Disability Index, Pain and Impairment Relationship Scale, Fear-Avoidance Beliefs Questionnaire; medical costs related to LBP and total medical costs incurred by participants during 1 year of follow-up. METHODS: Subjects were randomly assigned to receive a behavioral videotape or a control videotape. Other than the videotape, usual care was provided to each patient. RESULTS: No significant differences in any outcome measures or medical costs between the two groups at 12 months. However, baseline Vermont Disability Prediction Questionnaire was significantly lower in those who completed the entire study compared with those who did not complete the study. CONCLUSIONS: Compared with a standard instructional videotape, a behavioral videotape did not change beliefs, outcomes, or costs over 1 year. Cost-effective behavioral interventions with high patient retention rates are needed, especially for those at greatest risk of high utilization of resources.

Effect of a Motivational Interviewing-Based Health Coaching on Quality of Life in Subjects With COPD.

BACKGROUND: Improving quality of life (QOL) is a key goal in the care of patients with COPD. Pulmonary rehabilitation (PR) has clearly been shown to improve QOL, but is not accessible to many eligible patients. There is a need for alternative programs designed to improve patient well-being that are accessible to all patients with COPD. Our goal was to pilot test a simple, telephone-based health-coaching intervention that was recently shown to decrease readmission among hospitalized COPD patients and stable COPD patients eligible for PR. METHODS: Subjects received a 3-month intervention consisting of 10 health-coaching telephone calls based on motivational interviewing principles. Outcome measures included dyspnea level, measured by the modified Medical Research Council scale, and QOL, measured by the Chronic Respiratory Questionnaire and a single-item general self-rated health status. RESULTS: Fifty subjects with moderate to severe COPD were enrolled in the study. Forty-four subjects (86%) completed the study intervention. Dyspnea measured by the modified Medical Research Council score improved significantly after the intervention (P = .002). The domains of fatigue, emotional function, and mastery on the Chronic Respiratory Disease Questionnaire and the single-item QOL question also improved significantly after the 3 months of health coaching (P = .001, P = .001, P = .007, and P = .03, respectively). Thirty-six (71%) subjects had a clinically meaningful improvement in at least 1 study end point (either in the severity of dyspnea or a domain of QOL). Thirty subjects (58%) had an improvement of ≥0.5 points, the minimum clinically important difference in at least 1 component of the Chronic Respiratory Disease Questionnaire. CONCLUSIONS: A telephone-delivered motivational interviewing-based coaching program for COPD patients is a feasible, well-accepted (by both participants and providers), simple, and novel intervention to improve the well-being of patients with COPD. This pilot study provides insight into a possible alternative to a conventional PR program for patients with limited access to that program.

High Stress and Negative Health Behaviors: A Five-Year Wellness Center Member Cohort Study.

OBJECTIVE: The aim of this study was to examine the association between having a high stress level and health behaviors in employees of an academic medical center. METHODS: Beginning January 1, 2009, through December 31, 2013, an annual survey was completed by 676 worksite wellness members. RESULTS: Each year, about one-sixth of members had a high stress level, high stress individuals visited the wellness center less often, and most years there was a significant relationship (P < 0.05) between stress level and poor physical health behaviors (physical activity level and confidence, strength, climbing stairs), low mental health (quality of life, support, spiritual well-being and fatigue), poor nutritional habits (habits and confidence), and lower perceived overall health. CONCLUSIONS: High stress is associated with negative health behavior, and future studies, therefore, should explore strategies to effectively engage high stress employees into comprehensive wellness programs.

Improvements in Health Behaviors, Eating Self-Efficacy, and Goal-Setting Skills Following Participation in Wellness Coaching.

Purpose . This project examined potential changes in health behaviors following wellness coaching. Design . In a single cohort study design, wellness coaching participants were recruited in 2011, data were collected through July 2012, and were analyzed through December 2013. Items in the study questionnaire used requested information about 11 health behaviors, self-efficacy for eating, and goal-setting skills. Setting . Worksite wellness center. Participants . One-hundred employee wellness center members with an average age of 42 years; 90% were female and most were overweight or obese. Intervention . Twelve weeks of in-person, one-on-one wellness coaching. Method . Participants completed study questionnaires when they started wellness coaching (baseline), after 12 weeks of wellness coaching, and at a 3-month follow-up. Results . From baseline to week 12, these 100 wellness coaching participants improved their self-reported health behaviors (11 domains, 0- to 10-point scale) from an average of 6.4 to 7.7 (p < .001), eating self-efficacy from an average of 112 to 142 (on a 0- to 180-point scale; p < .001), and goal-setting skills from an average of 49 to 55 (on a 16- to 80-point scale; p < .001). Conclusion . These results suggest that participants improved their current health behaviors and learned skills for continued healthy living. Future studies that use randomized controlled trials are needed to establish causality for wellness coaching.

The effectiveness of wellness coaching for improving quality of life.

OBJECTIVE: To learn more about the potential psychosocial benefits of wellness coaching. Although wellness coaching is increasing in popularity, there are few published outcome studies. PATIENTS AND METHODS: In a single-cohort study design, 100 employees who completed the 12-week wellness coaching program were of a mean age of 42 years, 90% were women, and most were overweight or obese. Three areas of psychosocial functioning were assessed: quality of life (QOL; 5 domains and overall), depressive symptoms (Patient Health Questionnaire-9), and perceived stress level (Perceived Stress Scale-10). Participants were recruited from January 1, 2011, through December 31, 2011; data were collected up to July 31, 2012, and were analyzed from August 1, 2012, through October 31, 2013. RESULTS: These 100 wellness coaching completers exhibited significant improvements in all 5 domains of QOL and overall QOL (P<.0001), reduced their level of depressive symptoms (P<.0001), and reduced their perceived stress level (P<.001) after 12 weeks of in-person wellness coaching, and they maintained these improvements at the 24-week follow-up. CONCLUSION: In this single-arm cohort study (level 2b evidence), participating in wellness coaching was associated with improvement in 3 key areas of psychosocial functioning: QOL, mood, and perceived stress level. The results from this single prospective cohort study suggest that these areas of functioning improve after participating in wellness coaching; however, randomized clinical trials involving large samples of diverse individuals are needed to establish level 1 evidence for wellness coaching.

Anxiety levels, fear-avoidance beliefs, and disability levels at baseline and at 1 year among subjects with acute and chronic low back pain.

OBJECTIVE: To compare anxiety levels, fear-avoidance beliefs, and disability levels over 1 year for patients with acute (< or =3 months) and chronic (>3 months) low back pain (LBP). DESIGN: Prospective study with questionnaire measurements. SETTING: Tertiary care clinic. PATIENTS: Patients with acute or chronic LBP who resided in a 3-county local area and presented to our clinic for initial evaluation. METHODS: Administration of and results analysis from Fear-Avoidance Beliefs Questionnaire, Oswestry Disability Index, Pain and Impairment Relationship Scale, and Spielberger State-Trait Anxiety Inventory at baseline and 12 months. Trait anxiety was measured at baseline only. MAIN OUTCOME MEASUREMENTS: Scores from questionnaires assessing fear-avoidance beliefs and state and trait anxiety, as well as LBP disability levels. RESULTS: In total, 138 patients with acute LBP and 107 with chronic LBP were enrolled. Of these patients, 111 with acute and 86 with chronic LBP completed the study. The 2 groups were statistically indistinguishable at baseline on all measures except trait anxiety scores, which were significantly higher in the group with chronic LBP than in the acute group (P = .01). At 1 year, the acute group had a statistically significant improvement in all outcome measures except state anxiety. The group with chronic LBP had significant improvement in all measures except fear-avoidance beliefs and state anxiety. Overall, the group with acute LBP improved more in all measurement instruments than the chronic LBP group (a statistically significant difference) except state anxiety. CONCLUSIONS: The group with chronic LBP exhibited a higher level of trait anxiety at baseline than those with acute LBP and, unlike the acute LBP group, did not have improved fear-avoidance beliefs over 1 year. The relationship between anxiety and chronic LBP is novel. Because anxiety is potentially modifiable, future studies that evaluate the relationship between LBP and anxiety are warranted.

Uncontrolled eating and obesity in adult primary care patients.

OBJECTIVE: The purpose of this study was to assess the independent effects of health confidence and uncontrolled eating on obesity risk in primary care patients. METHODS: A random sample of primary care patients served by a large medical clinic in the mid-western United States was surveyed January-March of 2008; and 944 cases met criteria for the study. The odds of being obese (BMI ≥ 30) were modeled using multiple logistic regression. Uncontrolled eating was measured with a single question addressing problems with food control. Weight control motivation, health confidence, demographic variables, and health behaviors were used as covariates. RESULTS: Nearly 47 percent of our respondents reported uncontrolled eating; 42.2 percent of uncontrolled eaters were obese, compared with only 9.4 percent of persons who never had problems with food control. About 27 percent of non-obese persons reported no trouble with food control, compared to 9.4 percent of obese patients having no trouble. Over 70 percent of obese respondents reported at least some trouble with food control, compared to only 37 percent of non-obese patients. Not being able to control food or having some trouble controlling food exhibited the strongest independent association with obesity (OR 6.67, CI 3.91-11.4). CONCLUSIONS: Adult primary care patients who reported inability to control their eating behavior were more likely to be obese. These effects persisted after adjusting for demographic and behavioral variables. The results of this study suggest that obesity is partly the result of uncontrolled eating. Health promotion programs may have to be patterned after those designed for substance abuse and dependency.

Does behavioral bootstrapping boost weight control confidence?: a pilot study.

BACKGROUND: Since confidence is an important predictor of ability to lose weight, methods for increasing weight-control confidence are important. The purpose of this study was to test the relationship between short-term behavior changes ('behavioral bootstrapping') and change in weight-control confidence in a small prospective weight-loss project. METHODS: Data were available from 38 patients who received an initial motivational interview and a follow-up visit. Body mass index at baseline ranged from 25.5 kg/m to 50.4 kg/m (mean = 35.8, median = 34.4). Independent variables were change in weight (measured in kilograms in the clinic), self-reported change in minutes of physical activity, age, sex, and marital status. Minutes of physical activity were assessed at baseline and after 30 days, using the following question, "How many minutes do you exercise per week (e.g. fast walking, biking, treadmill)?" Weights were measured in the clinic. RESULTS: Weight change was inversely correlated with change in confidence (p = 0.01). An increase in physical activity was associated with an increase in confidence (p = 0.01). Age, sex, and marital status were not related to change in confidence. Independent effects of weight change and physical activity were estimated using multiple linear regression analysis: b = -0.44, p = 0.04 for change in weight, and b = 0.02, p = 0.03 for change in physical activity (r = 0.28). CONCLUSIONS: Short-term changes in behavior (losing weight and exercising more) lead to increased weight-control confidence in primary-care patients.

Revision of the Self-Administered Alcoholism Screening Test (SAAST-R): a pilot study.

The original Self-Administered Alcoholism Screening Test (SAAST; Swenson and Morse, 1975) is a self-report alcoholism screening measure intended for use with adult medical patients. However, the SAAST does not indicate the recency of alcohol use-related problems, not all items use the appropriate verb tense for assessing lifetime experience of alcohol use-related problems, many of the items contain out-dated language, and the diagnostic criteria for alcohol dependence and alcohol abuse are not fully represented. The SAAST was revised to address these issues. This paper describes the rationale for revision and the process through which the SAAST was revised. Preliminary information about comparability of the original SAAST and the revised version (SAAST-R) was obtained. Data are presented from two intervention trials for smokers in which both the SAAST and SAAST-R were administered. One sample was comprised of participants in recovery from alcoholism (N = 60; 82% male) and the other sample consisted of participants not meeting criteria for alcohol abuse or dependence within the previous year (N = 98; 45% male). The results suggest that the SAAST-R is highly correlated with the original SAAST, has a similar factor structure, good internal consistency, and correctly identifies those in recovery from alcoholism. Areas for refinement in the format and items of the SAAST-R were identified and suggestions for further validation studies are presented.