Methodology and preliminary results from the neurocognitive outcomes of depression in the elderly study.

A methodology is presented for following a cohort of older depressed patients to examine neurocognitive outcomes of depression. A total of 265 depressed individuals and 138 healthy, nondepressed controls age 60 and older who completed at least 1 year of follow-up data underwent periodic clinical evaluation by a geriatric psychiatrist. A subset of 141 patients and 137 controls had neuropsychological testing. A consensus panel of experts reviewed 63 depressed subjects with suspected cognitive impairment. Twenty-seven individuals in the depressed group were assigned diagnoses of dementia, including 11 with Alzheimer's disease, 8 with vascular dementia, and 8 with dementia of undetermined etiology. In addition, 25 individuals had other forms of cognitive impairment, and 11 were considered cognitively normal. Among elderly controls, 2 developed substantial cognitive impairment with clinical diagnoses of dementia. Among the depressed group, the incidence rates for dementia for this age are much higher than would be expected. These results are consistent with prior evidence linking depression and later dementia. Future studies are needed to examine neuroimaging and genetic, clinical, and social predictors of neurocognitive decline in depression.

Effect of Bupropion SR on the Quality of Life of Elderly Depressed Patients With Comorbid Medical Disorders.

BACKGROUND: There is a need for additional studies of the quality of life (QOL) of elderly depressed subjects with medical comorbidity. METHOD: We conducted an 8-week, open trial of bupropion sustained release (SR) in 18 elderly (60-81 years) subjects with DSM-IV major depressive disorder and one or more serious medical illnesses (e.g., congestive heart failure, type 1 diabetes mellitus, irritable bowel syndrome) with a week-12 follow-up interview. The intent-to-treat method with the last observation carried forward was used to analyze depression and QOL measures. Dosing was initiated at 100 mg once daily and increased at weekly intervals to a maximum of 150 mg twice daily as clinically indicated. RESULTS: Bupropion SR treatment was associated with reductions in Clinical Global Impressions-Severity of Illness scale (p <.0001) score and in the 17-item Hamilton Rating Scale for Depression (HAM-D) total score (p <.0001). QOL as measured by the Medical Outcomes Study Short Form-36 (SF-36) also tended to improve with treatment. The SF-36 "mental health" (p <.01) and "social functioning" (p <.0006) domains improved significantly by week 4. "Vitality" (p <.03) improved significantly by week 12. On the HAM-D, statistically significant improvement was noted on "depressed mood" (p <.0001), "feelings of guilt" (p <.01), "work and activities" (p <.001), "hypochondriasis" (p <.02), and "insomnia" (p <.01) at week 8. The mean dose of bupropion SR at endpoint was 222 mg/day, and the drug was relatively well tolerated. Two subjects dropped out owing to adverse events and 2 owing to other reasons. No drug-drug interactions occurred. CONCLUSION: These data suggest that bupropion SR is well tolerated and may improve depression, insomnia, somatic symptoms, work functioning, and certain quality-of-life measures in elderly depressed subjects with medical disorders. A randomized, placebo-controlled study is warranted to confirm these promising findings.

Use of augmentation agents for treating depression: analysis of a psychiatric electronic medical record data set.

OBJECTIVE: This study evaluated the relationship between patient characteristics and augmentation strategies for the treatment of major depressive disorder. METHODS: This retrospective, cross-sectional study used data from a psychiatric electronic medical record database for patients with depression without psychosis or psychotic features who initiated augmentation therapy between January 2001 and June 2011. Medical records were evaluated to identify factors predicting use of specific augmentation agents, and a multivariate logistic regression model was used to assess clinical and demographic predictors of augmentation strategy. RESULTS: Of 3,209 patients initiating augmentation therapy for depression, 75% received augmentation with an antidepressant combination and 11% received augmentation with second-generation antipsychotics. Baseline clinical severity (Clinical Global Impressions-Severity score) most strongly and consistently predicted augmentation with second-generation antipsychotics. CONCLUSIONS: Treatment of patients in specialty settings with depression was often augmented with an antidepressant combination, whereas those with severe depression had an increased likelihood of augmentation with second-generation antipsychotics.

Using electronic health records data to assess comorbidities of substance use and psychiatric diagnoses and treatment settings among adults.

OBJECTIVE: To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18-64 years (N = 40,099) in an electronic health records (EHR) database. METHOD: DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined. RESULTS: Among all patients, 24.9% (n = 9984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2-56.6%). Patients aged 18-24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment. CONCLUSION: Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings.

Comorbid substance use disorders with other Axis I and II mental disorders among treatment-seeking Asian Americans, Native Hawaiians/Pacific Islanders, and mixed-race people.

Little is known about behavioral healthcare needs of Asian Americans (AAs), Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race people (MRs)-the fastest growing segments of the U.S. population. We examined substance use disorder (SUD) prevalences and comorbidities among AAs, NHs/PIs, and MRs (N = 4572) in a behavioral health electronic health record database. DSM-IV diagnoses among patients aged 1-90 years who accessed behavioral healthcare from 11 sites were systematically captured: SUD, anxiety, mood, personality, adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic/schizophrenic, sleep, and somatoform diagnoses. Of all patients, 15.0% had a SUD. Mood (60%), anxiety (31.2%), adjustment (30.9%), and disruptive (attention deficit-hyperactivity, conduct, oppositional defiant, disruptive behavior diagnosis, 22.7%) diagnoses were more common than others (psychotic 14.2%, personality 13.3%, other childhood-onset 11.4%, impulse-control 6.6%, cognitive 2.8%, eating 2.2%, somatoform 2.1%). Less than 1% of children aged <12 years had SUD. Cannabis diagnosis was the primary SUD affecting adolescents aged 12-17. MRs aged 35-49 years had the highest prevalence of cocaine diagnosis. Controlling for age at first visit, sex, treatment setting, length of treatment, and number of comorbid diagnoses, NHs/PIs and MRs were about two times more likely than AAs to have ≥ 2 SUDs. Regardless of race/ethnicity, personality diagnosis was comorbid with SUD. NHs/PIs with a mood diagnosis had elevated odds of having SUD. Findings present the most comprehensive patterns of mental diagnoses available for treatment-seeking AAs, NHs/PIs, and MRs in the real-world medical setting. In-depth research is needed to elucidate intraracial and interracial differences in treatment needs.

The effectiveness of antidepressant monotherapy in a naturalistic outpatient setting.

OBJECTIVE: To assess a representative sample of clinically depressed outpatients during acute treatment with antidepressant medication monotherapy to determine clinical outcomes and evaluate relationships between outcomes and selected baseline/treatment features. METHOD: This naturalistic study examined data on outpatients at the Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, from January 2000 through December 2010. Eligible patients (N = 1,722) had a diagnosis of clinical depression (major depressive disorder, dysthymic disorder, or depressive disorder not otherwise specified as defined in DSM-IV-TR). Sociodemographic/clinical data were gathered at study entry (date of first treatment). The Clinical Global Impressions-improvement (CGI-I) and -severity of illness (CGI-S) scales were administered at entry and at study exit (end of follow-up) after 1 to 9 weeks of treatment. Analysis of variance, F tests, and t tests determined relationships between outcomes and treatment duration, baseline severity, and sociodemographic/clinical features. RESULTS: Thirty-nine percent of participants reported substantial improvement (CGI-I score = 1 or 2) from entry to exit, 33% reported minimal improvement (CGI-I score = 3), 22% reported no change, and approximately 7% reported worsened illness. Greater improvement (CGI-I score) and greater reduction in depressive severity (CGI-S score) were associated with greater baseline depressive severity and longer treatment duration (all P < .001). Participants with greater baseline depressive severity experienced larger reductions in depressive severity but reported worse CGI-I scores at exit. Less improvement in CGI-I scores was seen in women compared to men (P = .018). Less improvement in CGI-I scores and less reduction in CGI-S scores were seen in participants ≤ 60 years of age (P = .040 and P = .025, respectively) and those with comorbid substance abuse (P < .001 and P = .010, respectively) or anxiety (P = .018 and P < .001, respectively) disorders. CONCLUSIONS: Most depressive symptom improvement occurred within the first 4 to 6 weeks of antidepressant monotherapy. Greater baseline severity, comorbid substance abuse, and comorbid anxiety disorders are associated with worse outcomes.

Prevalence of HIV infection in a general psychiatric outpatient population.

The prevalence of human immunodeficiency virus (HIV) infection in the general psychiatric population is unknown. The authors conducted a retrospective review of all patients evaluated through the psychiatric outpatient clinics at Duke University Medical Center from 2001 to 2004 in order to determine the prevalence of comorbid HIV infection and mental illness. HIV infection was present in 1.2% of the psychiatric outpatients, approximately four times the occurrence of HIV infection in the general adult population of the United States. The major psychiatric diagnostic categories with a high prevalence of HIV infection were substance abuse disorders (5%), personality disorders (3.1%), bipolar disorders (2.6%), and posttraumatic stress disorder (2.1%).

Practical evidence-based medicine.

one, information is processed in step two, evidence-based libraries monitor clinical care for treatment recommendations in step three, and feedback is delivered to the clinician at the point of care in step four. This article describes the procedure for development of such a system.