Dynamic residential movement and depression among the World Trade Center Health Registry enrollees.

PURPOSE: Residential instability is associated with poor mental health, but its causal inference is challenging due to time-varying exposure and confounding, and the role of changing social environments. We tested the association between frequent residential moving and depression risk among adults exposed to the 9/11 disaster. METHODS: We used four waves of survey data from the World Trade Center Health Registry. We measured residential movement and depression using geocoded annual address records and the Personal Health Questionnaire Depression Scale, respectively, for a prospective cohort of 38,495 adults. We used the longitudinal Targeted Maximum Likelihood Method to estimate depression risk by frequent residential moving and conducted causal mediation analysis to evaluate a mediating role of social environments. RESULTS: Most enrollees (68%) did not move in 2007-2014, and 6% moved at least once every 4 years. The remaining 26% moved less frequently (e.g., only moving in 2007-2010). Frequent moving versus no moving was associated with risk of depression in 2015-16 (RR = 1.20, 95% CI = 1.06, 1.37). Frequent residential moving-depression pathway was mediated by high social integration (OR = 0.93, 95% CI = 0.90, 0.97). CONCLUSION: These findings demonstrate the importance of social networks in understanding increased risk of depression associated with housing instability.

Effect of Older vs Younger Age on Anthropometric and Metabolic Variables During Treatment of Psychotic Depression With Sertraline Plus Olanzapine: The STOP-PD II Study.

OBJECTIVE: To examine the effect of older versus younger age on change in anthropometric and metabolic measures during extended treatment of psychotic depression with sertraline plus olanzapine. METHODS: Two hundred and sixty-nine men and women aged 18-85 years with an episode of psychotic depression were treated with open-label sertraline plus olanzapine for up to 12 weeks. Participants who remained in remission following an 8-week stabilization phase were eligible to participate in a 36-week randomized controlled trial (RCT) that compared the efficacy and tolerability of sertraline plus olanzapine with sertraline plus placebo. Weight, waist circumference and plasma lipids, glucose, HbA1c, and insulin were measured at regular intervals during the acute, stabilization and randomized phases of the study. Linear mixed models were used to analyze the trajectories of anthropometric and metabolic measures. RESULTS: Participants aged 60 years or older experienced less weight gain and less increase in cholesterol during the combined acute and stabilization phases of the study compared with those aged 18-59 years. At the acute-stabilization termination visit, mean weight in older participants was 6.5 lb. less than premorbid weight, whereas it was 17.9 lb. more than premorbid weight in younger participants. In the RCT, there was a significant interaction of treatment and age group for the trajectory of weight, but the post hoc tests that compared age groups within each treatment arm were not statistically significant. There were no clinically significant differences between younger and older participants in glycemic measures. CONCLUSION: Older patients with psychotic depression experienced less increase in weight and total cholesterol than their younger counterparts during acute and stabilization treatment with sertraline plus olanzapine. In the older group, weight gained during the acute and stabilization phases appeared to be partial restoration of weight lost during the index episode of depression, whereas weight gain in younger participants was not.

Two Interventions for PatientsWith Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Quality of Life.

OBJECTIVE: Clinically significant depression occurs in approximately 40% of chronic obstructive pulmonary disease (COPD) patients, and both illnesses severely impair quality of life. This study tests the hypothesis that problem-solving integrated with a treatment adherence intervention, the Problem Solving-Adherence (PSA), is superior to a personalized treatment adherence intervention, the Personalized Intervention for Depressed Patients with COPD (PID-C), alone in improving quality of life in depressed COPD patients. METHODS: After screening 633 admissions for acute rehabilitation, we studied quality of life in 87 participants with major depression (by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and severe COPD randomly assigned to 14 sessions of PID-C or PSA over 26 weeks. Quality of life was assessed using the Word Health Organization Quality of Life-BREF at baseline and weeks 10, 14, and 26. RESULTS: The hypothesis was not supported. Exploratory latent class growth modeling identified two quality of life trajectories. In 80.5% of participants, quality of life remained unchanged and improved in the remaining 19.5% during the first 14 weeks. Patients with a stable quality trajectory had higher qualityof life at baseline and a stronger sense of personal agency. CONCLUSION: Maintaining quality of life is a favorable outcome in depressed patients with COPD whose course is one of deterioration. These findings highlight the usefulness of PID-C, an easy to learn, personalized adherence enhancement intervention that, after further testing, may be integrated into the rehabilitation and care of depressed COPD patients.

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission: The STOP-PD II Randomized Clinical Trial.

Importance: Psychotic depression is a severely disabling and potentially lethal disorder. Little is known about the efficacy and tolerability of continuing antipsychotic medication for patients with psychotic depression in remission. Objective: To determine the clinical effects of continuing antipsychotic medication once an episode of psychotic depression has responded to combination treatment with an antidepressant and antipsychotic agent. Design, Setting, and Participants: Thirty-six week randomized clinical trial conducted at 4 academic medical centers. Patients aged 18 years or older had an episode of psychotic depression acutely treated with sertraline plus olanzapine for up to 12 weeks and met criteria for remission of psychosis and remission or near-remission of depressive symptoms for 8 weeks before entering the clinical trial. The study was conducted from November 2011 to June 2017, and the final date of follow-up was June 13, 2017. Interventions: Participants were randomized either to continue olanzapine (n = 64) or switch from olanzapine to placebo (n = 62). All participants continued sertraline. Main Outcomes and Measures: The primary outcome was risk of relapse. Main secondary outcomes were change in weight, waist circumference, lipids, serum glucose, and hemoglobin A1c (HbA1c). Results: Among 126 participants who were randomized (mean [SD] age, 55.3 years [14.9 years]; 78 women [61.9%]), 114 (90.5%) completed the trial. At the time of randomization, the median dosage of sertraline was 150 mg/d (interquartile range [IQR], 150-200 mg/d) and the median dosage of olanzapine was 15 mg/d (IQR, 10-20 mg/d). Thirteen participants (20.3%) randomized to olanzapine and 34 (54.8%) to placebo experienced a relapse (hazard ratio, 0.25; 95% CI, 0.13 to 0.48; P < .001). The effect of olanzapine on the daily rate of anthropometric and metabolic measures significantly differed from placebo for weight (0.13 lb; 95% CI, 0.11 to 0.15), waist circumference (0.009 inches; 95% CI, 0.004 to 0.014), and total cholesterol (0.29 mg/dL; 95% CI, 0.13 to 0.45) but was not significantly different for low-density lipoprotein cholesterol (0.04 mg/dL; 95% CI, -0.01 to 0.10), high-density lipoprotein cholesterol (-0.01 mg/dL; 95% CI, -0.03 to 0.01), triglyceride (-0.153 mg/dL; 95% CI, -0.306 to 0.004), glucose (-0.02 mg/dL; 95% CI, -0.12 to 0.08), or HbA1c levels (-0.0002 mg/dL; 95% CI, -0.0021 to 0.0016). Conclusions and Relevance: Among patients with psychotic depression in remission, continuing sertraline plus olanzapine compared with sertraline plus placebo reduced the risk of relapse over 36 weeks. This benefit needs to be balanced against potential adverse effects of olanzapine, including weight gain. Trial Registration: ClinicalTrials.gov Identifier: NCT01427608.

Two Interventions for Patients with Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Dyspnea-Related Disability.

OBJECTIVE: The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles. METHODS: In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS: The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline. CONCLUSION: Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.

"Engage" Therapy: Behavioral Activation and Improvement of Late-Life Major Depression.

OBJECTIVE: Engage is a treatment for late-life depression developed to match the skills of community clinicians based on the theory that dysfunction in the Research Domain Criteria Project positive valence systems is a critical mechanism of late-life depression. Accordingly, it uses "reward exposure" (engagement in meaningful, rewarding activities) as its principal intervention. This study tests the hypothesis that change in behavioral activation, an index of positive valence systems function, during successive treatment periods with Engage and during follow-up predicts depression at the end of each period. METHODS: Forty-eight nondemented, older adults with unipolar major depression were treated openly with 9 weekly sessions of Engage and assessed 36 weeks after entry. Depression severity was assessed with the 24-item Hamilton Depression Rating Scale (HAM-D) and behavioral activation with the Behavioral Activation for Depression Scale (BADS) at baseline, 6 weeks (mid-treatment), 9 weeks (end of treatment), and 36 weeks. RESULTS: A mixed-effects model examined whether change in BADS in successive periods occurring during Engage treatment and during follow-up predicts depression at the end of each period. Both BADS change (F1,52 = 18.63, p < 0.0001) and time (F2,52 = 7.68, p = 0.0012) predicted HAM-D scores at the end of each observation period. Every point of increase in BADS change reduced the HAM-D by 0.105 points. HAM-D at each point did not predict subsequent change in BADS (F1,52 = 2.17, p = 0.146). CONCLUSION: During Engage treatment and follow-up, change in behavioral activation is followed by improvement of depressive symptoms and signs.

Two Behavioral Interventions for Patients with Major Depression and Severe COPD.

OBJECTIVE: Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. DESIGN: Randomized controlled trial. SETTING: Acute inpatient rehabilitation and community. PARTICIPANTS: A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. INTERVENTION: Fourteen sessions of PID-C versus PSA over 26 weeks. MEASUREMENTS: 24-item Hamilton Depression Rating Scale. RESULTS: PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. CONCLUSIONS: Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions. .

The Association between Socioeconomic Status and Race/Ethnicity with Home Evacuation of Lower Manhattan Residents following the 9/11/2001 World Trade Center Disaster.

On 11 September 2001, attacks on the World Trade Center (WTC) killed nearly three thousand people and exposed hundreds of thousands of rescue and recovery workers, passersby, area workers, and residents to varying amounts of dust and smoke. Former New York City Mayor Rudy Giuliani ordered the emergency evacuation of Lower Manhattan below Canal Street, but not all residents evacuated. Previous studies showed that those who did not evacuate had a higher incidence of newly diagnosed asthma. Among the 71,424 who enrolled in the WTC Health Registry in 2003-2004, we evaluated the bivariate association of educational attainment, household income, and race or ethnicity with reported evacuation on or after 9/11/01. We used log binomial regression to assess the relative risks of not evacuating from their home following the 9/11 attacks, adjusting for age, gender, and marital status. Out of a total of 11,871 enrollee residents of Lower Manhattan, 7345 or 61.79% reported evacuating their home on or after 9/11. In a fully adjusted model, the estimated relative risk for not evacuating was elevated for those who identified as non-Hispanic Black, Asian/Pacific Islander, and Hispanic residents compared to non-Hispanic White residents. Residents with a high school diploma/GED had an elevated estimated risk compared to those with at least a bachelor's degree. Those with lower household incomes had an elevated estimated risk compared to those with the highest income category. These significant inequities will need to be prevented in future disasters.

Post-traumatic stress disorder and risk of first-time and repeated opioid-related hospitalizations among World Trade Center Health Registry enrollees.

In 2021, and average of 220 deaths from opioid-related overdoses occurred daily in the US. Recent evidence suggests there is an association between post-traumatic stress disorder (PTSD) and increased opioid misuse, while little is known about opioid-related hospitalizations. This study used data from the World Trade Center Health Registry (WTCHR), a longitudinal cohort consisting of individuals directly exposed to the September 11th terrorist attacks with a high prevalence of resulting PTSD (3.8-29.6%). We linked WTCHR data to New York State hospitalization data to examine the question: do opioid-related hospitalizations (first time and repeated) differ by PTSD status. In a study sample of 37,968 adults, 145 experienced at least one episode of opioid-related hospitalization and 64 had repeated episodes during the study period. We found that in the 13-years post-9/11, individuals with PTSD had a significantly higher risk of a first-time opioid-related hospitalization (Hazard Ratio: 3.6, 95% CI: 2.7, 5.0) and repeated opioid-related hospitalizations (Hazard Ratio: 3.9, 95% CI: 2.7, 5.8) than those who did not have PTSD. Improved treatment of and increased screenings for PTSD may reduce the likelihood of opioid misuse in this population and consequently overdoses, hospitalizations, and healthcare costs.

Post-Traumatic Growth and Quality of Life among World Trade Center Health Registry Enrollees 16 Years after 9/11.

A recent study of World Trade Center Health Registry enrollees found that about one-third experienced post-traumatic growth (PTG) in the wake of the 9/11 attacks and that PTG was associated with social support and social integration. However, the implications of PTG for the enrollees' overall quality of life are unknown. The present study investigated the prevalence of PTG and its association with the SF-12 physical and mental functioning quality of life scales in a sample of 4760 enrollees from the Registry's Health and Quality of Life Study (HQoL) who completed the first four surveys, were older than 18 on 9/11, reported English as their primary spoken language, and provided consistent self-report of 9/11 physical injury at the Registry's baseline and HQoL surveys. We employed multivariable linear regression to evaluate the association between PTG and the SF-12 physical and mental scales, controlling for sociodemographic and other variables. We found that 31% of the sample enrollees experienced PTG and that PTG exhibited a clinically and statistically significant association with the SF-12 mental scale but not the physical scale (physical: b = 0.15 (-0.45, 0.75), mental: b = 3.61 (2.85, 4.37)). Those who were physically injured during 9/11 showed larger improvements in mental functioning than those who were not. PTG has implications for the overall mental quality of life that should be further investigated.

Associations of Embeddedness and Posttraumatic Stress Disorder among 9/11 Survivors.

Following exposures to traumatic events on 9/11, survivors have reported heightened levels of posttraumatic stress disorder (PTSD). Multiple factors contribute to both the exacerbation and amelioration of PTSD symptoms, including social integration and support. This cross-sectional study aimed to understand and identify associations of embeddedness and psychosocial risk factors by PTSD status for survivors and first responders of 9/11. Results indicate that those with chronic PTSD had the lowest prevalence of both social and emotional embeddedness and many who reported no PTSD symptoms following 9/11 reported moderate levels of social and emotional embeddedness. Overall, our findings suggest those individuals who reported little to no PTSD also reported the most social/emotional embeddedness; whereas those individuals who report greater or chronic PTSD report the least social/emotional embeddedness. As such, it may be beneficial for clinicians across multiple care disciplines and contexts to consider and address the social lives and needs of those individuals experiencing symptoms of PTSD to ensure their emotional and physical needs are truly being met.

World Trade Center Exposure and Posttraumatic Growth: Assessing Positive Psychological Change 15 Years after 9/11.

We evaluated the presence of posttraumatic growth (PTG) among survivors of the 9/11 terrorist attack and how indicators of psychosocial well-being, direct 9/11-related exposure, and posttraumatic stress symptoms (PTSS) relate to PTG. PTG was examined among 4934 participants using the Posttraumatic Growth Inventory (PTGI). A confirmatory factor analysis (CFA) was conducted to determine if the original factor structure of the PTGI fits our data and principal component analysis (PCA) to identify the appropriate factor structure. Multivariable linear regression models were used to examine the association between PTG and indicators of psychosocial well-being, 9/11-related exposure, and PTSS, controlling for covariates. CFA identified a two-factor structure of the PTGI as a better fit than the original five-factor model. Participants who experienced very high 9/11-related exposure level (ß = 7.72; 95% CI: 5.75-9.70), higher PTSS at waves 1 (ß = 0.13; 95% CI: 0.08-0.18) and 2 (ß = 0.09; 95% CI: 0.05-0.14), high social integration (ß = 5.71; 95% CI: 4.47, 6.96), greater social support (ß = 0.49; 95% CI: 0.37, 0.61), and higher self-efficacy (ß = 1.26; 95% CI: 1.04, 1.48) had higher PTGI scores. Our findings suggest PTG is present, 15 years following the 9/11 terrorist attack. Very high-level 9/11 exposure, PTSS, and indicators of psychosocial well-being were associated with PTG.

"Engage" therapy: Prediction of change of late-life major depression.

OBJECTIVE: Engage grew out of the need for streamlined psychotherapies that can be accurately used by community therapists in late-life depression. Engage was based on the view that dysfunction of reward networks is the principal mechanism mediating depressive symptoms. Accordingly, Engage uses "reward exposure" (exposure to meaningful activities) and assumes that repeated activation of reward networks will normalize these systems. This study examined whether change in a behavioral activation scale, an index of reward system function, predicts change in depressive symptomatology. METHODS: The participants (N = 48) were older adults with major depression treated with 9 weekly sessions of Engage and assessed 27 weeks after treatment. Depression was assessed with the 24-item Hamilton Depression Rating Scale (HAM-D) and behavioral activation with the four subscales of Behavioral Activation for Depression Scale (activation, avoidance/rumination, work impairment, social impairment) at baseline, 6 weeks (mid-treatment), 9 weeks (end of treatment), and 36 weeks. RESULTS: Change only in the Activation subscale during successive periods of assessment predicted depression severity (HAM-D) at the end of each period (F1, 47 = 21.05, p<0.0001). An increase of one standard deviation in the Activation score resulted in a 2.04 (95% CI: 1.17-2.92) point decrease in HAM-D. For every one point increase in the Activation score, HAM-D was decreased by 0.22 points (95% CI: 0.12-0.31). LIMITATIONS: No comparison group. Partial overlap of Activation Subscale with HAM-D, lack of detailed neurocognitive assessment and social support. CONCLUSION: Change in behavioral activation predicts improvement of depressive symptoms and signs in depressed older adults treated with Engage.