Barriers to Physical and Mental Condition Integrated Service Delivery 12 Jul 2010

Objective: To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression.

Methods: We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs.

Results: All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services.

Conclusions: Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

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Social Interaction Prevents the Development of Depressive-Like Behavior Post Nerve Injury in Mice: A Potential Role for Oxytocin 12 Jul 2010

Objective: To examine the salubrious role of social interaction in modulating the development of allodynia (increased sensitivity to typically innocuous physical stimuli) and depressive-like behavior post peripheral nerve injury in mice. The determination of potential mechanisms that mediate social influences on the behavioral and physiological response to peripheral nerve injury.

Methods: Mice were pair housed or socially isolated for 2 weeks before spared nerve injury (SNI). Animals were cannulated; socially isolated animals were centrally treated with oxytocin; and socially paired animals were centrally treated with an oxytocin receptor antagonist. Animals were subsequently monitored for the development of mechanical allodynia and depressive-like behavior, and tissue was collected for analysis of the central levels of the cytokine interleukin 1 beta (IL-1β).

Results: Depressive-like behavior was assessed via the Porsolt forced swim test, developed only among socially isolated mice with nerve injury. Socially isolated mice with nerve injury also were the only experimental group to exhibit increased frontal cortex IL-1β gene expression on day 7 post injury. Moreover, central treatment of socially isolated mice with oxytocin, a neuropeptide associated with social bonding, attenuated the effects of SNI on depressive-like behavior and reduced frontal cortex IL-1β protein levels in socially isolated animals. Conversely, pair-housed animals treated with a selective oxytocin receptor antagonist developed depressive-like behavior equivalent to that of socially isolated animals and displayed increased IL-1β protein levels within the frontal cortex.

Conclusion: These data suggest that social interaction significantly alters the affective and neuroinflammatory responses to SNI through a mechanism that could involve oxytocin.

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Depressive Symptoms and Mortality in Patients After Kidney Transplantation: A Prospective Prevalent Cohort Study 12 Jul 2010

Objective: To analyze in a prospective cohort study if depressive symptoms are an independent predictor of mortality in kidney transplant recipients.

Methods: Data from 840 transplanted patients followed at a single outpatient transplant center were analyzed. Sociodemographic parameters and clinical data were collected at enrollment (between August 2002 and February 2003). Participants completed the Center for Epidemiologic Studies-Depression (CES-D) scale. Depression was defined as CES-D score of ≥18. Data on 5-year outcomes (death censored graft loss or mortality) were collected.

Results: The prevalence of depression was 22%. Mortality was higher (21% versus 13%; p = .004) in patients with versus without depression. In a multivariate Cox proportional hazard model, both the baseline CES-D score (hazard ratio_{for each 1-point increase} = 1.02; 95% confidence interval, 1.00–1.04) and the presence of depression at baseline (hazard ratio_presence = 1.66; 95% confidence interval, 1.12–2.47) were significantly associated with mortality. The baseline CES-D score also significantly predicted death censored graft loss (hazard ratio_{for each 1-point increase} = 1.03; 95% confidence interval, 1.01–1.05).

Conclusion: Depressive symptoms are an independent predictor of mortality in kidney transplanted patients.

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Evidence of Early Retinal Microvascular Changes in Patients With Type 2 Diabetes and Depression 12 Jul 2010

Objective: To examine retinal vascular caliber, an indicator of early microvascular disease and depression in patients with Type 2 diabetes.

Methods: We conducted a clinic-based study, comparing participants with Type 2 diabetes with major depression (n = 43), without depression (n = 49), and healthy controls without diabetes or depression (n = 54). Retinal vascular caliber was measured from digital photographs. Depression status was determined, using standardized clinical assessment.

Results: After adjusting for age and gender, participants with diabetes and depression had larger arteriolar and venular calibers (147.7 µm for arteriolar and 215.7 µm for venular calibers) than participants with diabetes but without depression (143.3 µm and 213.9 µm) and healthy controls (135.8 µm and 202.5 µm, p for trend = .002 for arteriolar and p = .02 for venular caliber). In multivariate models adjusting for duration of diabetes, systolic blood pressure, cigarette smoking, serum glucose, Cerebrovascular Risk Factor Scale, Cumulative Illness Rating Scale, and retinopathy levels, this relationship remained significant for retinal arterioles (p = .02) but not for retinal venules (p = .10).

Conclusions: These data show that patients with Type 2 diabetes with major depression have wider retinal arterioles, supporting the concept that depression is associated with early microvascular changes in Type 2 diabetes.

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Polysomnographic and Subjective Profiles of Sleep Continuity Before and After Mindfulness-Based Cognitive Therapy in Partially Remitted Depression 12 Jul 2010

Objectives: To examine whether mindfulness meditation (MM) was associated with changes in objectively measured polysomnographic (PSG) sleep profiles and to relate changes in PSG sleep to subjectively reported changes in sleep and depression within the context of a randomized controlled trial. Previous studies have indicated that mindfulness and other forms of meditation training are associated with improvements in sleep quality. However, none of these studies used objective PSG sleep recordings within longitudinal randomized controlled trials of naïve subjects.

Methods: Twenty-six individuals with partially remitted depression were randomized into an 8-week Mindfulness-Based Cognitive Therapy (MBCT) course or a waitlist control condition. Pre-post measurements included PSG sleep studies and subjectively reported sleep and depression symptoms.

Results: According to PSG sleep, MM practice was associated with several indices of increased cortical arousal, including more awakenings and stage 1 sleep and less slow-wave sleep relative to controls, in proportion to amount of MM practice. According to sleep diaries, subjectively reported sleep improved post MBCT but not above and beyond controls. Beck Depression Inventory scores decreased more in the MBCT group than controls. Improvements in depression were associated with increased subjective sleep continuity and increased PSG arousal.

Conclusions: MM is associated with increases in objectively measured arousal during sleep with simultaneous improvements in subjectively reported sleep quality and mood disturbance. This pattern is similar to the profiles of positive responders to common antidepressant medications.

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Self-Rated Versus Objective Health Indicators as Predictors of Major Cardiovascular Events: The NHLBI-Sponsored Women's Ischemia Syndrome Evaluation 12 Jul 2010

Objective: To determine the association between self-rated health and major cardiovascular events in a sample of women with suspected myocardial ischemia. Previous studies showed that self-rated health is a predictor of objective health outcomes, such as mortality.

Method: At baseline, 900 women rated their health on a 5-point scale ranging from poor to excellent as part of a protocol that included quantitative coronary angiography, cardiovascular disease (CVD) risk factor assessment, cardiac symptoms, psychotropic medication use, and functional impairment. Participants were followed for a maximum of 9 years (median, 5.9 years) to determine the prevalence of major CVD events (myocardial infarction, heart failure, stroke, and CVD-related death).

Results: A total of 354 (39.3% of sample) participants reported their health as either poor or fair. After adjusting for demographic factors, CVD risk factors, and coronary artery disease severity, women who rated their health as poor (hazard ratio, 2.1 [1.1-4.2]) or fair (hazard ratio, 2.0 [1.2-3.6]) experienced significantly shorter times to major CVD events compared with women who rated their health as excellent or very good. Further adjustment for functional impairment, however, attenuated the self-rated health relationships with major CVD events.

Conclusions: Among women with suspected myocardial ischemia, self-rated health predicted major CVD events independent of demographic factors, CVD risk factors, and angiogram-defined disease severity. However, functional impairment seemed to explain much of the self-rated health association. These results support the clinical utility of self-rated health scores in women and encourage a multidimensional approach to conceptualizing these measures.

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Hostility, Anger Control, and Anger Expression as Predictors of Cardiovascular Disease 12 Jul 2010

Objective: To examine in a prospective setting whether different hostility measures, including Cynical Distrust, Trait Anger, Anger Out, Anger In, and Anger Control, are related to cardiovascular disease (CVD) and ischemic heart disease (IHD).

Methods: Participants comprised 25- to 74-year-old men (n = 3850) and women (n = 4083), followed up for 10 to 15 years. Trait Anger, Anger Out, Anger In, and Anger Control were assessed with the Spielberger State-Trait Anger Expression Inventory and Cynical Hostility with the Cynical Distrust Scale. Incident CVD and IHD were derived from hospital records/death certificates. Subjects with a history of CVD or IHD at baseline were excluded.

Results: Subjects in the lowest Anger Control tertile had a higher risk of first nonfatal and fatal CVD incidence (relative risk [RR], 1.35; 95% confidence interval [CI], 1.06-1.73) than subjects in the highest tertile after adjustment for age, gender, education, marital status, smoking, body mass index, blood pressure, cholesterol, alcohol consumption, and depressive symptoms. Higher Cynical Distrust scores predicted nonfatal and fatal CVD (RR, 1.31; 95% CI, 1.09-1.56) and IHD (RR, 1.37; 95% CI, 1.08-1.74) events after adjustment for age, but these associations disappeared after further adjustment for gender, education, and marital status. Other hostility measures, i.e., Trait Anger, Anger Out, or Anger In, were not related to CVD or IHD outcomes.

Conclusions: This is the first study to show that compared with four other hostility dimensions, low Anger Control predicts CVD events. Further studies should examine whether Anger Control is specific to anger or reflects more general psychosocial factors.

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Prognostic Association of Anxiety Post Myocardial Infarction With Mortality and New Cardiac Events: A Meta-Analysis 12 Jul 2010

Objective: To assess the association of anxiety after myocardial infarction (MI) with cardiac prognosis.

Methods: A meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975–March 2009) was performed without language restrictions. End point was cardiac outcome defined as all-cause mortality, cardiac mortality, and cardiac events. The authors selected prospective studies with at least 6 months follow-up, and anxiety had to be assessed within 3 months after MI with reliable and valid instruments.

Results: Twelve papers met selection criteria. These studies described follow-up (on average, 2.6 years) of 5750 patients with MI. Anxious patients were at risk of adverse events (odds ratio (OR) fixed, 1.36; 95% confidence interval (CI), 1.18–1.56; p < .001). Anxiety was also specifically associated with all-cause mortality (OR fixed, 1.47; 95% CI, 1.02–2.13; p = .04), cardiac mortality (OR fixed, 1.23; 95% CI, 1.03–1.47; p = .02), and new cardiac events (OR fixed, 1.71; 95% CI, 1.31–2.23; p < .001).

Conclusions: Post-MI anxiety is associated with a 36% increased risk of adverse cardiac outcomes in bivariate analyses. Because the existing literature is small and contains several limitations, more research is needed to evaluate the association of anxiety and prognosis in patients with MI and to assess the extent to which this association is independent of clinical variables, such as disease severity, and other psychological variables, especially depression.

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Prolonged Cardiac Effects of Momentary Assessed Stressful Events and Worry Episodes 12 Jul 2010

Objectives: To test the hypothesize that increased heart rate (HR) and decreased heart rate variability (HRV) are not only due to concurrent stressful events and worries but also to stressors and worries occurring in the preceding hours or stressors anticipated to occur in the next hour. Worry was expected to mediate at least part of the prolonged effects of stressors.

Methods: Ambulatory HR and HRV of 73 teachers were recorded for 4 days, during which the participants reported occurrence and duration of worry episodes and stressful events on an hourly basis, using computerized diaries. Multilevel regression models were used, accounting for effects of several biobehavioral variables.

Results: Stressful events were not associated with changes in HR or HRV. However, worry episodes had effects on concurrent HR and HRV (2.55 beats/minute; –5.76 milliseconds) and HR and HRV in the succeeding hour (3.05 beats/minute; –5.80 milliseconds) and 2 hours later (1.52 beats/minute; –3.14 milliseconds). These findings were independent of emotions, physical activity, posture, and other biobehavioral factors.

Conclusion: Worry has effects on cardiac activity, and these effects were still visible after 2 hours. The latter finding suggests that a considerable part of prolonged activation may be induced by unconscious stress-related cognition.

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It's More than Sex: Exploring the Dyadic Nature of Sleep and Implications for Health 12 Jul 2010

Sleep is a critical health behavior and one that is typically shared between husbands and wives or romantic partners. However, the science of sleep has traditionally conceptualized and evaluated sleep at the level of the individual. Considering the social context of sleep represents a significant shift in sleep research and also offers a critical opportunity for investigating sleep as a novel pathway linking close relationships with health. The purpose of this review is to integrate research that focuses on how sleep affects or is affected by close relationship functioning and to provide a heuristic framework for understanding the interface between close relationships, sleep, and health. Exploring the links between close relationships and sleep may contribute to our understanding of why some relationships confer health benefits, whereas others confer health risks.

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Confirmatory Factor Analysis: An Introduction for Psychosomatic Medicine Researchers 12 Jul 2010

We present an introduction to the basic concepts essential to understanding confirmatory factor analysis (CFA). We initially discuss the underlying mathematical model and its graphical representation. We then show how parameters are estimated for the CFA model based on the maximum likelihood function. Finally, we discuss several ways in which model fit is evaluated as well as introduce the concept of model identification. In our presentation, we use an example to illustrate the application of CFA to psychosomatic research and touch on the more general role of structural equation modeling in psychosomatic research.

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LOW-CALORIE DIETING AND DIETERS' CORTISOL LEVELS: DON'T FORGET CORTISONE 12 Jul 2010

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THE AUTHORS REPLY 12 Jul 2010

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