Antidepressant treatment and blood pressure control in patients with comorbid depression and treatment resistant hypertension.

BACKGROUND: Though inconsistent, the majority of studies support an association between depression and incident hypertension and poor blood pressure control. However, none have investigated whether antidepressant medication (ADM) therapy is associated with blood pressure control in patients with comorbid depression and treatment resistant hypertension. METHODS: Optum® de-identified Electronic Health Record data (2010-2018) were used to create a retrospective cohort of patients (≥18 years of age) with comorbid depression and treatment resistant hypertension. Patients were categorized into adequate ADM, inadequate ADM and no ADM treatment. A modified Poisson regression approach with robust error variance was used to estimate the association between ADM status and blood pressure control before and after adjusting for covariates. RESULTS: Patients were, on average, 55.7 (SD ± 9.9) years of age, 63.9% were female, 76.2% were white and 19.2% Black race. In crude models, inadequate ADM (RR = 1.06; 95%CI:1.01-1.11) and adequate ADM (RR = 1.08; 95%CI:1.03-1.14), compared to no ADM treatment, were associated with blood pressure control. After adjusting for covariates this relationship was attenuated and no longer significant. CONCLUSIONS: The modest association between ADM therapy and blood pressure control in patients with treatment resistant hypertension is largely explained by traditional risk factors for hypertension such as obesity and older age. Treating depression is not a robust factor in blood pressure control among those with treatment resistant hypertension.

Prescribing Patterns and Use of Risk-Reduction Tools After Implementing an Opioid-Prescribing Protocol.

BACKGROUND: The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted. METHODS: Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ2 and t-tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized. RESULTS: The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation (P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines. CONCLUSIONS: Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia.

OBJECTIVE: Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population. DESIGN: Retrospective cohort. SETTING AND SUBJECTS: Medical record data obtained from 38,976 patients, ≥18 years of age with a primary care encounter between July 1, 2008, to June 30, 2016. METHODS: International Classification of Diseases-9 codes were used to define fibromyalgia, psychiatric diagnoses, and conditions associated with chronic pain. Unadjusted associations between patient demographics, comorbid conditions, and fibromyalgia were computed using binary logistic regression for the entire cohort and separately by gender. RESULTS: Overall, 4.6% of the sample had a fibromyalgia diagnosis, of whom 76.1% were women. Comorbid conditions were more prevalent among patients with vs without fibromyalgia. Depression and arthritis were more strongly related to fibromyalgia among women (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 2.50-3.13; and OR = 5.19, 95% CI = 4.62-5.84) compared with men (OR = 2.16, 95% CI = 1.71-2.71; and (OR = 3.91, 95% CI = 3.22-4.75). The relationship of fibromyalgia and other diagnoses did not significantly differ by gender. CONCLUSIONS: Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care.

Antidepressants and Incident Hypertension in Primary Care Patients.

OBJECTIVE: Many ADMs can alter blood pressure (BP), but the research on the effect of antidepressant medication (ADMs) on incident hypertension is mixed. We investigated whether the use of ADMs was associated with the subsequent development of hypertension. METHODS: A retrospective cohort study was conducted using electronic medical record data from 6224 patients with primary care visits from 2008 to 2015. Prescription orders were used to identify ADM use, and hypertension was defined by medical record diagnosis. Using package insert warnings, a 3-level ADM exposure variable was created: ADMs that increase BP (ADM BP+), ADMs that do not increase BP, and no ADM. Unadjusted and adjusted Cox proportional hazard models were computed to estimate the association between the ADM exposure and incident hypertension. RESULTS: Unadjusted results revealed that ADM BP+ use compared with the no ADM group was significantly associated with incident hypertension (hazard ratio, 1.30; 95% confidence interval, 1.08-1.57). After adjusting for covariates, ADM BP+ use was no longer significantly associated with incident hypertension (hazard ratio, 1.20; 95% confidence interval, 0.97-1.49). CONCLUSIONS: Commonly used ADMs were not associated with incident hypertension after controlling for other factors associated with ADM use and hypertension. Research on potential dose and duration effects is warranted.

Cardiomyopathy: An Overview.

The definition and classification of cardiomyopathy have evolved considerably in recent years. Cardiomyopathy can be separated into primary (genetic, mixed, or acquired) and secondary categories, which result in varied phenotypes including dilated, hypertrophic, and restrictive patterns. Hypertrophic cardiomyopathy is the most common primary cardiomyopathy and can cause exertional dyspnea, presyncope, atypical chest pain, heart failure, and sudden cardiac death. Dilated cardiomyopathy can be genetic or acquired and typically presents with classic symptoms of heart failure with reduced ejection fraction. Restrictive cardiomyopathy is much less common and often associated with systemic disease. Family physicians should be alert for acquired variants of cardiomyopathy, including peripartum and stress-induced cardiomyopathy, as well as rare variants, such as arrhythmogenic right ventricular dysplasia and left ventricular noncompaction. In addition to history and physical examination, diagnosis of cardiomyopathy includes electrocardiography and echocardiography testing. Treatment may include appropriately staged therapy for heart failure, appropriate activity restriction, evaluation for implantable cardioverter-defibrillator placement, and consideration of heart transplantation in refractory cases. Genetic testing of families is an emerging modality with some potential to augment traditional screening performed by family physicians.