Factors Associated With Diabetes Care Quality Among Patients With Schizophrenia in Ontario, Canada.

OBJECTIVE: The authors investigated demographic, clinical, and service-utilization factors that affected the quality of diabetes care among patients with schizophrenia. METHODS: This was a retrospective cohort study of adults with schizophrenia and diabetes (N=26,259) in Ontario, Canada. Quality of care was based on receipt of three guideline-concordant diabetes care procedures between 2011 and 2013. A cumulative logit regression model was used to determine characteristics associated with optimal testing. RESULTS: Factors associated with optimal diabetes testing included more frequent outpatient psychiatrist visits (odds ratio [OR]=1.28, 95% confidence interval [CI]=1.20-1.37) and primary care visits for nonmental health reasons (OR=2.10, 95% CI=1.85-2.39). High-frequency primary care visits for mental health reasons, any hospitalizations, and emergency visits for mental health reasons were associated with lower odds of testing. CONCLUSIONS: Diabetes quality of care may be contingent on receipt of medically focused primary care, psychiatric stability, and receipt of specialist psychiatric care.

Impact of prior treatment on remission with intermittent theta burst versus high-frequency repetitive transcranial magnetic stimulation in treatment resistant depression.

BACKGROUND: Multiple prior treatment failures are associated with reduced rates of remission to subsequent antidepressant treatment, including rTMS. The degree of treatment resistance that is especially predictive of inferior outcome is uncertain. Intermittent theta burst stimulation (iTBS) is a newer form of rTMS where less is known regarding clinical predictors of remission. The THREE-D study demonstrated that iTBS is non-inferior to 10 Hz rTMS for the treatment of depression. OBJECTIVE: Determine if the number and type of prior pharmacotherapy trials affect the rate of remission with two types of rTMS. METHOD: Compare remission rates based on prior pharmacotherapy using data from the THREE-D trial (NCT01887782). RESULTS: No differences in remission rates were noted between the three levels of treatment resistance, however, participants with 3 compared to <3 treatment failures had lower rates of remission: 17.3% versus 29.4% (χ2 4.87; df = 1; p = 0.03). CONCLUSIONS: Three or more treatment failures may be associated with lower remission rates with rTMS.

Clinical Predictors of Extrapyramidal Symptoms Associated With Aripiprazole Augmentation for the Treatment of Late-Life Depression in a Randomized Controlled Trial.

OBJECTIVE: Augmentation with aripiprazole is an effective pharmacotherapy for treatment-resistant late-life depression (LLD). However, aripiprazole can cause extrapyramidal symptoms (EPS) such as akathisia and parkinsonism; these symptoms are distressing and can contribute to treatment discontinuation. We investigated the clinical trajectories and predictors of akathisia and parkinsonism in older patients receiving aripiprazole augmentation for treatment-resistant LLD. METHODS: Between 2009 and 2013, depressed older adults who did not remit with venlafaxine were randomized to aripiprazole or placebo in a 12-week trial. Participants were 60 years or older and met DSM-IV-TR criteria for major depressive episode with at least moderate symptoms. The presence of akathisia and parkinsonism was measured at each visit using the Barnes Akathisia Scale (BAS) and Simpson-Angus Scale (SAS), respectively. In an exploratory analysis, we examined a broad set of potential clinical predictors and correlates: age, sex, ethnicity, weight, medical comorbidity, baseline anxiety severity, depression severity, concomitant medications including rescue medications, and aripiprazole dosage. RESULTS: Twenty-four (26.7%) of 90 participants randomized to aripiprazole and who had akathisia scores available developed akathisia compared to 11 (12.2%) of 90 randomized to placebo. Greater depression severity was the main predictor of treatment-emergent akathisia. Most participants who developed akathisia improved over time, especially with reductions in dosage. Fifteen (16.5%) of 91 participants taking aripiprazole and who had parkinsonism scores available developed parkinsonism, but no clinical predictors or correlates were identified. CONCLUSIONS: Akathisia is a common side effect of aripiprazole, but it is typically mild and responds to dose reduction. Patients with greater baseline depression may warrant closer monitoring for akathisia. More research is needed to understand the course and predictors of treatment-emergent EPS with antipsychotic augmentation for treatment-resistant LLD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00892047.

An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Co-morbid Pain and Depressive Symptoms.

PURPOSE: Review recent meta-analyses and clinical trials investigating the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) for concurrent pain and depressive symptoms. RECENT FINDINGS: Recent meta-analyses have included both pain and depression outcomes in fibromyalgia and chronic pain. Randomized controlled trials have also been conducted in post-herpetic neuralgia, trauma-related headache, and neuropathic pain with attention to both pain and depressive symptoms. In general, studies have demonstrated reduction in pain in patients with fibromyalgia as an add-on treatment, post-herpetic neuralgia, trauma-related headache, and neuropathic pain. There are variable findings for reduction in depressive symptoms in patients with co-morbid pain disorders. Theta burst stimulation (TBS) is a novel rTMS protocol that has recently been investigated in patients with depression and some smaller trials in patients with co-morbid pain disorders. These emerging treatment options may have similar or greater therapeutic potency and may be delivered with greater efficiency. There is evidence to support the use of rTMS for its analgesic effects in various pain syndromes. The variable results between trials for treatment of concurrent depressive symptoms may be due to heterogeneity in treatment protocols including parameters such as site of stimulation (primary motor cortex versus dorsolateral prefrontal cortex) and restrictions in the patient population which usually exclude primary psychiatric diagnoses. Future trials should work to standardize these protocols, investigate novel protocols like TBS, and continue to include standardized assessment of concurrent psychiatric outcomes such as depression and anxiety.

Impact of Prior Treatment on Remission of Late-Life Depression with Venlafaxine and Subsequent Aripiprazole or Placebo Augmentation.

OBJECTIVE: Treatment history can inform clinical decisions about subsequent treatment choices. The authors examined the impact of prior antidepressant treatment on treatment outcomes with venlafaxine only and then with augmentation with aripiprazole or placebo in depressed older adults. METHODS: The authors analyzed outcome data from a randomized, placebo-controlled clinical trial of aripiprazole augmentation in depressed older adults. The study consisted of an open-label lead-in phase with venlafaxine XR, followed by a placebo-controlled phase of aripiprazole augmentation. Treatment history was assessed with the Antidepressant Treatment History Form. RESULTS: Documented prior treatment failure predicted a reduced remission rate with venlafaxine. However, aripiprazole augmentation was efficacious in those with prior treatment failure (42.6% remission with aripiprazole versus 25.8% with placebo; χ(2) = 3.87 df = 1, p = 0.049). CONCLUSION: Aripiprazole augmentation is an efficacious strategy in older depressed adults who fail to remit with two or more adequate antidepressant trials, including a course of venlafaxine.

A Review of Brain Stimulation Treatments for Late-Life Depression.

Opinion Statement Recurrence, relapse and resistance to first-line therapies are common and pervasive issues in the treatment of depression in older adults. As a result, brain stimulation modalities are essential treatment options in this population. The majority of data for the effectiveness of brain stimulation modalities comes from electroconvulsive therapy (ECT) studies. Current ECT trials are focused on prolonging response after a successful course and mitigating the cognitive adverse effects. Newer forms of brain stimulation have emerged; unfortunately, as with most advances in medicine older adults have not been systematically included in clinical trials. Repetitive transcranial magnetic stimulation has demonstrated efficacy in younger adults and there is emerging data to support its use in late-life depression (LLD). It will be imperative that older adults be included in future transcranial direct current stimulation and magnetic seizure therapy clinical trials. Unclear efficacy results are a concern for both vagus nerve stimulation and deep brain stimulation.

Determining risk for out-of-hospital cardiac arrest by location type in a Canadian urban setting to guide future public access defibrillator placement.

STUDY OBJECTIVE: Automated external defibrillator use by lay bystanders during out-of-hospital cardiac arrest rarely occurs but can improve survival. We seek to estimate risk for out-of-hospital cardiac arrest by location type and evaluate current automated external defibrillator deployment in a Canadian urban setting to guide future automated external defibrillator deployment. METHODS: This was a retrospective analysis of a population-based out-of-hospital cardiac arrest database. We included consecutive public location, nontraumatic, out-of-hospital cardiac arrests occurring in Toronto from January 1, 2006, to June 30, 2010, captured in the Resuscitation Outcomes Consortium Epistry database. Two investigators independently categorized each out-of-hospital cardiac arrest and automated external defibrillator location into one of 38 categories. Total site counts in each location category were used to estimate average annual per-site cardiac arrest incidence and determine the relative automated external defibrillator coverage for each location type. RESULTS: There were 608 eligible out-of-hospital cardiac arrest cases. The top 5 location categories by average annual out-of-hospital cardiac arrests per site were race track/casino (0.67; 95% confidence interval [CI] 0 to 1.63), jail (0.62; 95% CI 0.3 to 1.06), hotel/motel (0.15; 95% CI 0.12 to 0.18), hostel/shelter (0.14; 95% CI 0.067 to 0.19), and convention center (0.11; 95% CI 0 to 0.43). Although schools were relatively lower risk for cardiac arrest, they represented 72.5% of automated external defibrillator-covered locations in the study region. Some higher-risk location types such as hotel/motel, hostel/shelter, and rail station were severely underrepresented with respect to automated external defibrillator coverage. CONCLUSION: We have identified types of locations with higher per-site risk for cardiac arrest relative to others. We have also identified potential mismatches between cardiac arrest risk by location type and registered automated external defibrillator distribution in a Canadian urban setting.