Interrelationships between symptom burden and health functioning and health care utilization among veterans with persistent physical symptoms.

BACKGROUND: Between 10 and 50% of primary care patients present with persistent physical symptoms (PPS). Patients with PPS tend to utilize excessive or inappropriate health care services, while being stuck in a deleterious cycle of inactivity, deconditioning, and further worsening of symptoms and disability. Since military deployment (relative to non-deployment) is associated with greater likelihood of PPS, we examined the interrelationships of health care utilization, symptom burden and functioning among a sample of recently deployed Veterans with new onset persistent physical symptoms. METHODS: This study analyzed a cohort of 790 U.S. soldiers who recently returned from deployment to Iraq or Afghanistan. Data for this analysis were obtained at pre- and post-deployment. We used moderation analyses to evaluate interactions between physical symptom burden and physical and mental health functioning and four types of health care utilization one-year after deployment, after adjusting for key baseline measures. RESULTS: Moderation analyses revealed significant triple interactions between physical symptom burden and health functioning and: primary care (F = 3.63 [2, 303], R2Δ = .02, p = 0.03), specialty care (F = 6.81 [2, 303] R2Δ =0.03, p < .001), allied therapy care (F = 3.76 [2, 302], R2Δ = .02, p = 0.02), but not mental health care (F = 1.82 [1, 303], R2Δ = .01, p = .16), one-year after deployment. CONCLUSIONS: Among U.S. Veterans with newly emerging persistent physical symptoms one-year after deployment, increased physical symptom burden coupled with decreased physical and increased mental health functioning was associated with increased medical care use in the year after deployment. These findings support whole health initiatives aimed at improving health function/well-being, rather than merely symptom alleviation.

Resilience during war: Better unit cohesion and reductions in avoidant coping are associated with better mental health function after combat deployment.

OBJECTIVE: The majority of individuals who endure traumatic events are resilient; however, we do not yet understand why some individuals are more resilient than others. We used data from a prospective longitudinal study Army National Guard and Reserve personnel to examine how unit cohesion (military-specific social support) and avoidant coping relate to resilience over the first year after return from deployment. METHOD: Soldiers (N = 767) were assessed at 4 phases: predeployment (P1), immediately postdeployment (P2), 3 months' postdeployment (P3), and 1-year postdeployment (P4). RESULTS: After controlling for predeployment avoidant coping and overall social support, higher unit cohesion was associated with a reduction in avoidant coping (from P1 to P3). This reduction in avoidant coping (from P1 to P3) mediated the relationship between unit cohesion (P2) and improvement in mental health function (from P1 to P3). CONCLUSIONS: The results are consistent with the hypothesis that higher unit cohesion may mitigate increases in avoidant coping in military personnel after a combat deployment and in turn may improve mental health function. (PsycINFO Database Record

The influence of psychological variables on health-related quality of life among HIV-positive individuals with a history of intravenous drug use.

OBJECTIVE: Intravenous drug use (IDU) remains a prominent pathway of HIV transmission in the United States, though little is known about modifiable factors influencing quality of life among IDUs. The goal of this study was to evaluate the influence of psychological variables (e.g., depression and anxiety) on health-related quality of life among HIV-positive individuals with a history of IDU who were enrolled in outpatient treatment for opioid dependence. METHOD: 108 HIV-positive individuals with a history of IDU and participating in current outpatient treatment for opiate dependence who were screened for participation in a depression and adherence study reported sociodemographic data, depressive and anxiety symptoms, and health-related quality of life (HRQoL; Multidimensional Health Assessment using the ACTG-SF 21). RESULTS: Multiple regression models controlling for disease stage and background characteristics identified significant negative relationships between General Health Perception and Functioning without Pain for anxiety and depression, and between Role Functioning and Physical Functioning for anxiety. CD4 cell count was significantly related to Physical Functioning only. CONCLUSIONS: Results indicate that distress (both depression and anxiety) contribute significantly to variation in HRQoL over and above the effects of disease variables. Effective depression and anxiety treatment may result in improved overall functioning.

Cognitive-behavioral therapy for the treatment of depression and adherence in patients with type 1 diabetes: pilot data and feasibility.

OBJECTIVE: Depression is one of the most common psychological problems affecting individuals with type 1 diabetes, and it is associated with treatment nonadherence and worse clinical outcomes. The research on treating depression or nonadherence in adults with type 1 diabetes is limited. We adapted an evidence-supported treatment, individual cognitive-behavioral therapy for adherence and depression (CBT-AD), for type 1 diabetes and examined its feasibility, acceptability, and potential for an effect. METHOD: The pilot study included 9 patients with a DSM-IV diagnosis of major depression, dysthymia, or residual depressive symptoms despite treatment with an antidepressant; a diagnosis of type 1 diabetes per patient self-report; and a glycosylated hemoglobin A1c (HbA1c) level of 8.0% or greater. Patients were referred by their diabetes care providers to a behavioral medicine specialty setting and received 10 to 12 sessions of CBT-AD. Main outcome measures included percent of eligible participants who enrolled in the study, session attendance, independently-rated Montgomery-Asberg Depression Rating Scale (MADRS) score, self-reported adherence to diabetes care activities, and adherence to self-monitoring of blood glucose levels. Data were collected from June 27, 2008, through March 31, 2010. RESULTS: There was a clinically meaningful decrease in depression severity (mean [SD] MADRS score decrease from 26.0 [4.73] to 12.3 [7.37], Cohen d = 2.90), demonstrated improvements in diabetes self-care (increase in blood glucose monitoring from 65.0 [26.72] to 82.7 [22.75], Cohen d = -0.66, and a difference in self-reported percent insulin doses in the past 2 weeks from 77.1 [29.84] to 87.1 [23.6], Cohen d = -0.34), and possible improvement in glycemic control (decrease in HbA1c levels from 9.6 [1.32] to 9.0 [1.04], Cohen d = 0.45). CONCLUSIONS: These preliminary results provide evidence for the acceptability, feasibility, and potential utility of CBT-AD for patients with type 1 diabetes and depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01527981.

A review of treating depression in diabetes: emerging findings.

BACKGROUND: Depression in patients with diabetes is associated with poorer adherence and worse health outcomes, however treating depression may help improve these outcomes. OBJECTIVE: The present systematic review identified published papers to evaluate treatments for depression in patients with diabetes. RESULTS: Seventeen studies that met criteria were identified, indicating that psychosocial interventions, particularly cognitive-behavior therapy, anti-depressant medications, and collaborative care are effective in the treatment of depression in patients with diabetes. CONCLUSION: Evidence for the efficacy of these interventions in improving glycemic control was mixed. No study targeted adherence to treatment or health behaviors in addition to depression, which may be necessary to maximize improvement in diabetes outcomes such as glycemic control.

Perceived impact of diabetes genetic risk testing among patients at high phenotypic risk for type 2 diabetes.

OBJECTIVE: Rapid advances in diabetes genetic epidemiology may lead to a new era of "personalized medicine" based on individual genetic risk assessment. There is minimal experience to guide how best to clinically implement such testing so that results (e.g., "higher" or "lower" relative genetic risk) improve rather than reduce patient motivation for behavior change. RESEARCH DESIGN AND METHODS: Between November 2009 and May 2010, we conducted in-depth interviews with 22 overweight participants at high phenotypic risk for type 2 diabetes to explore perceptions of diabetes genetic risk testing compared with currently available prediction using nongenetic risk factors (e.g., family history, abnormal fasting glucose, obesity). We used hypothetical scenarios to specifically investigate the impact of both "higher" and "lower" relative genetic risk results on participants' views about diabetes prevention. RESULTS: Many participants conferred a unique value on personal genetic risk information relative to nongenetic risk based on the perceived scientific certainty and durability of genetic results. In contrast, other participants considered their genetic risk within the overall context of their other measured risk factors. Reactions to diabetes genetic test results differed by current motivation levels. Whereas most subjects reported that "higher" risk results would motivate behavior change, subjects with lower current motivation often reported that "lower" genetic risk results would further reduce their motivation to engage in diabetes prevention behaviors. CONCLUSIONS: To be effective, future clinical implementation of type 2 diabetes genetic risk testing should be individualized based on each patient's risk perception and current level of motivation to prevent diabetes.

Childhood sexual abuse and health risk behaviors in patients with HIV and a history of injection drug use.

Childhood sexual abuse (CSA) is related to poorer health outcomes, associated with increased risk for HIV acquisition, and prevalent among HIV risk groups. Links between CSA and health behavior are an important health concern. We examined the relationship between CSA and transmission risk behavior and medication adherence in 119 HIV-infected individuals with an injection drug use history. 47% reported CSA, with no gender difference. Individuals who experienced CSA were more likely to report sexual HIV transmission risk behavior in the past 6 months, more sexual partners, use of heroin in the past 30 days, and worse adherence to HIV medication than those who did not. These findings confirm that rates of CSA are high in this population, and suggest that a history of CSA may place people managing both HIV and opioid dependence at increased risk for HIV transmission, poor adherence to medication, and vulnerability to substance use relapse.

The exercise and affect relationship: evidence for the dual-mode model and a modified opponent process theory.

This study examined the relationship between exertion level and affect using the framework of opponent-process theory and the dual-mode model, with the Activation-Deactivation Adjective Checklist and the State Anxiety Inventory among 14 active and 14 sedentary participants doing 20 min of treadmill exercise at speeds of 5% below, 5% above, and at lactate threshold (LT). We found a significant effect of time, condition, Time × Condition, and Time × Group, but no group, Group × Condition, or Time × Group × Condition effects, such that the 5% above LT condition produced a worsening of affect in-task compared with all other conditions whereas, across conditions, participants experienced in-task increases in energy and tension, and in-task decreases in tiredness and calmness relative to baseline. Posttask, participants experienced mood improvement (decreased tension, anxiety, and increased calmness) across conditions, with a 30-min delay in the above LT condition. These results partially support the dual-mode model and a modified opponent-process theory.

Psychopathology in the young offspring of parents with bipolar disorder: a controlled pilot study.

Studies have suggested that the offspring of parents with bipolar disorder are at risk for a spectrum of psychopathology, but few have focused on children in the youngest age ranges or examined the impact of comorbid parental disorders. We utilized a pre-existing sample of young (mean age: 6.8 years) offspring of parents with bipolar disorder (n=34), of parents with panic or major depression (n=179), and of parents with neither mood or anxiety disorder (n=95). Children were assessed blindly to parental diagnoses using the Schedule for Affective Disorders and Schizophrenia-Epidemiologic version (K-SADS-E). Offspring of bipolar parents had significantly higher rates of disruptive behavior and anxiety disorders than offspring from both of the comparison groups, accounted for by elevated rates of ADHD and overanxious disorder. These comparisons were significant even when lifetime histories of the corresponding categories of comorbid disorders in the parents (disruptive behavior disorders and anxiety disorders) were covaried. In addition, offspring of bipolar parents had increased rates of bipolar I disorder, compared with psychiatric controls. Results support the hypotheses of elevated behavior, anxiety, and mood disorders among offspring at risk for bipolar disorder, and suggest that this psychopathology is already evident in early childhood.

Absence of gender differences in pediatric bipolar disorder: findings from a large sample of referred youth.

BACKGROUND: Because little is known about gender differences in pediatric bipolar disorder, we evaluated whether gender moderates the expression of pediatric bipolar disorder in a large clinical sample. METHODS: Subjects were consecutively referred youth aged 18 years or less who met full criteria for DSM-III-R bipolar disorder (BPD) (females, n=74; BD males, n=224). All subjects were assessed with a structured diagnostic interview and measures of psychosocial and family functioning. RESULTS: Most of the bipolar subjects (91% of males, 70% of females) also had ADHD. Bipolar disorder was equally prevalent in both genders. Among females and males, severe irritability (83% and 80%, respectively), mixed presentation (87% and 84%, respectively), chronic course (84% and 77%, respectively) and prepubertal onset (78% and 93%, respectively) predominated the clinical picture. We found no meaningful differences between genders in the number of BPD symptoms, type of treatment for BPD (counseling, medication, hospitalization), severity of educational deficits, severity of family and interpersonal functioning or patterns of psychiatric comorbidity. CONCLUSIONS: Because gender does not moderate the clinical expression of pediatric bipolar disorder, our data does not suggest that gender specific criteria for the disorder are warranted.