Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease.

BACKGROUND: There is conflicting evidence as to the impact of mental health treatment on outcomes in patients with heart disease. The aim of this study was to examine whether individuals who received mental health treatment for anxiety or depression after being hospitalized for ischemic disorders or heart failure had a reduced frequency of rehospitalizations, emergency department visits, or mortality compared with those who did not receive treatment. METHODS AND RESULTS: A population-based, retrospective, cohort design was used to examine the association between psychotherapy or antidepressant medication prescription and health service utilization and mortality in patients with coronary artery disease or heart failure and comorbid anxiety or depression. Those receiving versus not receiving mental health treatment were compared based on the frequency of rehospitalization, emergency department visits, and mortality. The study sample included 1563 patients who had a mean age of 50.1 years. Individuals who received both forms of mental health treatment for anxiety or depression were 75% less likely to be rehospitalized, 74% less likely to have an emergency department visit, and 66% less likely to die from any cause. CONCLUSIONS: Mental health treatment for anxiety or depression has a significant impact on outcomes in patients with cardiovascular disease consisting of reduced hospitalizations, emergency department visits, and in some conditions improved survival.

Integrative Medical Care Plus Mindfulness Training for Patients With Congestive Heart Failure: Proof of Concept.

Congestive heart failure (CHF) has a high rate of morbidity and mortality. It is often accompanied by other medical and psychosocial comorbidities that complicate treatment and adherence. We conducted a proof of concept pilot project to determine the feasibility of providing integrative group medical visits plus mindfulness training for patients recently discharged with CHF. Patients were eligible if they had been discharged from an inpatient stay for CHF within the 12 months prior to the new program. The Compassionate Approach to Lifestyle and Mind-Body (CALM) Skills for Patients with CHF consisted of 8 weekly visits focusing on patient education about medications, diet, exercise, sleep, and stress management; group support; and training in mind-body skills such as mindfulness, self-compassion, and loving-kindness. Over two 8-week sessions, 8/11 (73%) patients completed at least 4 visits. The patients had an average age of 57 years. The most common comorbidities were weight gain, sleep problems, and fatigue. After the sessions, 100% of patients planned to make changes to their diet, exercise, and stress management practices. Over half of the patients who met with a pharmacist had a medication-related problem. Improvements were observed in depression, fatigue, and satisfaction with life. Integrative group visits focusing on healthy lifestyle, support, and skill-building are feasible even among CHF patients and should be evaluated in controlled trials as a patient-centered approach to improving outcomes related to improving medication management, depression, fatigue, and quality of life.

The relationship between sleep and anxiety in older adults.

Anxiety and sleep problems are major barriers to healthy aging and are frequently comorbid conditions in older adults. In the current review, we present recent advances in understanding the extensive overlap among older adults between anxiety and one specific related sleep problem, insomnia. These proposals suggest that anxiety and insomnia may share a common vulnerability to negative emotionality and at times may act as risk factors for each other in older adults. We also highlight developmental shifts in motivation that are likely to impact cognitive-behavioral mechanisms of anxiety and insomnia. Finally, we characterize the current state of treatment for comorbid anxiety and insomnia among older adults and identify future directions for research and clinical practice.

Women and non-cardiac chest pain: gender differences in symptom presentation.

A substantial number of individuals evaluated for complaints of chest pain do not suffer from coronary heart disease (CHD). Studies show that many patients who complain of symptoms that might be caused by CHD, such as shortness of breath or chest pain, may actually have an anxiety disorder. Gender differences in how patients present with these symptoms have not been adequately explored. The purpose of this study was to explore possible gender differences in the presentation of patients with CHD-like symptoms. Two groups were examined, one comprising 6,381 individuals self-referred for electron beam tomography (EBT) studies and a subset of these individuals who defined a "low-risk" group based on the absence of risk factors for CHD and low coronary artery calcium (CAC) scores. We explored gender differences in symptom presentation in each group after controlling for relevant variables by using logistic regression models. These analyses showed that women were significantly more likely than men to endorse CHD symptoms that might also be caused by an anxiety disorder. Women in the low risk group reported CHD symptoms also referable to anxiety more often than men, but unlike men did not complain primarily of chest pain. Women were also more likely to have been prescribed antianxiety or antidepressant medication. In previous studies, non-cardiac chest pain has been considered a hallmark of anxiety in individuals seen in medical settings. This study suggests that in individuals with low risk for CHD chest pain was not related to gender, but other anxiety-related symptoms including heart flutter, lightheadedness, nausea, and shortness of breath were more likely to be reported in women than in men.

Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report.

OBJECTIVE: About half of outpatients with major depressive disorder also have clinically meaningful levels of anxiety. The authors conducted a secondary data analysis to compare antidepressant treatment outcomes for patients with anxious and nonanxious major depression in Levels 1 and 2 of the STAR*D study. METHOD: A total of 2,876 adult outpatients with major depressive disorder, enrolled from 18 primary and 23 psychiatric care sites, received citalopram in Level 1 of STAR*D. In Level 2, a total of 1,292 patients who did not remit with or tolerate citalopram were randomly assigned either to switch to sustained-release bupropion (N=239), sertraline (N=238), or extended-release venlafaxine (N=250) or to continue taking citalopram and receive augmentation with sustained-release bupropion (N=279) or buspirone (N=286). Treatment could last up to 14 weeks in each level. Patients were designated as having anxious depression if their anxiety/somatization factor score from the 17-item Hamilton Depression Rating Scale (HAM-D) was 7 or higher at baseline. Rates of remission and response as well as times to remission and response were compared between patients with anxious depression and those with nonanxious depression. RESULTS: In Level 1 of STAR*D, 53.2% of patients had anxious depression. Remission was significantly less likely and took longer to occur in these patients than in those with nonanxious depression. Ratings of side effect frequency, intensity, and burden, as well as the number of serious adverse events, were significantly greater in the anxious depression group. Similarly, in Level 2, patients with anxious depression fared significantly worse in both the switching and augmentation options. CONCLUSIONS: Anxious depression is associated with poorer acute outcomes than nonanxious depression following antidepressant treatment.

Cardiac anxiety in people with and without coronary atherosclerosis.

Many studies have shown that cardiac anxiety when occurring in the absence of coronary artery disease is common and quite costly. The Cardiac Anxiety Questionnaire (CAQ) is an 18-item self-report measure that assesses anxiety related to cardiac symptoms. To better understand the construct of cardiac anxiety, a factor analysis was conducted on CAQ data from 658 individuals who were self or physician-referred for electron beam tomographic screening to determine whether clinically significant coronary atherosclerosis was present. A four-factor solution was judged to provide the best fit with the results reflecting the following factor composition: heart-focused attention, avoidance of activities that bring on symptoms, worry or fear regarding symptoms, and reassurance-seeking. Factorial invariance across groups was also assessed to determine whether the factor structure of the CAQ was similar in individuals with and without clear evidence of coronary atherosclerosis. The factor structure of the CAQ did not differ between the two groups. However, the group without coronary atherosclerosis had significantly higher mean scores on their attention and worry/fear factors suggesting that people without a diagnosed cardiac condition pay more attention to and worry more about their cardiac-related symptoms than those people who have coronary atherosclerosis.

Jumping to interpretations: social anxiety disorder and the identification of emotional facial expressions.

A small body of research suggests that socially anxious individuals show biases in interpreting the facial expressions of others. The current study included a clinically anxious sample in a speeded emotional card-sorting task in two conditions (baseline and threat) to investigate several hypothesized biases in interpretation. Following the threat manipulation, participants with generalized social anxiety disorders (GSADs) sorted angry cards with greater accuracy, but also evidenced a greater rate of neutral cards misclassified as angry, as compared to nonanxious controls. The controls showed the opposite pattern, sorting neutral cards with greater accuracy but also misclassifying a greater proportion of angry cards as neutral, as compared to GSADs. These effects were accounted for primarily by low-intensity angry cards. Results are consistent with previous studies showing a negative interpretive bias, and can be applied to the improvement of clinical interventions.

Do dysfunctional beliefs play a role in all types of obsessive-compulsive disorder?

Some but not all models of obsessive-compulsive disorder (OCD) emphasize the role of dysfunctional beliefs in the etiology and maintenance of this disorder. Clinical observations suggest that some OCD patients have prominent dysfunctional beliefs associated with their obsessions and compulsions, while other patients do not show this pattern. It is possible that dysfunctional beliefs play a role in only a subgroup of cases of OCD and, by extension, that different models might apply to different subtypes of the disorder. To examine this issue, patients with OCD (N = 244) completed measures of dysfunctional OC-related beliefs, along with measures of OC symptoms and demographics. These measures were also completed by three comparison groups; anxious (N = 103), student (N = 284), and community (N = 86) controls. Cluster analysis revealed two OCD clusters: low versus high scores on beliefs (OC-low, OC-high). Belief scores for OC-low were in the range of scores for the comparison groups, which were all significantly lower than those of OC-high. Thus, a cluster of OCD patients was identified who did not have elevated scores on measures of dysfunctional beliefs. OC-low and OC-high did not differ on some OC measures (contamination, checking, grooming), but OC-high had higher scores on measures of harming obsessions. These results are consistent with the view that dysfunctional beliefs may play a role in only some types of OCD.

What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension.

OBJECTIVE: We previously found that 46% of the first 1450 outpatients with depression participating in the multicentre Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project qualified for the designation of anxious depression. This study was designed to replicate and extend our initial findings in a subsequent, larger cohort of outpatient STAR*D participants with nonpsychotic major depressive disorder (MDD). METHODS: Baseline clinical and sociodemographic data were collected on 2337 consecutive STAR*D participants. A baseline 17-item Hamilton Depression Rating Scale Anxiety-Somatization factor score of 7 or higher was designated as anxious depression. We identified concurrent Axis I disorders with the Psychiatric Diagnostic Screening Questionnaire (PDSQ), using a 90% specificity threshold. Depressive symptoms were assessed by clinical telephone interview with the 30-item Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C30). RESULTS: The prevalence of anxious depression in this population was 45.1%. Patients with anxious MDD were significantly more likely to be in primary care settings and to be women, nonsingle, unemployed, Hispanic, less educated, and suffering from severe depression, both before and after adjustment for overall depression severity. Patients with anxious depression were significantly more likely to meet PDSQ thresholds for generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, agoraphobia, hypochondriasis, and somatoform disorder, both before and after adjusting for baseline depression severity. Individuals with anxious depression were also significantly less likely to endorse IDS-C30 items concerning atypical features and were significantly more likely to endorse items concerning melancholic-endogenous depression features, both before and after adjusting for baseline depression severity. CONCLUSIONS: This study clearly replicates our previous STAR*D findings and supports the notion that anxious depression may be a valid diagnostic subtype of MDD, with distinct psychiatric comorbidities and clinical and sociodemographic features.

The role of cognitions in OCD treatment: toward rapprochement.

The authors of the papers in this special issue have underscored the efficacy of both psychological and pharmacological treatments for OCD. Despite the potency of these interventions, complete symptom remission rarely occurs. Furthermore, problems related to treatment drop-out, the persistence of residual symptoms despite adequate therapy, patients' vulnerability to relapse and recurrence, and the lack of a clear method for managing co-morbidity or treating OCD subtypes remain incompletely addressed. This response to the authors' papers evaluates their positions and extends their papers by examining issues such as how cognitive therapy and exposure and response prevention can best be integrated, the role of medication in OCD treatment, factors that impact treatment readiness and/or resistance, and the need for effectiveness research.

Obsessive-compulsive disorder subtypes: an attempted replication and extension of a symptom-based taxonomy.

A symptom-based subgroup taxonomy for obsessive-compulsive disorder (OCD) was evaluated and refined. The Yale-Brown Obsessive-Compulsive Scale symptom checklist was scored and cluster analysis was conducted with a sample of OCD patients (N = 114). Results were compared to Calamari et al.'s (Behaviour Research and Therapy 37 (1999) 113) five subgroup model. Rules for determining the number of subgroups supported a more complex model. In between sample comparisons, a stable contamination subgroup was found in both a five and seven subgroup taxonomy. Between sample stability was not as strong for Harming, Obsessionals, Symmetry, and Certainty subgroups. Hoarding, as a distinctive subgroup, was unstable in separate samples. When the Calamari et al. sample and the present sample were combined (N = 220), we found a reliable Hoarding subgroup. More interpretable and stable models emerged with the combined samples suggesting that large clinical samples are needed to identify OCD subgroups. Greater support was found for a seven subgroup taxonomy based subgroup interpretability and validation measure differences. The potential utility of symptom-based subgroup models of OCD and alternative approaches are discussed. Identification of reliable and valid OCD subtypes may advance theory and treatment.

Clinical correlates and symptom patterns of anxious depression among patients with major depressive disorder in STAR*D.

BACKGROUND: Anxious depression, defined as Major Depressive Disorder (MDD) with high levels of anxiety symptoms, may represent a relatively common depressive subtype, with distinctive features. OBJECTIVE: The objective of this study was to determine the prevalence of anxious depression and to define its clinical correlates and symptom patterns. METHOD: Baseline clinical and sociodemographic data were collected on 1450 subjects participating in the STAR*D study. A baseline Hamilton Rating Scale for Depression (HAM-D) Anxiety/ Somatization factor score of > or =7 was considered indicative of anxious depression. The types and degree of concurrent psychiatric symptoms were measured using the Psychiatric Diagnostic Screening Questionnaire (PDSQ), by recording the number of items endorsed by study participants for each diagnostic category. MDD symptoms were assessed by clinical telephone interview with the 30-item Inventory of Depressive Symptomatology (IDS-C30). RESULTS: The prevalence of anxious depression in this population was 46 %. Patients with anxious MDD were significantly more likely to be older, unemployed, less educated, more severely depressed, and to have suicidal ideation before and after adjustment for severity of depression. As far as concurrent psychiatric symptoms are concerned, patients with anxious depression were significantly more likely to endorse symptoms related to generalized anxiety, obsessive compulsive, panic, post-traumatic stress, agoraphobia, hypochondriasis, and somatoform disorders before and after adjustment for severity of depression. Anxious-depression individuals were also significantly less likely to endorse IDS-C30 items concerning atypical features, and were significantly more likely to endorse items concerning melancholic/endogenous depression features. CONCLUSION: This study supports specific clinical and sociodemographic correlates of MDD associated with high levels of anxiety (anxious depression).

Cardiac anxiety in patients self-referred for electron beam tomography.

Studies have repeatedly shown that as many as 43% of patients undergoing coronary angiograms have no evidence of coronary heart disease (CHD). Fear of cardiac-related sensations has been posited as one explanation for complaints of chest pain in patients without CHD. The purpose of this study is to examine variables associated with cardiac anxiety in a sample of individuals self-referred for noninvasive coronary calcium screening. Nearly one quarter of the subjects screened experienced chest pain in the absence of coronary artery calcium (CAC). Individuals without evidence of CAC were more likely to report higher levels of heart-focused attention, even when subjects with any risk factors for CHD were excluded from the analyses. Men were more likely to have evidence of coronary calcium, although a greater proportion of women reported chest pain. Women generally endorsed higher levels of cardioprotective behavior, heart-focused attention, and fear of heart-related sensations. Findings are discussed in relation to treatment of cardiac anxiety and the prevention of unnecessary medical procedures.

Treatment of late-onset OCD following basal ganglia infarct.

Current consensus on the treatment of obsessive-compulsive disorder (OCD) includes cognitive behavior therapy (CBT) in the form of exposure and response prevention (ERP). However, the generalizability of these methods to elderly populations remains largely undocumented. This clinical case study examines the effectiveness of medications and intensive, inpatient ERP in an elderly patient with onset of OCD following basal ganglia infarcts. There was a dramatic reduction from baseline to follow-up in both obsessions and compulsions with Yale-Brown Obsessive-Compulsive Scale [YBOCS; Goodman et al., 1989] total scores decreasing by over 20 points. These gains were maintained up to 1 year post-treatment. Age-specific issues and the application of standard therapeutic methods to elderly clients are discussed.