Somatic Disorders

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

SAN FRANCISCO – Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who's pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” he said. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality. This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH. The overall rate of sleep apnea for these women was 1.14/10,000–but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database is much lower than the 2%–4% rate of OSA estimated for the general population. He attributed this in part to the failure of physicians to ask their pregnant patients about sleep-disordered breathing.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who's pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” he said. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality. This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH. The overall rate of sleep apnea for these women was 1.14/10,000–but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database is much lower than the 2%–4% rate of OSA estimated for the general population. He attributed this in part to the failure of physicians to ask their pregnant patients about sleep-disordered breathing.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who's pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” he said. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality. This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH. The overall rate of sleep apnea for these women was 1.14/10,000–but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database is much lower than the 2%–4% rate of OSA estimated for the general population. He attributed this in part to the failure of physicians to ask their pregnant patients about sleep-disordered breathing.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – A panel of 70 transplant professionals has published a consensus document on the psychosocial evaluation of living unrelated kidney donors, Dr. Francis L. Delmonico reported at the American Transplant Congress.

The guidelines are intended to help transplant centers exclude donors who are unsuitable for a variety of nonmedical reasons, such as coercion, unrealistic expectations, and psychological disorders. “The objective was to assess the characteristics of a prospective unrelated donor that might either increase the risk or serve as a protective factor against a poor donor psychosocial outcome,” said Dr. Delmonico, professor of surgery at Harvard Medical School, Boston.

Describing the current situation as “an era of changing donor-recipient relationships,” Dr. Delmonico said that the guidelines will likely allow transplant centers to be “somewhat more secure in proceeding ahead in very careful assessment and within an ethical framework.”

The new guidelines are the result of a meeting convened in May 2006 by the United Network for Organ Sharing in collaboration with the American Society of Transplant Surgeons and the American Society of Transplantation. That panel recommended several revisions to earlier consensus statements on living donors and offered a new list of required components for the psychosocial evaluation of living unrelated kidney donors. (See box.)

The new document notes that biologically unrelated donors constitute 35% of the living kidney donors in the United States. Among living donors, the percentage without a biologic or close emotional relationship to the recipient rose from 6.5% to 23% between 1996 and 2006 (Am. J. Transplant. 2007;7:1047–54).

Some of the factors that would tend to increase the risks of living unrelated kidney donation are significant psychiatric symptoms or disorders; substance abuse or dependence; a lack of health insurance; a limited capacity to understand risks; motives reflecting a desire for recognition; a subordinate relationship to the patient, such as employee or employer; or an expectation of secondary gain.

Several other factors would tend to decrease the risk, including financial resources that could cover unexpected costs, realistic expectations about the donation experience, little or no ambivalence, a history of medical altruism, an absence of recent significant life stressors, and support from family for the donation.

In its changes to earlier consensus statements, the panel noted that novel forms of donor solicitation, such as Internet sites, point to an increased need to ascertain that the prospective donor was not pressured and does not expect financial gain.

This meeting was cosponsored by the American Society of Transplant Surgeons and the American Society of Transplantation.

Assessing Unrelated Prospective Donors

The following are the required components of psychosocial evaluations for living unrelated kidney donors, as agreed to by a panel convened by the United Network for Organ Sharing, the American Society of Transplant Surgeons, and the American Society of Transplantation:

▸ History and current status. Assess factors such as the prospective donor's educational level, employment, legal offense history, and citizenship.

▸ Capacity. Ensure that the prospective donor's cognitive status and capacity to comprehend information are not compromised.

▸ Psychological status. Determine whether the prospective donor has ever had any psychiatric disorders.

▸ Relationship with the transplant candidate. How close is the relationship, and would the transplant impose expectations or perceived obligations?

▸ Motivation. Determine the voluntariness of the proposed donation. Is it consistent with past behaviors and values? Is it free of coercion, inducements, ambivalence, impulsivity, and ulterior motives?

▸ Donor knowledge, understanding, and preparation. Does the prospective donor understand potential short- and long-term risks, including recuperation time and financial ramifications?

▸ Social support. Evaluate familial, social, and employer support networks available to the prospective donor.

▸ Financial suitability. Determine whether the prospective donor is financially stable and has resources available to cover expected and unexpected donation-related expenses.

Source: Am. J. Transplant. 2007;7:1047–54.

SAN FRANCISCO – A panel of 70 transplant professionals has published a consensus document on the psychosocial evaluation of living unrelated kidney donors, Dr. Francis L. Delmonico reported at the American Transplant Congress.

The guidelines are intended to help transplant centers exclude donors who are unsuitable for a variety of nonmedical reasons, such as coercion, unrealistic expectations, and psychological disorders. “The objective was to assess the characteristics of a prospective unrelated donor that might either increase the risk or serve as a protective factor against a poor donor psychosocial outcome,” said Dr. Delmonico, professor of surgery at Harvard Medical School, Boston.

Describing the current situation as “an era of changing donor-recipient relationships,” Dr. Delmonico said that the guidelines will likely allow transplant centers to be “somewhat more secure in proceeding ahead in very careful assessment and within an ethical framework.”

The new guidelines are the result of a meeting convened in May 2006 by the United Network for Organ Sharing in collaboration with the American Society of Transplant Surgeons and the American Society of Transplantation. That panel recommended several revisions to earlier consensus statements on living donors and offered a new list of required components for the psychosocial evaluation of living unrelated kidney donors. (See box.)

The new document notes that biologically unrelated donors constitute 35% of the living kidney donors in the United States. Among living donors, the percentage without a biologic or close emotional relationship to the recipient rose from 6.5% to 23% between 1996 and 2006 (Am. J. Transplant. 2007;7:1047–54).

Some of the factors that would tend to increase the risks of living unrelated kidney donation are significant psychiatric symptoms or disorders; substance abuse or dependence; a lack of health insurance; a limited capacity to understand risks; motives reflecting a desire for recognition; a subordinate relationship to the patient, such as employee or employer; or an expectation of secondary gain.

Several other factors would tend to decrease the risk, including financial resources that could cover unexpected costs, realistic expectations about the donation experience, little or no ambivalence, a history of medical altruism, an absence of recent significant life stressors, and support from family for the donation.

In its changes to earlier consensus statements, the panel noted that novel forms of donor solicitation, such as Internet sites, point to an increased need to ascertain that the prospective donor was not pressured and does not expect financial gain.

This meeting was cosponsored by the American Society of Transplant Surgeons and the American Society of Transplantation.

Assessing Unrelated Prospective Donors

The following are the required components of psychosocial evaluations for living unrelated kidney donors, as agreed to by a panel convened by the United Network for Organ Sharing, the American Society of Transplant Surgeons, and the American Society of Transplantation:

▸ History and current status. Assess factors such as the prospective donor's educational level, employment, legal offense history, and citizenship.

▸ Capacity. Ensure that the prospective donor's cognitive status and capacity to comprehend information are not compromised.

▸ Psychological status. Determine whether the prospective donor has ever had any psychiatric disorders.

▸ Relationship with the transplant candidate. How close is the relationship, and would the transplant impose expectations or perceived obligations?

▸ Motivation. Determine the voluntariness of the proposed donation. Is it consistent with past behaviors and values? Is it free of coercion, inducements, ambivalence, impulsivity, and ulterior motives?

▸ Donor knowledge, understanding, and preparation. Does the prospective donor understand potential short- and long-term risks, including recuperation time and financial ramifications?

▸ Social support. Evaluate familial, social, and employer support networks available to the prospective donor.

▸ Financial suitability. Determine whether the prospective donor is financially stable and has resources available to cover expected and unexpected donation-related expenses.

Source: Am. J. Transplant. 2007;7:1047–54.

SAN FRANCISCO – A panel of 70 transplant professionals has published a consensus document on the psychosocial evaluation of living unrelated kidney donors, Dr. Francis L. Delmonico reported at the American Transplant Congress.

The guidelines are intended to help transplant centers exclude donors who are unsuitable for a variety of nonmedical reasons, such as coercion, unrealistic expectations, and psychological disorders. “The objective was to assess the characteristics of a prospective unrelated donor that might either increase the risk or serve as a protective factor against a poor donor psychosocial outcome,” said Dr. Delmonico, professor of surgery at Harvard Medical School, Boston.

Describing the current situation as “an era of changing donor-recipient relationships,” Dr. Delmonico said that the guidelines will likely allow transplant centers to be “somewhat more secure in proceeding ahead in very careful assessment and within an ethical framework.”

The new guidelines are the result of a meeting convened in May 2006 by the United Network for Organ Sharing in collaboration with the American Society of Transplant Surgeons and the American Society of Transplantation. That panel recommended several revisions to earlier consensus statements on living donors and offered a new list of required components for the psychosocial evaluation of living unrelated kidney donors. (See box.)

The new document notes that biologically unrelated donors constitute 35% of the living kidney donors in the United States. Among living donors, the percentage without a biologic or close emotional relationship to the recipient rose from 6.5% to 23% between 1996 and 2006 (Am. J. Transplant. 2007;7:1047–54).

Some of the factors that would tend to increase the risks of living unrelated kidney donation are significant psychiatric symptoms or disorders; substance abuse or dependence; a lack of health insurance; a limited capacity to understand risks; motives reflecting a desire for recognition; a subordinate relationship to the patient, such as employee or employer; or an expectation of secondary gain.

Several other factors would tend to decrease the risk, including financial resources that could cover unexpected costs, realistic expectations about the donation experience, little or no ambivalence, a history of medical altruism, an absence of recent significant life stressors, and support from family for the donation.

In its changes to earlier consensus statements, the panel noted that novel forms of donor solicitation, such as Internet sites, point to an increased need to ascertain that the prospective donor was not pressured and does not expect financial gain.

This meeting was cosponsored by the American Society of Transplant Surgeons and the American Society of Transplantation.

Assessing Unrelated Prospective Donors

The following are the required components of psychosocial evaluations for living unrelated kidney donors, as agreed to by a panel convened by the United Network for Organ Sharing, the American Society of Transplant Surgeons, and the American Society of Transplantation:

▸ History and current status. Assess factors such as the prospective donor's educational level, employment, legal offense history, and citizenship.

▸ Capacity. Ensure that the prospective donor's cognitive status and capacity to comprehend information are not compromised.

▸ Psychological status. Determine whether the prospective donor has ever had any psychiatric disorders.

▸ Relationship with the transplant candidate. How close is the relationship, and would the transplant impose expectations or perceived obligations?

▸ Motivation. Determine the voluntariness of the proposed donation. Is it consistent with past behaviors and values? Is it free of coercion, inducements, ambivalence, impulsivity, and ulterior motives?

▸ Donor knowledge, understanding, and preparation. Does the prospective donor understand potential short- and long-term risks, including recuperation time and financial ramifications?

▸ Social support. Evaluate familial, social, and employer support networks available to the prospective donor.

▸ Financial suitability. Determine whether the prospective donor is financially stable and has resources available to cover expected and unexpected donation-related expenses.

Source: Am. J. Transplant. 2007;7:1047–54.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

WASHINGTON – Depressed or anxious patients who are referred to cardiac rehabilitation programs are significantly more likely to comply poorly or have a poorer outcome than are patients without the conditions, Angele McGrady, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Because of this, patients who are referred to cardiac rehabilitation programs “need to be quickly screened for depression and anxiety prior to entering rehabilitation, said Dr. McGrady, professor of psychiatry at the University of Toledo (Ohio).

Depression is a known risk factor for the development and worsening of coronary heart disease (Psychosom. Med. 2005;67[suppl. 1]:S19-S25).

Anxiety also may be a risk factor for CHD. Recent research has associated high levels of phobic anxiety with an increased risk of a fatal cardiac event (Circulation 2005;111:480–7).

At the University of Toledo Medical Center, patients who have angina or chronic heart failure, or who have had a myocardial infarction or coronary artery bypass graft (CABG), get referred to the cardiac rehabilitation program. Such programs are known to be effective in reducing mortality. But in order for patients to benefit, they must complete the full program of exercise, stress management, and nutritional counseling, Dr. McGrady said.

In the rehabilitation program, patients are first psychologically assessed using the Beck Depression Inventory, the Beck Anxiety Inventory, and the SF-36 quality of life measure. A week later, patients come back for a walk test (number of feet walked in a certain period of time).

Over the next 6 months, the patients attend 36 sessions that are largely exercise based; these sessions also include stress management, smoking cessation, and lifestyle counseling, such as nutritional assessment and recommendations for improving nutrition. At the end of 6 months, psychological and physical tests are repeated.

Of 380 consecutive patients who were referred to the medical center over a period of about 2 years, exactly half completed the full rehabilitation program. Other centers have reported dropout rates at cardiac rehabilitation centers ranging from 20% to 65%, she said.

The overall sample had an average age of 61 years; most patients were males (63%) and white (79%). Completers tended to have a higher average age (63 years vs. 59 years) and were more often male (67% vs. 60%) than were noncompleters.

On entry to the rehabilitation program, the 190 patients who completed the program had a significantly lower mean Beck Depression Inventory score than did the 190 noncompleters (8.6 vs. 11.7). The completers also reported a significantly higher initial quality of life than did noncompleters in physical (39.2 vs. 35.7) and mental health (47.6 vs. 43.4).

Beck Anxiety Inventory scores were significantly lower among the completers than in a group of 68 early dropout patients who did not come back at week 2 for the walk test and did not begin the program.

This means that the only chance to catch the nearly 20% of patients who dropped out early, before even starting the actual rehabilitation process, was at the time of the psychological assessment. Early interventions at this point could improve adherence to the program and subsequent outcomes, Dr. McGrady said.

According to the diagnostic category of patients, those who had myocardial infarction, angina, or heart failure had significantly higher anxiety scores than did patients who underwent CABG. Heart failure patients also had significantly higher depression scores than did those who underwent CABG.

No significant differences between patients in different diagnostic categories were found on walk tests or in the patients' perceptions of physical health.

CHICAGO – Depression prevalence may be as high as 30% in transformed migraine, according to a preliminary analysis of the American Migraine Prevalence and Prevention study presented on June 8 at the American Headache Society meeting.

By contrast, only 6%–7% of the U.S. general population has depression, said Dawn C. Buse, Ph.D., director of psychology at the Montefiore Headache Center at the Montefiore Medical Center in the Bronx.

Dr. Buse presented the analysis on behalf of colleagues at the Albert Einstein College of Medicine, New York; the Vedanta Research in Chapel Hill, N.C.; and the Diamond Headache Clinic in Chicago.

The American Migraine Prevalence and Prevention (AMPP) study is an ongoing multisite survey that began in 2004 when a random sample of 120,000 households was mailed self-administered headache questionnaires. Of the 162,576 individuals who responded, 30,721 self-reported severe headaches. A follow-up survey was sent in 2005 to a random subsample of 24,000 of the headache sufferers.

The data presented by Dr. Buse came from the follow-up survey. Respondents were asked for body mass index, and to respond to the Migraine Disability Assessment (MIDAS) questionnaire and the Patient Health Questionnaire-Nine Item Depressive Scale (PHQ-9).

The goal was to determine the relationship among depression, headache type, BMI, and disability.

Data were analyzed from 3,840 (16%) respondents whose scores placed them in the moderately-severe or severe major depression category.

Depression rates were highest in patients with transformed migraine, at 30% (1,152 patients), followed by chronic daily headache at about 20% (768 patients). Eighteen percent (691) of migraine patients had depression, followed by 15% (576) of other types of headache, 13% (500) of tension headache and 12% (461) of probable migraine.

Among patients with depression, 25% were morbidly obese, while 19% were underweight, Dr. Buse said.

Depression increased with rising disability. Only 11% of depressed patients had MIDAS Grade 1 disability, compared with 33% of those with MIDAS grade 4 disability, Dr. Buse said.

Because AMPP is a cross-sectional study, it cannot get at the mechanisms for these interrelationships, she said, adding that she and her colleagues currently are collecting data on medications used, and psychiatric and other comorbidities, and will be following this population for at least another survey, so there may be opportunities for cause-effect analyses in the future.

The AMPP study was supported by the National Headache Foundation through a grant from Ortho-McNeil. Dr. Buse reported that that she consults for Ortho-McNeil and Allergan Pharmaceuticals.

CHICAGO – Depression prevalence may be as high as 30% in transformed migraine, according to a preliminary analysis of the American Migraine Prevalence and Prevention study presented on June 8 at the American Headache Society meeting.

By contrast, only 6%–7% of the U.S. general population has depression, said Dawn C. Buse, Ph.D., director of psychology at the Montefiore Headache Center at the Montefiore Medical Center in the Bronx.

Dr. Buse presented the analysis on behalf of colleagues at the Albert Einstein College of Medicine, New York; the Vedanta Research in Chapel Hill, N.C.; and the Diamond Headache Clinic in Chicago.

The American Migraine Prevalence and Prevention (AMPP) study is an ongoing multisite survey that began in 2004 when a random sample of 120,000 households was mailed self-administered headache questionnaires. Of the 162,576 individuals who responded, 30,721 self-reported severe headaches. A follow-up survey was sent in 2005 to a random subsample of 24,000 of the headache sufferers.

The data presented by Dr. Buse came from the follow-up survey. Respondents were asked for body mass index, and to respond to the Migraine Disability Assessment (MIDAS) questionnaire and the Patient Health Questionnaire-Nine Item Depressive Scale (PHQ-9).

The goal was to determine the relationship among depression, headache type, BMI, and disability.

Data were analyzed from 3,840 (16%) respondents whose scores placed them in the moderately-severe or severe major depression category.

Depression rates were highest in patients with transformed migraine, at 30% (1,152 patients), followed by chronic daily headache at about 20% (768 patients). Eighteen percent (691) of migraine patients had depression, followed by 15% (576) of other types of headache, 13% (500) of tension headache and 12% (461) of probable migraine.

Among patients with depression, 25% were morbidly obese, while 19% were underweight, Dr. Buse said.

Depression increased with rising disability. Only 11% of depressed patients had MIDAS Grade 1 disability, compared with 33% of those with MIDAS grade 4 disability, Dr. Buse said.

Because AMPP is a cross-sectional study, it cannot get at the mechanisms for these interrelationships, she said, adding that she and her colleagues currently are collecting data on medications used, and psychiatric and other comorbidities, and will be following this population for at least another survey, so there may be opportunities for cause-effect analyses in the future.

The AMPP study was supported by the National Headache Foundation through a grant from Ortho-McNeil. Dr. Buse reported that that she consults for Ortho-McNeil and Allergan Pharmaceuticals.

CHICAGO – Depression prevalence may be as high as 30% in transformed migraine, according to a preliminary analysis of the American Migraine Prevalence and Prevention study presented on June 8 at the American Headache Society meeting.

By contrast, only 6%–7% of the U.S. general population has depression, said Dawn C. Buse, Ph.D., director of psychology at the Montefiore Headache Center at the Montefiore Medical Center in the Bronx.

Dr. Buse presented the analysis on behalf of colleagues at the Albert Einstein College of Medicine, New York; the Vedanta Research in Chapel Hill, N.C.; and the Diamond Headache Clinic in Chicago.

The American Migraine Prevalence and Prevention (AMPP) study is an ongoing multisite survey that began in 2004 when a random sample of 120,000 households was mailed self-administered headache questionnaires. Of the 162,576 individuals who responded, 30,721 self-reported severe headaches. A follow-up survey was sent in 2005 to a random subsample of 24,000 of the headache sufferers.

The data presented by Dr. Buse came from the follow-up survey. Respondents were asked for body mass index, and to respond to the Migraine Disability Assessment (MIDAS) questionnaire and the Patient Health Questionnaire-Nine Item Depressive Scale (PHQ-9).

The goal was to determine the relationship among depression, headache type, BMI, and disability.

Data were analyzed from 3,840 (16%) respondents whose scores placed them in the moderately-severe or severe major depression category.

Depression rates were highest in patients with transformed migraine, at 30% (1,152 patients), followed by chronic daily headache at about 20% (768 patients). Eighteen percent (691) of migraine patients had depression, followed by 15% (576) of other types of headache, 13% (500) of tension headache and 12% (461) of probable migraine.

Among patients with depression, 25% were morbidly obese, while 19% were underweight, Dr. Buse said.

Depression increased with rising disability. Only 11% of depressed patients had MIDAS Grade 1 disability, compared with 33% of those with MIDAS grade 4 disability, Dr. Buse said.

Because AMPP is a cross-sectional study, it cannot get at the mechanisms for these interrelationships, she said, adding that she and her colleagues currently are collecting data on medications used, and psychiatric and other comorbidities, and will be following this population for at least another survey, so there may be opportunities for cause-effect analyses in the future.

The AMPP study was supported by the National Headache Foundation through a grant from Ortho-McNeil. Dr. Buse reported that that she consults for Ortho-McNeil and Allergan Pharmaceuticals.

BOSTON – Depression, anxiety, and sleep problems rather than disease explain why some patients with Parkinson's disease call their physicians more frequently than others, according to results of a study presented by Dr. Melissa J. Nirenberg in a poster presentation at the annual meeting of the American Academy of Neurology.

Treating these “invisible” symptoms may both help the patients' quality of life and decrease their health care use, she reported.

In the study, frequent callers–who made an average of 2.4 calls in 100 days–had significantly higher anxiety scores on the Beck Anxiety Inventory and higher depression scores on the Beck Depression Inventory than did those who called infrequently–or a mean of 0.6 calls in 100 days. They also had lower quality of life scores on the Parkinson's Disease Quality of Life scale, reported Dr. Nirenberg. Sleep problems were a universal complaint among frequent callers, but these issues were reported by only 36% of the infrequent callers, a significant difference.

While patients in both groups had moderate motor disability, no differences between groups were found as measured by the motor Unified Parkinson's Disease Rating Scale, Hoehn and Yahr scale, or Schwab and England Disability scale.

The study comprised 44 nondemented Parkinson's disease outpatients who were treated over 4 months in a movement disorders clinic. They all underwent neuropsychiatric and disability testing. Patients who called more than the mean rate of 1.9 calls in 100 days were assigned to the frequent callers group, and those who called less than the mean rate were assigned to the infrequent callers group. Calling history was determined by retrospective chart review.

“These [frequent callers] look good but feel bad,” says Dr. Nirenberg, who is the associate director of the Parkinson's Disease and Movement Disorders Institute at Cornell University, New York. She believes that because anxiety, depression, and sleep disorders are not readily apparent, it might make sense to focus instead on treating the motor symptoms. Even physicians who recognize the importance of the nonmotor symptoms of Parkinson's disease may not have time to ask about them during a routine office visit, and as a result, may be undertreating these symptoms.

Increased telephone health care use has a significant impact on physicians, said Dr. Nirenberg. These calls take up a tremendous amount of the time. While not assessed in this study, it is likely that these patients also make increased demands on other health care services.

“You need to have a high index of suspicion for anxiety and depression, particularly in patients who call frequently,” Dr. Nirenberg said. She says that while the ideal treatments for these nonmotor symptoms of Parkinson's disease have not been established, cognitive-behavioral therapy, anxiolytics, antidepressants, and Parkinson's medications may help. It is also important to be aware that treatment of one of these nonmotor problems might exacerbate another–for example, an SSRI prescribed for depression has the potential to worsen anxiety, she said.

BOSTON – Depression, anxiety, and sleep problems rather than disease explain why some patients with Parkinson's disease call their physicians more frequently than others, according to results of a study presented by Dr. Melissa J. Nirenberg in a poster presentation at the annual meeting of the American Academy of Neurology.

Treating these “invisible” symptoms may both help the patients' quality of life and decrease their health care use, she reported.

In the study, frequent callers–who made an average of 2.4 calls in 100 days–had significantly higher anxiety scores on the Beck Anxiety Inventory and higher depression scores on the Beck Depression Inventory than did those who called infrequently–or a mean of 0.6 calls in 100 days. They also had lower quality of life scores on the Parkinson's Disease Quality of Life scale, reported Dr. Nirenberg. Sleep problems were a universal complaint among frequent callers, but these issues were reported by only 36% of the infrequent callers, a significant difference.

While patients in both groups had moderate motor disability, no differences between groups were found as measured by the motor Unified Parkinson's Disease Rating Scale, Hoehn and Yahr scale, or Schwab and England Disability scale.

The study comprised 44 nondemented Parkinson's disease outpatients who were treated over 4 months in a movement disorders clinic. They all underwent neuropsychiatric and disability testing. Patients who called more than the mean rate of 1.9 calls in 100 days were assigned to the frequent callers group, and those who called less than the mean rate were assigned to the infrequent callers group. Calling history was determined by retrospective chart review.

“These [frequent callers] look good but feel bad,” says Dr. Nirenberg, who is the associate director of the Parkinson's Disease and Movement Disorders Institute at Cornell University, New York. She believes that because anxiety, depression, and sleep disorders are not readily apparent, it might make sense to focus instead on treating the motor symptoms. Even physicians who recognize the importance of the nonmotor symptoms of Parkinson's disease may not have time to ask about them during a routine office visit, and as a result, may be undertreating these symptoms.

Increased telephone health care use has a significant impact on physicians, said Dr. Nirenberg. These calls take up a tremendous amount of the time. While not assessed in this study, it is likely that these patients also make increased demands on other health care services.

“You need to have a high index of suspicion for anxiety and depression, particularly in patients who call frequently,” Dr. Nirenberg said. She says that while the ideal treatments for these nonmotor symptoms of Parkinson's disease have not been established, cognitive-behavioral therapy, anxiolytics, antidepressants, and Parkinson's medications may help. It is also important to be aware that treatment of one of these nonmotor problems might exacerbate another–for example, an SSRI prescribed for depression has the potential to worsen anxiety, she said.

BOSTON – Depression, anxiety, and sleep problems rather than disease explain why some patients with Parkinson's disease call their physicians more frequently than others, according to results of a study presented by Dr. Melissa J. Nirenberg in a poster presentation at the annual meeting of the American Academy of Neurology.

Treating these “invisible” symptoms may both help the patients' quality of life and decrease their health care use, she reported.

In the study, frequent callers–who made an average of 2.4 calls in 100 days–had significantly higher anxiety scores on the Beck Anxiety Inventory and higher depression scores on the Beck Depression Inventory than did those who called infrequently–or a mean of 0.6 calls in 100 days. They also had lower quality of life scores on the Parkinson's Disease Quality of Life scale, reported Dr. Nirenberg. Sleep problems were a universal complaint among frequent callers, but these issues were reported by only 36% of the infrequent callers, a significant difference.

While patients in both groups had moderate motor disability, no differences between groups were found as measured by the motor Unified Parkinson's Disease Rating Scale, Hoehn and Yahr scale, or Schwab and England Disability scale.

The study comprised 44 nondemented Parkinson's disease outpatients who were treated over 4 months in a movement disorders clinic. They all underwent neuropsychiatric and disability testing. Patients who called more than the mean rate of 1.9 calls in 100 days were assigned to the frequent callers group, and those who called less than the mean rate were assigned to the infrequent callers group. Calling history was determined by retrospective chart review.

“These [frequent callers] look good but feel bad,” says Dr. Nirenberg, who is the associate director of the Parkinson's Disease and Movement Disorders Institute at Cornell University, New York. She believes that because anxiety, depression, and sleep disorders are not readily apparent, it might make sense to focus instead on treating the motor symptoms. Even physicians who recognize the importance of the nonmotor symptoms of Parkinson's disease may not have time to ask about them during a routine office visit, and as a result, may be undertreating these symptoms.

Increased telephone health care use has a significant impact on physicians, said Dr. Nirenberg. These calls take up a tremendous amount of the time. While not assessed in this study, it is likely that these patients also make increased demands on other health care services.

“You need to have a high index of suspicion for anxiety and depression, particularly in patients who call frequently,” Dr. Nirenberg said. She says that while the ideal treatments for these nonmotor symptoms of Parkinson's disease have not been established, cognitive-behavioral therapy, anxiolytics, antidepressants, and Parkinson's medications may help. It is also important to be aware that treatment of one of these nonmotor problems might exacerbate another–for example, an SSRI prescribed for depression has the potential to worsen anxiety, she said.

NEW ORLEANS – Depression is common among patients with heart failure and is independently associated with poor outcomes, Dr. Aldo P. Maggioni said at the annual meeting of the American College of Cardiology.

He presented a retrospective study involving 18,623 patients with heart failure over age 60 identified in an administrative health care database covering two regions of Italy. At entry, 13% were being treated for depression.

In a multivariate logistic regression analysis, comorbid depression was independently associated with a highly significant 28% increased risk of all-cause mortality at 1 year, compared with the risk in heart failure patients not treated for depression.

Depression also was associated with an adjusted 36% increased risk of a 1-year composite end point consisting of MI, stroke, or transient ischemic attack, along with an 18% increase in all-cause hospitalization. However, the risk of rehospitalization for heart failure was no greater in patients treated for depression than in those who weren't, according to Dr. Maggioni, a cardiologist at the Mario Negri Research Consortium South, Santa Maria Imbaro, Italy.

He noted that while the adverse effect of comorbid depression on outcomes in patients with coronary artery disease is well established, there is much less evidence regarding the mood disorder's effect in patients with heart failure. Most previous studies have been quite small.

The strength of the new Italian study is its very large numbers. Its weakness is that there was no systematic screening for depression, so it's entirely possible the “nondepressed” comparator group included a fair number of heart failure patients with undiagnosed and untreated depression. Regardless, Dr. Maggioni said, the study conclusion was essentially the same as in the much smaller studies in which heart failure patients were screened for depression by questionnaire or interview: Depression is associated with poor outcomes in heart failure.

The mean age of participants in this study was 78 years. Patients treated for comorbid depression were significantly older than those who weren't. Sixty-nine percent were women, compared with 58% of heart failure patients not treated for depression. Patients with depression also were significantly more likely to have a baseline history of stroke, TIA, cancer, and chronic obstructive pulmonary disease.

Dr. Maggioni offered three potential explanations for the worse clinical outcomes in heart failure patients treated for depression. One possibility is that some antidepressant medications might have adverse effects in this population. Another is that depression exacerbates the underlying pathophysiology of heart failure, which is plausible in light of the fact that both conditions involve increased sympathetic nervous system activity, platelet activation, and systemic inflammation. But the most likely explanation for the association, in Dr. Maggioni's view, is that depressed patients have less social support and are less adherent to their cardiovascular therapy.

The big, unanswered question is whether treatment of depression improves heart failure outcomes, he said. There are no data, and a definitive randomized clinical trial would need to be very large.

“You need the numbers. If you're testing a new drug, just to see a 15% relative difference in mortality, you need perhaps 7,000 patients,” Dr. Maggioni noted in an interview.

Session Chair Douglas P. Zipes called the Italian report linking depression to worse outcomes in heart failure “a very important observation” regarding an issue that doesn't receive sufficient attention from nonpsychiatrists.

“I think we tend to focus on more tangible issues, such as which coronary artery is occluded [and] the warfarin dose. My impression is that issues such as depression, sexual activity, and support groups aren't discussed at length–and they should be,” said Dr. Zipes, Distinguished Professor of Medicine, Pharmacology, and Toxicology at Indiana University, Indianapolis.

The risk of stroke or transient ischemic attack also was greater among patients with depression. DR. MAGGIONI

NEW ORLEANS – Depression is common among patients with heart failure and is independently associated with poor outcomes, Dr. Aldo P. Maggioni said at the annual meeting of the American College of Cardiology.

He presented a retrospective study involving 18,623 patients with heart failure over age 60 identified in an administrative health care database covering two regions of Italy. At entry, 13% were being treated for depression.

In a multivariate logistic regression analysis, comorbid depression was independently associated with a highly significant 28% increased risk of all-cause mortality at 1 year, compared with the risk in heart failure patients not treated for depression.

Depression also was associated with an adjusted 36% increased risk of a 1-year composite end point consisting of MI, stroke, or transient ischemic attack, along with an 18% increase in all-cause hospitalization. However, the risk of rehospitalization for heart failure was no greater in patients treated for depression than in those who weren't, according to Dr. Maggioni, a cardiologist at the Mario Negri Research Consortium South, Santa Maria Imbaro, Italy.

He noted that while the adverse effect of comorbid depression on outcomes in patients with coronary artery disease is well established, there is much less evidence regarding the mood disorder's effect in patients with heart failure. Most previous studies have been quite small.

The strength of the new Italian study is its very large numbers. Its weakness is that there was no systematic screening for depression, so it's entirely possible the “nondepressed” comparator group included a fair number of heart failure patients with undiagnosed and untreated depression. Regardless, Dr. Maggioni said, the study conclusion was essentially the same as in the much smaller studies in which heart failure patients were screened for depression by questionnaire or interview: Depression is associated with poor outcomes in heart failure.

The mean age of participants in this study was 78 years. Patients treated for comorbid depression were significantly older than those who weren't. Sixty-nine percent were women, compared with 58% of heart failure patients not treated for depression. Patients with depression also were significantly more likely to have a baseline history of stroke, TIA, cancer, and chronic obstructive pulmonary disease.

Dr. Maggioni offered three potential explanations for the worse clinical outcomes in heart failure patients treated for depression. One possibility is that some antidepressant medications might have adverse effects in this population. Another is that depression exacerbates the underlying pathophysiology of heart failure, which is plausible in light of the fact that both conditions involve increased sympathetic nervous system activity, platelet activation, and systemic inflammation. But the most likely explanation for the association, in Dr. Maggioni's view, is that depressed patients have less social support and are less adherent to their cardiovascular therapy.

The big, unanswered question is whether treatment of depression improves heart failure outcomes, he said. There are no data, and a definitive randomized clinical trial would need to be very large.

“You need the numbers. If you're testing a new drug, just to see a 15% relative difference in mortality, you need perhaps 7,000 patients,” Dr. Maggioni noted in an interview.

Session Chair Douglas P. Zipes called the Italian report linking depression to worse outcomes in heart failure “a very important observation” regarding an issue that doesn't receive sufficient attention from nonpsychiatrists.

“I think we tend to focus on more tangible issues, such as which coronary artery is occluded [and] the warfarin dose. My impression is that issues such as depression, sexual activity, and support groups aren't discussed at length–and they should be,” said Dr. Zipes, Distinguished Professor of Medicine, Pharmacology, and Toxicology at Indiana University, Indianapolis.

The risk of stroke or transient ischemic attack also was greater among patients with depression. DR. MAGGIONI

NEW ORLEANS – Depression is common among patients with heart failure and is independently associated with poor outcomes, Dr. Aldo P. Maggioni said at the annual meeting of the American College of Cardiology.

He presented a retrospective study involving 18,623 patients with heart failure over age 60 identified in an administrative health care database covering two regions of Italy. At entry, 13% were being treated for depression.

In a multivariate logistic regression analysis, comorbid depression was independently associated with a highly significant 28% increased risk of all-cause mortality at 1 year, compared with the risk in heart failure patients not treated for depression.

Depression also was associated with an adjusted 36% increased risk of a 1-year composite end point consisting of MI, stroke, or transient ischemic attack, along with an 18% increase in all-cause hospitalization. However, the risk of rehospitalization for heart failure was no greater in patients treated for depression than in those who weren't, according to Dr. Maggioni, a cardiologist at the Mario Negri Research Consortium South, Santa Maria Imbaro, Italy.

He noted that while the adverse effect of comorbid depression on outcomes in patients with coronary artery disease is well established, there is much less evidence regarding the mood disorder's effect in patients with heart failure. Most previous studies have been quite small.

The strength of the new Italian study is its very large numbers. Its weakness is that there was no systematic screening for depression, so it's entirely possible the “nondepressed” comparator group included a fair number of heart failure patients with undiagnosed and untreated depression. Regardless, Dr. Maggioni said, the study conclusion was essentially the same as in the much smaller studies in which heart failure patients were screened for depression by questionnaire or interview: Depression is associated with poor outcomes in heart failure.

The mean age of participants in this study was 78 years. Patients treated for comorbid depression were significantly older than those who weren't. Sixty-nine percent were women, compared with 58% of heart failure patients not treated for depression. Patients with depression also were significantly more likely to have a baseline history of stroke, TIA, cancer, and chronic obstructive pulmonary disease.

Dr. Maggioni offered three potential explanations for the worse clinical outcomes in heart failure patients treated for depression. One possibility is that some antidepressant medications might have adverse effects in this population. Another is that depression exacerbates the underlying pathophysiology of heart failure, which is plausible in light of the fact that both conditions involve increased sympathetic nervous system activity, platelet activation, and systemic inflammation. But the most likely explanation for the association, in Dr. Maggioni's view, is that depressed patients have less social support and are less adherent to their cardiovascular therapy.

The big, unanswered question is whether treatment of depression improves heart failure outcomes, he said. There are no data, and a definitive randomized clinical trial would need to be very large.

“You need the numbers. If you're testing a new drug, just to see a 15% relative difference in mortality, you need perhaps 7,000 patients,” Dr. Maggioni noted in an interview.

Session Chair Douglas P. Zipes called the Italian report linking depression to worse outcomes in heart failure “a very important observation” regarding an issue that doesn't receive sufficient attention from nonpsychiatrists.

“I think we tend to focus on more tangible issues, such as which coronary artery is occluded [and] the warfarin dose. My impression is that issues such as depression, sexual activity, and support groups aren't discussed at length–and they should be,” said Dr. Zipes, Distinguished Professor of Medicine, Pharmacology, and Toxicology at Indiana University, Indianapolis.

The risk of stroke or transient ischemic attack also was greater among patients with depression. DR. MAGGIONI

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

WASHINGTON – Psychosocial risk factors contribute a level of risk for cardiovascular events in clinically symptomatic women that is similar to the traditional major risk factors, Thomas Rutledge, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

Dr. Rutledge and his associates prospectively studied the risk factors of smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, depression, and social isolation in a cohort of 734 women with clinical symptoms of myocardial ischemia. Each underwent coronary angiography and psychosocial testing. About 30% of the patients had one event during a follow-up of 6 years.

The women were clinically symptomatic, but the rate of obstructive coronary artery disease was relatively low (39%). Risk factors tended to cluster, which was associated with about a threefold increase from the lowest group to the highest group in death and CVD rates. Those events occurred in 12% of women with none or one risk factor, 19% with two to three risk factors, and 30% with four to six risk factors. The magnitude of the effects for depression and social isolation was comparable with those for the major CVD risk factors.

CHICAGO – Major depressive disorder, bipolar disorder, panic disorder, and social phobia were diagnosed twice as often in those with migraine as in those without headache in a major Canadian population survey, Dr. Nathalie Jette said at the American Headache Society meeting.

The data came from the Canadian Community Health Survey, which was conducted in 2002, said Dr. Jette, of the clinical neurosciences department at the University of Calgary, Alta.

Many studies have shown an association between migraine and psychiatric conditions; the goal of this study was to determine potential impact on health outcomes and implications for health policies in Canada, Dr. Jette said. Patients with migraine and psychiatric comorbidities tend to use more health resources; identifying them can lead to more preventive treatment and better-targeted therapies, Dr. Jette said.

Some 36,984 Canadian residents were randomly selected for the survey. Of these, 70% agreed to participate; all the subjects were interviewed at home by trained interviewers, she said.

Dr. Jette said that he estimated lifetime prevalence of migraine in Canada is 7%–17%. In the survey, 15% of women and 6% of men self-reported that they had physician-diagnosed migraine. Mental health was assessed using the World Health Mental Composite International Diagnostic Interview.

As has been seen in other studies, migraine was most prevalent among lower-income respondents. Married respondents were less likely to have migraine than were those who were widowed, separated, or divorced, Dr. Jette said.

Psychiatric comorbidities were twice as common in those with migraine than in those without. After assessing the data, the researchers found that the higher prevalence of psychiatric disorders in migraineurs was not related to sociodemographics.

Major depression and bipolar disorder were more common among migraineurs. Middle- and higher-income respondents were less likely to have either condition, regardless of headache status, Dr. Jette said.

The authors also analyzed survey data on health-related outcomes, including 2-week disability, restrictions on activities, quality of life, and use of mental health care. They found that patients with a combination of migraine and major depressive disorder, bipolar disorder, panic disorder, or social phobia had a reduced likelihood of a good health outcome.

The study's strengths included its high participation rate and that it was a representative sample, said Dr. Jette, who reported no conflicts of interest. But, she noted, it did not use International Classification of Headache Disorder (ICHD) criteria, and it is cross-sectional, which she said limits inference on causal mechanisms for the relationship between migraine and psychiatric conditions.

CHICAGO – Major depressive disorder, bipolar disorder, panic disorder, and social phobia were diagnosed twice as often in those with migraine as in those without headache in a major Canadian population survey, Dr. Nathalie Jette said at the American Headache Society meeting.

The data came from the Canadian Community Health Survey, which was conducted in 2002, said Dr. Jette, of the clinical neurosciences department at the University of Calgary, Alta.

Many studies have shown an association between migraine and psychiatric conditions; the goal of this study was to determine potential impact on health outcomes and implications for health policies in Canada, Dr. Jette said. Patients with migraine and psychiatric comorbidities tend to use more health resources; identifying them can lead to more preventive treatment and better-targeted therapies, Dr. Jette said.

Some 36,984 Canadian residents were randomly selected for the survey. Of these, 70% agreed to participate; all the subjects were interviewed at home by trained interviewers, she said.

Dr. Jette said that he estimated lifetime prevalence of migraine in Canada is 7%–17%. In the survey, 15% of women and 6% of men self-reported that they had physician-diagnosed migraine. Mental health was assessed using the World Health Mental Composite International Diagnostic Interview.

As has been seen in other studies, migraine was most prevalent among lower-income respondents. Married respondents were less likely to have migraine than were those who were widowed, separated, or divorced, Dr. Jette said.

Psychiatric comorbidities were twice as common in those with migraine than in those without. After assessing the data, the researchers found that the higher prevalence of psychiatric disorders in migraineurs was not related to sociodemographics.

Major depression and bipolar disorder were more common among migraineurs. Middle- and higher-income respondents were less likely to have either condition, regardless of headache status, Dr. Jette said.

The authors also analyzed survey data on health-related outcomes, including 2-week disability, restrictions on activities, quality of life, and use of mental health care. They found that patients with a combination of migraine and major depressive disorder, bipolar disorder, panic disorder, or social phobia had a reduced likelihood of a good health outcome.

The study's strengths included its high participation rate and that it was a representative sample, said Dr. Jette, who reported no conflicts of interest. But, she noted, it did not use International Classification of Headache Disorder (ICHD) criteria, and it is cross-sectional, which she said limits inference on causal mechanisms for the relationship between migraine and psychiatric conditions.

CHICAGO – Major depressive disorder, bipolar disorder, panic disorder, and social phobia were diagnosed twice as often in those with migraine as in those without headache in a major Canadian population survey, Dr. Nathalie Jette said at the American Headache Society meeting.

The data came from the Canadian Community Health Survey, which was conducted in 2002, said Dr. Jette, of the clinical neurosciences department at the University of Calgary, Alta.

Many studies have shown an association between migraine and psychiatric conditions; the goal of this study was to determine potential impact on health outcomes and implications for health policies in Canada, Dr. Jette said. Patients with migraine and psychiatric comorbidities tend to use more health resources; identifying them can lead to more preventive treatment and better-targeted therapies, Dr. Jette said.

Some 36,984 Canadian residents were randomly selected for the survey. Of these, 70% agreed to participate; all the subjects were interviewed at home by trained interviewers, she said.

Dr. Jette said that he estimated lifetime prevalence of migraine in Canada is 7%–17%. In the survey, 15% of women and 6% of men self-reported that they had physician-diagnosed migraine. Mental health was assessed using the World Health Mental Composite International Diagnostic Interview.

As has been seen in other studies, migraine was most prevalent among lower-income respondents. Married respondents were less likely to have migraine than were those who were widowed, separated, or divorced, Dr. Jette said.

Psychiatric comorbidities were twice as common in those with migraine than in those without. After assessing the data, the researchers found that the higher prevalence of psychiatric disorders in migraineurs was not related to sociodemographics.

Major depression and bipolar disorder were more common among migraineurs. Middle- and higher-income respondents were less likely to have either condition, regardless of headache status, Dr. Jette said.

The authors also analyzed survey data on health-related outcomes, including 2-week disability, restrictions on activities, quality of life, and use of mental health care. They found that patients with a combination of migraine and major depressive disorder, bipolar disorder, panic disorder, or social phobia had a reduced likelihood of a good health outcome.

The study's strengths included its high participation rate and that it was a representative sample, said Dr. Jette, who reported no conflicts of interest. But, she noted, it did not use International Classification of Headache Disorder (ICHD) criteria, and it is cross-sectional, which she said limits inference on causal mechanisms for the relationship between migraine and psychiatric conditions.

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT