Somatic Disorders

NEW ORLEANS – A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from local outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

“The two-question instrument was a sensitive tool for identifying depression in CHD patients from diverse outpatient care settings,” Dr. McManus said.

The instrument can be easily integrated into outpatient visits, “even in the busiest cardiology practices,” he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD.

NEW ORLEANS – A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from local outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

“The two-question instrument was a sensitive tool for identifying depression in CHD patients from diverse outpatient care settings,” Dr. McManus said.

The instrument can be easily integrated into outpatient visits, “even in the busiest cardiology practices,” he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD.

NEW ORLEANS – A brief, two-question screening instrument is sensitive for identifying depression in patients with coronary heart disease, a study has shown.

Because major depression is associated with adverse outcomes in this patient population, the availability of a quick, effective tool for improving detection and referral rates could improve patient outcomes substantially, David D. McManus, M.D., reported at the annual meeting of the Society of General Internal Medicine.

Using data from the Heart and Soul Study of the University of California, San Francisco, Dr. McManus and his colleagues compared the test characteristics of four depression case-finding instruments with those of the Diagnostic Interview for Depression in 1,024 adults with stable coronary heart disease (CHD) recruited from local outpatient clinics.

The instruments selected for comparison were the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), and a brief screen that asks patients about depressed mood and anhedonia.

Specifically, the brief screen asks patients, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” Dr. McManus said. An answer of “yes” to either of these questions was considered a positive screen.

Of the 1,024 study participants, 224 had major depression by standard measure (Diagnostic Interview for Depression). The brief, two-question screen was, at 90%, the most sensitive of the four test measures. The sensitivity of the CES-D, the PHQ-9, and the PHQ-2 was 76%, 54%, and 39%, respectively. The specificity of the brief screen was 69%, compared with 79%, 90%, and 92% for the CES-D, the PHQ-9, and the PHQ-2.

“The two-question instrument was a sensitive tool for identifying depression in CHD patients from diverse outpatient care settings,” Dr. McManus said.

The instrument can be easily integrated into outpatient visits, “even in the busiest cardiology practices,” he said. “A negative response to both questions effectively rules out depression, and a positive response to either suggests the patient might benefit from referral or treatment.”

The Heart and Soul Study is an ongoing, prospective cohort study designed to determine how psychosocial factors influence disease progression in patients with CHD.

DENVER – Obstructive sleep apnea is far more common during pregnancy than most physicians realize and in its more severe forms can jeopardize the fetus, Meir H. Kryger, M.D., said at a satellite symposium held in conjunction with the annual meeting of the Associated Professional Sleep Societies.

“I've had cases of sleep apnea in pregnant women who actually before diagnosis had several spontaneous abortions. I have no doubt that in some cases the baby was lost when it became very, very hypoxic,” added Dr. Kryger, professor of medicine and director of the sleep disorders center at the University of Manitoba, Winnipeg.

The treatment for obstructive sleep apnea in pregnancy is continuous positive airway pressure (CPAP). It's considered safe for both mother and fetus.

The prevalence of habitual snoring–that is, snoring nearly every night–climbs from 4% in nonpregnant women to 14%–23% during pregnancy. The increase during pregnancy is believed to be due to weight gain coupled with hormonally induced changes in the elasticity of the pharyngeal airway and other tissues.

“Sleep apnea is actually quite common in pregnant women. I don't know why more doctors don't pick it up,” Dr. Kryger said.

He advises routinely performing polysomnography in pregnant heavy snorers (especially if they are also observed to stop breathing), treating with CPAP those who meet the criteria for obstructive sleep apnea, and repeating the sleep lab testing post partum. The reason he advocates an aggressive approach is the documented adverse effects of heavy snoring in pregnancy. He pointed to a Swedish study conducted several years ago that highlighted the implications of heavy snoring during pregnancy.

The study by Karl A. Franklin, M.D., Ph.D., a pulmonologist at University Hospital, Umeå, and his colleagues involved 113 habitual snorers and 289 infrequent or nonsnorers. All had singleton pregnancies. On their delivery day, they and their partners completed a detailed questionnaire focusing on snoring, daytime tiredness, and witnessed sleep apneas.

Habitual snoring proved to be associated with significantly higher rates of preeclampsia, new-onset hypertension, facial edema, and edema at other sites. Heavy snoring was also associated with significantly higher rates of babies who were small for their gestational age and of low 1- and 5-minute Apgar scores.

“One of the really important things to remember is that if a woman has sleep apnea and she delivers a baby, she's going to be very, very sleepy and will have a great deal of difficulty caring for a newborn,” Dr. Kryger said. In fact, this sleep disturbance and the resultant feelings of maternal inadequacy because of profound fatigue can prove a factor in postpartum depression, the most common complication of childbearing, Dr. Kryger said.

The Swedish study is one of several that have identified obesity as the major risk factor for sleep apnea in pregnancy. Habitual snorers in pregnancy were considerably heavier before pregnancy and gained more weight during pregnancy than did the infrequent snorers.

The link between habitual snoring and pregnancy-induced hypertension reported by Dr. Franklin and his coworkers has also been found by others. Preeclampsia has been associated not only with upper airway narrowing, snoring, and frequent arousals from sleep, but also with restless legs syndrome and other periodic limb movements. “A pregnant woman who develops hypertension or protein in the urine may need to have a sleep evaluation,” Dr. Kryger said.

The good news, only recently documented, is that sleep-disordered breathing arising in late pregnancy often improves following parturition, according to Dr. Kryger, who pointed to a study by Natalie Edwards, Ph.D., and her colleagues at the University of Sydney (Australia). In 10 women referred for sleep-disordered breathing in the third trimester, significant improvements were found in the apnea-hypopnea index, and minimum arterial oxyhemoglobin saturation occurred in all 10 postnatally (Sleep 2005;28:737–41). Peak arterial blood pressure responses to apnea also dropped markedly.

DENVER – Obstructive sleep apnea is far more common during pregnancy than most physicians realize and in its more severe forms can jeopardize the fetus, Meir H. Kryger, M.D., said at a satellite symposium held in conjunction with the annual meeting of the Associated Professional Sleep Societies.

“I've had cases of sleep apnea in pregnant women who actually before diagnosis had several spontaneous abortions. I have no doubt that in some cases the baby was lost when it became very, very hypoxic,” added Dr. Kryger, professor of medicine and director of the sleep disorders center at the University of Manitoba, Winnipeg.

The treatment for obstructive sleep apnea in pregnancy is continuous positive airway pressure (CPAP). It's considered safe for both mother and fetus.

The prevalence of habitual snoring–that is, snoring nearly every night–climbs from 4% in nonpregnant women to 14%–23% during pregnancy. The increase during pregnancy is believed to be due to weight gain coupled with hormonally induced changes in the elasticity of the pharyngeal airway and other tissues.

“Sleep apnea is actually quite common in pregnant women. I don't know why more doctors don't pick it up,” Dr. Kryger said.

He advises routinely performing polysomnography in pregnant heavy snorers (especially if they are also observed to stop breathing), treating with CPAP those who meet the criteria for obstructive sleep apnea, and repeating the sleep lab testing post partum. The reason he advocates an aggressive approach is the documented adverse effects of heavy snoring in pregnancy. He pointed to a Swedish study conducted several years ago that highlighted the implications of heavy snoring during pregnancy.

The study by Karl A. Franklin, M.D., Ph.D., a pulmonologist at University Hospital, Umeå, and his colleagues involved 113 habitual snorers and 289 infrequent or nonsnorers. All had singleton pregnancies. On their delivery day, they and their partners completed a detailed questionnaire focusing on snoring, daytime tiredness, and witnessed sleep apneas.

Habitual snoring proved to be associated with significantly higher rates of preeclampsia, new-onset hypertension, facial edema, and edema at other sites. Heavy snoring was also associated with significantly higher rates of babies who were small for their gestational age and of low 1- and 5-minute Apgar scores.

“One of the really important things to remember is that if a woman has sleep apnea and she delivers a baby, she's going to be very, very sleepy and will have a great deal of difficulty caring for a newborn,” Dr. Kryger said. In fact, this sleep disturbance and the resultant feelings of maternal inadequacy because of profound fatigue can prove a factor in postpartum depression, the most common complication of childbearing, Dr. Kryger said.

The Swedish study is one of several that have identified obesity as the major risk factor for sleep apnea in pregnancy. Habitual snorers in pregnancy were considerably heavier before pregnancy and gained more weight during pregnancy than did the infrequent snorers.

The link between habitual snoring and pregnancy-induced hypertension reported by Dr. Franklin and his coworkers has also been found by others. Preeclampsia has been associated not only with upper airway narrowing, snoring, and frequent arousals from sleep, but also with restless legs syndrome and other periodic limb movements. “A pregnant woman who develops hypertension or protein in the urine may need to have a sleep evaluation,” Dr. Kryger said.

The good news, only recently documented, is that sleep-disordered breathing arising in late pregnancy often improves following parturition, according to Dr. Kryger, who pointed to a study by Natalie Edwards, Ph.D., and her colleagues at the University of Sydney (Australia). In 10 women referred for sleep-disordered breathing in the third trimester, significant improvements were found in the apnea-hypopnea index, and minimum arterial oxyhemoglobin saturation occurred in all 10 postnatally (Sleep 2005;28:737–41). Peak arterial blood pressure responses to apnea also dropped markedly.

DENVER – Obstructive sleep apnea is far more common during pregnancy than most physicians realize and in its more severe forms can jeopardize the fetus, Meir H. Kryger, M.D., said at a satellite symposium held in conjunction with the annual meeting of the Associated Professional Sleep Societies.

“I've had cases of sleep apnea in pregnant women who actually before diagnosis had several spontaneous abortions. I have no doubt that in some cases the baby was lost when it became very, very hypoxic,” added Dr. Kryger, professor of medicine and director of the sleep disorders center at the University of Manitoba, Winnipeg.

The treatment for obstructive sleep apnea in pregnancy is continuous positive airway pressure (CPAP). It's considered safe for both mother and fetus.

The prevalence of habitual snoring–that is, snoring nearly every night–climbs from 4% in nonpregnant women to 14%–23% during pregnancy. The increase during pregnancy is believed to be due to weight gain coupled with hormonally induced changes in the elasticity of the pharyngeal airway and other tissues.

“Sleep apnea is actually quite common in pregnant women. I don't know why more doctors don't pick it up,” Dr. Kryger said.

He advises routinely performing polysomnography in pregnant heavy snorers (especially if they are also observed to stop breathing), treating with CPAP those who meet the criteria for obstructive sleep apnea, and repeating the sleep lab testing post partum. The reason he advocates an aggressive approach is the documented adverse effects of heavy snoring in pregnancy. He pointed to a Swedish study conducted several years ago that highlighted the implications of heavy snoring during pregnancy.

The study by Karl A. Franklin, M.D., Ph.D., a pulmonologist at University Hospital, Umeå, and his colleagues involved 113 habitual snorers and 289 infrequent or nonsnorers. All had singleton pregnancies. On their delivery day, they and their partners completed a detailed questionnaire focusing on snoring, daytime tiredness, and witnessed sleep apneas.

Habitual snoring proved to be associated with significantly higher rates of preeclampsia, new-onset hypertension, facial edema, and edema at other sites. Heavy snoring was also associated with significantly higher rates of babies who were small for their gestational age and of low 1- and 5-minute Apgar scores.

“One of the really important things to remember is that if a woman has sleep apnea and she delivers a baby, she's going to be very, very sleepy and will have a great deal of difficulty caring for a newborn,” Dr. Kryger said. In fact, this sleep disturbance and the resultant feelings of maternal inadequacy because of profound fatigue can prove a factor in postpartum depression, the most common complication of childbearing, Dr. Kryger said.

The Swedish study is one of several that have identified obesity as the major risk factor for sleep apnea in pregnancy. Habitual snorers in pregnancy were considerably heavier before pregnancy and gained more weight during pregnancy than did the infrequent snorers.

The link between habitual snoring and pregnancy-induced hypertension reported by Dr. Franklin and his coworkers has also been found by others. Preeclampsia has been associated not only with upper airway narrowing, snoring, and frequent arousals from sleep, but also with restless legs syndrome and other periodic limb movements. “A pregnant woman who develops hypertension or protein in the urine may need to have a sleep evaluation,” Dr. Kryger said.

The good news, only recently documented, is that sleep-disordered breathing arising in late pregnancy often improves following parturition, according to Dr. Kryger, who pointed to a study by Natalie Edwards, Ph.D., and her colleagues at the University of Sydney (Australia). In 10 women referred for sleep-disordered breathing in the third trimester, significant improvements were found in the apnea-hypopnea index, and minimum arterial oxyhemoglobin saturation occurred in all 10 postnatally (Sleep 2005;28:737–41). Peak arterial blood pressure responses to apnea also dropped markedly.

ATLANTA – Psychiatrists treating depression associated with an acute coronary event should look to severity of a depressive episode, recurrence of major depression, and the onset of depression prior to hospitalization as predictors of drug benefit.

Most clinicians will typically consider severity in evaluating whether to treat depressed patients, but prior episodes of depression and the timing of the onset of the present episode are also important factors in assessing the possible success of drug treatment, Alexander H. Glassman, M.D., said at the annual meeting of the American Psychiatric Association.

These “two historic considerations, [which] most clinicians never use in deciding who to treat, have a very strong impact on who's going to have a drug response,” said Dr. Glassman, who is professor of clinical psychiatry at Columbia University, New York.

Even without proof of reduced mortality, depression associated with an acute coronary event can be safely and effectively treated, he said.

Dr. Glassman pointed to the results from the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), which looked at the effects of sertraline versus placebo in patients who suffered from depression that was associated with acute MI or unstable angina (JAMA 2002;288:701–9).

Dr. Glassman was a member of the steering committee for SADHART and has been a consultant for Pfizer, which markets sertraline (Zoloft).

The trial included 369 patients who were given a 2-week single-blind placebo run-in and then randomly assigned to receive sertraline or placebo for 24 weeks.

The patients selected for SADHART were not seeking psychiatric treatment and, as a result, the sample had much milder depression and depressive episodes that were shorter than would normally be expected in a typical drug trial.

The effect of the drug was modest in the overall sample, but for those patients with recurrent depression–about half of the sample–the results were dramatically different, Dr. Glassman said at the meeting.

Of those patients with no prior episodes of depression, about 59% responded to the drug, compared with 55% on placebo.

In the case of patients with any recurrent depression, however, there was a very real difference, with 72% getting better on the drug versus 51% on placebo.

The SADHART study also showed that more than half of the cases of depression began before hospitalization for the coronary event. Of those patients whose depression began before hospitalization, 93% began more than a month before and could have contributed to the heart attack, Dr. Glassman said.

Similarly, the time of onset was also a predictor of drug response. The SADHART study showed that, of those patients who had depression onset in the hospital, there was no drug-placebo difference.

In the group with earlier onset of depression, though, 63% responded to the drug, compared with 46% on placebo, he said.

When the patient had both prior history of depression and onset before hospitalization, the drug was effective in 73% of patients, compared with 43% for placebo.

Even though the evidence that depression is a risk factor for cardiovascular events is overwhelming, specialists outside of psychiatry have been slow to pick it up.

Academic institutions are just beginning to recognize it as a risk factor, and in the general community hospital setting, recognition is poor, Dr. Glassman said.

There is more to the story, however: Those in other areas of medicine may be overlooking depression, but psychiatrists generally don't ask patients about their medical risk factors, he said.

“We see patients in our office all the time who are depressed, and I'll bet that the majority of people in this room can't tell if all their patients are smokers or not,” Dr. Glassman said.

ATLANTA – Psychiatrists treating depression associated with an acute coronary event should look to severity of a depressive episode, recurrence of major depression, and the onset of depression prior to hospitalization as predictors of drug benefit.

Most clinicians will typically consider severity in evaluating whether to treat depressed patients, but prior episodes of depression and the timing of the onset of the present episode are also important factors in assessing the possible success of drug treatment, Alexander H. Glassman, M.D., said at the annual meeting of the American Psychiatric Association.

These “two historic considerations, [which] most clinicians never use in deciding who to treat, have a very strong impact on who's going to have a drug response,” said Dr. Glassman, who is professor of clinical psychiatry at Columbia University, New York.

Even without proof of reduced mortality, depression associated with an acute coronary event can be safely and effectively treated, he said.

Dr. Glassman pointed to the results from the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), which looked at the effects of sertraline versus placebo in patients who suffered from depression that was associated with acute MI or unstable angina (JAMA 2002;288:701–9).

Dr. Glassman was a member of the steering committee for SADHART and has been a consultant for Pfizer, which markets sertraline (Zoloft).

The trial included 369 patients who were given a 2-week single-blind placebo run-in and then randomly assigned to receive sertraline or placebo for 24 weeks.

The patients selected for SADHART were not seeking psychiatric treatment and, as a result, the sample had much milder depression and depressive episodes that were shorter than would normally be expected in a typical drug trial.

The effect of the drug was modest in the overall sample, but for those patients with recurrent depression–about half of the sample–the results were dramatically different, Dr. Glassman said at the meeting.

Of those patients with no prior episodes of depression, about 59% responded to the drug, compared with 55% on placebo.

In the case of patients with any recurrent depression, however, there was a very real difference, with 72% getting better on the drug versus 51% on placebo.

The SADHART study also showed that more than half of the cases of depression began before hospitalization for the coronary event. Of those patients whose depression began before hospitalization, 93% began more than a month before and could have contributed to the heart attack, Dr. Glassman said.

Similarly, the time of onset was also a predictor of drug response. The SADHART study showed that, of those patients who had depression onset in the hospital, there was no drug-placebo difference.

In the group with earlier onset of depression, though, 63% responded to the drug, compared with 46% on placebo, he said.

When the patient had both prior history of depression and onset before hospitalization, the drug was effective in 73% of patients, compared with 43% for placebo.

Even though the evidence that depression is a risk factor for cardiovascular events is overwhelming, specialists outside of psychiatry have been slow to pick it up.

Academic institutions are just beginning to recognize it as a risk factor, and in the general community hospital setting, recognition is poor, Dr. Glassman said.

There is more to the story, however: Those in other areas of medicine may be overlooking depression, but psychiatrists generally don't ask patients about their medical risk factors, he said.

“We see patients in our office all the time who are depressed, and I'll bet that the majority of people in this room can't tell if all their patients are smokers or not,” Dr. Glassman said.

ATLANTA – Psychiatrists treating depression associated with an acute coronary event should look to severity of a depressive episode, recurrence of major depression, and the onset of depression prior to hospitalization as predictors of drug benefit.

Most clinicians will typically consider severity in evaluating whether to treat depressed patients, but prior episodes of depression and the timing of the onset of the present episode are also important factors in assessing the possible success of drug treatment, Alexander H. Glassman, M.D., said at the annual meeting of the American Psychiatric Association.

These “two historic considerations, [which] most clinicians never use in deciding who to treat, have a very strong impact on who's going to have a drug response,” said Dr. Glassman, who is professor of clinical psychiatry at Columbia University, New York.

Even without proof of reduced mortality, depression associated with an acute coronary event can be safely and effectively treated, he said.

Dr. Glassman pointed to the results from the Sertraline Antidepressant Heart Attack Randomized Trial (SADHART), which looked at the effects of sertraline versus placebo in patients who suffered from depression that was associated with acute MI or unstable angina (JAMA 2002;288:701–9).

Dr. Glassman was a member of the steering committee for SADHART and has been a consultant for Pfizer, which markets sertraline (Zoloft).

The trial included 369 patients who were given a 2-week single-blind placebo run-in and then randomly assigned to receive sertraline or placebo for 24 weeks.

The patients selected for SADHART were not seeking psychiatric treatment and, as a result, the sample had much milder depression and depressive episodes that were shorter than would normally be expected in a typical drug trial.

The effect of the drug was modest in the overall sample, but for those patients with recurrent depression–about half of the sample–the results were dramatically different, Dr. Glassman said at the meeting.

Of those patients with no prior episodes of depression, about 59% responded to the drug, compared with 55% on placebo.

In the case of patients with any recurrent depression, however, there was a very real difference, with 72% getting better on the drug versus 51% on placebo.

The SADHART study also showed that more than half of the cases of depression began before hospitalization for the coronary event. Of those patients whose depression began before hospitalization, 93% began more than a month before and could have contributed to the heart attack, Dr. Glassman said.

Similarly, the time of onset was also a predictor of drug response. The SADHART study showed that, of those patients who had depression onset in the hospital, there was no drug-placebo difference.

In the group with earlier onset of depression, though, 63% responded to the drug, compared with 46% on placebo, he said.

When the patient had both prior history of depression and onset before hospitalization, the drug was effective in 73% of patients, compared with 43% for placebo.

Even though the evidence that depression is a risk factor for cardiovascular events is overwhelming, specialists outside of psychiatry have been slow to pick it up.

Academic institutions are just beginning to recognize it as a risk factor, and in the general community hospital setting, recognition is poor, Dr. Glassman said.

There is more to the story, however: Those in other areas of medicine may be overlooking depression, but psychiatrists generally don't ask patients about their medical risk factors, he said.

“We see patients in our office all the time who are depressed, and I'll bet that the majority of people in this room can't tell if all their patients are smokers or not,” Dr. Glassman said.

VANCOUVER, B.C. – Depressed patients with coronary artery disease are less likely to take prescribed medications than are those who are not depressed, Karina W. Davidson, Ph.D., and Mary Whooley, M.D., reported in separate presentations at the annual meeting of the American Psychosomatic Society.

The findings from two large trials both suggest that medication nonadherence is one possible mechanism by which depression adversely impacts cardiovascular disease outcome, the investigators said.

Dr. Davidson, of Columbia University, New York, reported her findings from the Coronary Psychosocial Evaluation Study, funded by the National Heart, Lung, and Blood Institute. Unlike previous adherence studies that have relied on patient self-reports, this one employed the Medication Event Monitoring System, in which an electronic device is stored in the cap of a pill bottle that records the date and time the container is opened.

The study involved 65 patients with acute coronary syndrome (ST- and non-ST-elevation myocardial infarction or unstable angina) who were prescribed a daily dose of either 81 mg or 325 mg of aspirin and were given a 90-day supply upon hospital discharge. Pill data were downloaded at 1-month and 3-month follow-up visits.

A total of 29 patients were considered nondepressed, having scored 0–4 on the Beck Depression Inventory (BDI) at baseline (in the hospital 1 week after the initial cardiac event). Another 17 patients who scored 10 or greater on the BDI at baseline but subsequently dropped below a score of 10 at 3 months were classified as “remittent depressed,” while the remaining 19 patients who scored 10 or above on the BDI at both baseline and 3 months were classified as persistently depressed.

The persistently depressed patients were more likely than were the other two groups to be female and Hispanic, and to have lower levels of education and family income. All three groups were similar with regard to age, race, and current employment, she said.

Adherence–defined as the percentage of days that the correct dose of aspirin was taken–was 67% for the persistently depressed group, compared with 86% for the remittent depressed and 87% for the nondepressed patients. The difference between the persistent and remittent groups was not explained by baseline BDI severity, which differed only slightly (17 persistent vs. 15.06 intermittent, compared with 1.9 in the nondepressed). Reports of side effects to aspirin did not differ between the groups.

“Persistently depressed patients are the ones uniquely not taking their medication,” Dr. Davidson noted, adding that the results are particularly noteworthy given that the aspirin regimen is a once-daily pill. “This is the simplest, easiest medicine for patients to take, [yet] the persistently depressed are taking it two-thirds of the time they're supposed to.”

In the other study, presented by Dr. Whooley, depressed heart disease patients tended to skip prescribed β-blockers.

The cross-sectional data came from the Heart and Soul Study, a cohort investigation of potential mechanisms linking depression and cardiovascular outcomes. Of 1,024 patients with known coronary disease, 940 were taking one or more cardiac medications, including β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), aspirin, and/or statins.

All of the patients had stable disease, with none having had an acute coronary syndrome in the previous 6 months, noted Dr. Whooley, who is with the departments of medicine, epidemiology, and biostatistics at the University of California, San Francisco.

Current major depression–as measured by the Diagnostic Interview Schedule and the Patient Health Questionnaire–was present in 22% (204) of the 940 patients.

Those with depression were younger (62 vs. 69 years), more likely to be female (27% vs. 13%), and to be current smokers (31% vs. 16%). The groups were similar with regard to race, education, proportion with MI (52% depressed/57% nondepressed), and were taking similar numbers of cardiac medications (2.6 depressed/2.8 nondepressed).

Patients were considered adherent if they said they took their medications as prescribed “all” or “nearly all” of the time. Those who took their medications “most,” “about half,” or “less than half” of the time were classified as nonadherent.

Fourteen percent of depressed patients reported nonadherence, compared with 5% of the nondepressed, and the percentage reporting nonadherence increased with the number of depressive symptoms. After adjustment for several factors including race, education, and current angina, depressed patients were more than twice as likely to report not taking their medication as prescribed, Dr. Whooley said.

VANCOUVER, B.C. – Depressed patients with coronary artery disease are less likely to take prescribed medications than are those who are not depressed, Karina W. Davidson, Ph.D., and Mary Whooley, M.D., reported in separate presentations at the annual meeting of the American Psychosomatic Society.

The findings from two large trials both suggest that medication nonadherence is one possible mechanism by which depression adversely impacts cardiovascular disease outcome, the investigators said.

Dr. Davidson, of Columbia University, New York, reported her findings from the Coronary Psychosocial Evaluation Study, funded by the National Heart, Lung, and Blood Institute. Unlike previous adherence studies that have relied on patient self-reports, this one employed the Medication Event Monitoring System, in which an electronic device is stored in the cap of a pill bottle that records the date and time the container is opened.

The study involved 65 patients with acute coronary syndrome (ST- and non-ST-elevation myocardial infarction or unstable angina) who were prescribed a daily dose of either 81 mg or 325 mg of aspirin and were given a 90-day supply upon hospital discharge. Pill data were downloaded at 1-month and 3-month follow-up visits.

A total of 29 patients were considered nondepressed, having scored 0–4 on the Beck Depression Inventory (BDI) at baseline (in the hospital 1 week after the initial cardiac event). Another 17 patients who scored 10 or greater on the BDI at baseline but subsequently dropped below a score of 10 at 3 months were classified as “remittent depressed,” while the remaining 19 patients who scored 10 or above on the BDI at both baseline and 3 months were classified as persistently depressed.

The persistently depressed patients were more likely than were the other two groups to be female and Hispanic, and to have lower levels of education and family income. All three groups were similar with regard to age, race, and current employment, she said.

Adherence–defined as the percentage of days that the correct dose of aspirin was taken–was 67% for the persistently depressed group, compared with 86% for the remittent depressed and 87% for the nondepressed patients. The difference between the persistent and remittent groups was not explained by baseline BDI severity, which differed only slightly (17 persistent vs. 15.06 intermittent, compared with 1.9 in the nondepressed). Reports of side effects to aspirin did not differ between the groups.

“Persistently depressed patients are the ones uniquely not taking their medication,” Dr. Davidson noted, adding that the results are particularly noteworthy given that the aspirin regimen is a once-daily pill. “This is the simplest, easiest medicine for patients to take, [yet] the persistently depressed are taking it two-thirds of the time they're supposed to.”

In the other study, presented by Dr. Whooley, depressed heart disease patients tended to skip prescribed β-blockers.

The cross-sectional data came from the Heart and Soul Study, a cohort investigation of potential mechanisms linking depression and cardiovascular outcomes. Of 1,024 patients with known coronary disease, 940 were taking one or more cardiac medications, including β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), aspirin, and/or statins.

All of the patients had stable disease, with none having had an acute coronary syndrome in the previous 6 months, noted Dr. Whooley, who is with the departments of medicine, epidemiology, and biostatistics at the University of California, San Francisco.

Current major depression–as measured by the Diagnostic Interview Schedule and the Patient Health Questionnaire–was present in 22% (204) of the 940 patients.

Those with depression were younger (62 vs. 69 years), more likely to be female (27% vs. 13%), and to be current smokers (31% vs. 16%). The groups were similar with regard to race, education, proportion with MI (52% depressed/57% nondepressed), and were taking similar numbers of cardiac medications (2.6 depressed/2.8 nondepressed).

Patients were considered adherent if they said they took their medications as prescribed “all” or “nearly all” of the time. Those who took their medications “most,” “about half,” or “less than half” of the time were classified as nonadherent.

Fourteen percent of depressed patients reported nonadherence, compared with 5% of the nondepressed, and the percentage reporting nonadherence increased with the number of depressive symptoms. After adjustment for several factors including race, education, and current angina, depressed patients were more than twice as likely to report not taking their medication as prescribed, Dr. Whooley said.

VANCOUVER, B.C. – Depressed patients with coronary artery disease are less likely to take prescribed medications than are those who are not depressed, Karina W. Davidson, Ph.D., and Mary Whooley, M.D., reported in separate presentations at the annual meeting of the American Psychosomatic Society.

The findings from two large trials both suggest that medication nonadherence is one possible mechanism by which depression adversely impacts cardiovascular disease outcome, the investigators said.

Dr. Davidson, of Columbia University, New York, reported her findings from the Coronary Psychosocial Evaluation Study, funded by the National Heart, Lung, and Blood Institute. Unlike previous adherence studies that have relied on patient self-reports, this one employed the Medication Event Monitoring System, in which an electronic device is stored in the cap of a pill bottle that records the date and time the container is opened.

The study involved 65 patients with acute coronary syndrome (ST- and non-ST-elevation myocardial infarction or unstable angina) who were prescribed a daily dose of either 81 mg or 325 mg of aspirin and were given a 90-day supply upon hospital discharge. Pill data were downloaded at 1-month and 3-month follow-up visits.

A total of 29 patients were considered nondepressed, having scored 0–4 on the Beck Depression Inventory (BDI) at baseline (in the hospital 1 week after the initial cardiac event). Another 17 patients who scored 10 or greater on the BDI at baseline but subsequently dropped below a score of 10 at 3 months were classified as “remittent depressed,” while the remaining 19 patients who scored 10 or above on the BDI at both baseline and 3 months were classified as persistently depressed.

The persistently depressed patients were more likely than were the other two groups to be female and Hispanic, and to have lower levels of education and family income. All three groups were similar with regard to age, race, and current employment, she said.

Adherence–defined as the percentage of days that the correct dose of aspirin was taken–was 67% for the persistently depressed group, compared with 86% for the remittent depressed and 87% for the nondepressed patients. The difference between the persistent and remittent groups was not explained by baseline BDI severity, which differed only slightly (17 persistent vs. 15.06 intermittent, compared with 1.9 in the nondepressed). Reports of side effects to aspirin did not differ between the groups.

“Persistently depressed patients are the ones uniquely not taking their medication,” Dr. Davidson noted, adding that the results are particularly noteworthy given that the aspirin regimen is a once-daily pill. “This is the simplest, easiest medicine for patients to take, [yet] the persistently depressed are taking it two-thirds of the time they're supposed to.”

In the other study, presented by Dr. Whooley, depressed heart disease patients tended to skip prescribed β-blockers.

The cross-sectional data came from the Heart and Soul Study, a cohort investigation of potential mechanisms linking depression and cardiovascular outcomes. Of 1,024 patients with known coronary disease, 940 were taking one or more cardiac medications, including β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), aspirin, and/or statins.

All of the patients had stable disease, with none having had an acute coronary syndrome in the previous 6 months, noted Dr. Whooley, who is with the departments of medicine, epidemiology, and biostatistics at the University of California, San Francisco.

Current major depression–as measured by the Diagnostic Interview Schedule and the Patient Health Questionnaire–was present in 22% (204) of the 940 patients.

Those with depression were younger (62 vs. 69 years), more likely to be female (27% vs. 13%), and to be current smokers (31% vs. 16%). The groups were similar with regard to race, education, proportion with MI (52% depressed/57% nondepressed), and were taking similar numbers of cardiac medications (2.6 depressed/2.8 nondepressed).

Patients were considered adherent if they said they took their medications as prescribed “all” or “nearly all” of the time. Those who took their medications “most,” “about half,” or “less than half” of the time were classified as nonadherent.

Fourteen percent of depressed patients reported nonadherence, compared with 5% of the nondepressed, and the percentage reporting nonadherence increased with the number of depressive symptoms. After adjustment for several factors including race, education, and current angina, depressed patients were more than twice as likely to report not taking their medication as prescribed, Dr. Whooley said.

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

Reception of a living liver graft is more acceptable in German and American culture than it is in Japanese society, according to data from a study of 330 undergraduate medical students from Germany, Japan, and the United States.

Liver transplantation from a living donor is becoming more common, but ethical questions remain as to donor morbidity and mortality after the operation, said Marc H. Dahlke, M.D., of the University of Regensburg (Germany) and his colleagues.

They compared attitudes toward living liver donation among people from three different nations with comparable socioeconomic structures but diversity in traditional values, religious beliefs, and politics. A total of 165 German students, 99 Japanese students, and 66 American students completed the 28-item questionnaire.

Most of the German and American students said they would accept a living liver donation under any circumstances, while most of Japanese students were undecided. Most of the students from all three nations, however, would accept a living liver graft in a life-and-death situation (Psychosomatics 2005;46:58–64).

The willingness to accept a living liver donation decreased across all groups if there was a significant risk to the donor and if it was suggested that the results from a living donation would be worse than a cadaveric donation. In addition, American and German students were more willing than Japanese students to receive a cadaveric liver instead of a living liver.

The study was supported by a grant from Roche Germany and by Fujisawa Germany.

NEW ORLEANS – Cognitive-behavioral therapy reduced depressive symptoms and enhanced immune function in a small pilot study of women with depression following coronary artery bypass graft surgery, Lynn V. Doering, D.N.Sc., reported at the annual scientific sessions of the American Heart Association.

Women who received a course of cognative-behavioral therapy (CBT) also experienced significantly fewer colds and other minor infectious illness episodes during 6 months of follow-up than did depressed controls who got usual care, said Dr. Doering, chair of the acute care section in the school of nursing at the University of California, Los Angeles.

An estimated 20% of patients experience major depression following CABG surgery. They have worse outcomes than nondepressed patients post CABG. To learn more about the relationship between depression and immunity after CABG, Dr. Doering and her coinvestigators twice interviewed 52 women post CABG, once at hospital discharge and again 2 weeks later.

Based upon these interviews, 15 patients were diagnosed as having major depression. They were randomized to an 8-week program of individual CBT or usual care, consisting of routine postoperative medical and nursing follow-up, plus a consultation by a psychiatrist.

Depressed controls were found to have significantly fewer circulating natural killer cells and higher levels of inflammatory mediators such as interleukin-6, interleukin-1β, and C-reactive protein than nondepressed patients at both 2 weeks and 6 months after discharge.

In contrast, CBT was associated with moderate to large improvements in natural killer cell count and activity, inflammatory mediators, number of infectious illness episodes, and depressive symptoms.

At 6 months none of the CBT-treated patients remained clinically depressed, whereas three of eight patients in the usual care group met diagnostic criteria for major depression and another had minor depression.

Although the study size was far too small to draw definitive conclusions, the results suggest CBT holds promise for treatment of post-CABG depression as well as for immune enhancement in this immunologically compromised population, she said.

NEW ORLEANS – Cognitive-behavioral therapy reduced depressive symptoms and enhanced immune function in a small pilot study of women with depression following coronary artery bypass graft surgery, Lynn V. Doering, D.N.Sc., reported at the annual scientific sessions of the American Heart Association.

Women who received a course of cognative-behavioral therapy (CBT) also experienced significantly fewer colds and other minor infectious illness episodes during 6 months of follow-up than did depressed controls who got usual care, said Dr. Doering, chair of the acute care section in the school of nursing at the University of California, Los Angeles.

An estimated 20% of patients experience major depression following CABG surgery. They have worse outcomes than nondepressed patients post CABG. To learn more about the relationship between depression and immunity after CABG, Dr. Doering and her coinvestigators twice interviewed 52 women post CABG, once at hospital discharge and again 2 weeks later.

Based upon these interviews, 15 patients were diagnosed as having major depression. They were randomized to an 8-week program of individual CBT or usual care, consisting of routine postoperative medical and nursing follow-up, plus a consultation by a psychiatrist.

Depressed controls were found to have significantly fewer circulating natural killer cells and higher levels of inflammatory mediators such as interleukin-6, interleukin-1β, and C-reactive protein than nondepressed patients at both 2 weeks and 6 months after discharge.

In contrast, CBT was associated with moderate to large improvements in natural killer cell count and activity, inflammatory mediators, number of infectious illness episodes, and depressive symptoms.

At 6 months none of the CBT-treated patients remained clinically depressed, whereas three of eight patients in the usual care group met diagnostic criteria for major depression and another had minor depression.

Although the study size was far too small to draw definitive conclusions, the results suggest CBT holds promise for treatment of post-CABG depression as well as for immune enhancement in this immunologically compromised population, she said.

NEW ORLEANS – Cognitive-behavioral therapy reduced depressive symptoms and enhanced immune function in a small pilot study of women with depression following coronary artery bypass graft surgery, Lynn V. Doering, D.N.Sc., reported at the annual scientific sessions of the American Heart Association.

Women who received a course of cognative-behavioral therapy (CBT) also experienced significantly fewer colds and other minor infectious illness episodes during 6 months of follow-up than did depressed controls who got usual care, said Dr. Doering, chair of the acute care section in the school of nursing at the University of California, Los Angeles.

An estimated 20% of patients experience major depression following CABG surgery. They have worse outcomes than nondepressed patients post CABG. To learn more about the relationship between depression and immunity after CABG, Dr. Doering and her coinvestigators twice interviewed 52 women post CABG, once at hospital discharge and again 2 weeks later.

Based upon these interviews, 15 patients were diagnosed as having major depression. They were randomized to an 8-week program of individual CBT or usual care, consisting of routine postoperative medical and nursing follow-up, plus a consultation by a psychiatrist.

Depressed controls were found to have significantly fewer circulating natural killer cells and higher levels of inflammatory mediators such as interleukin-6, interleukin-1β, and C-reactive protein than nondepressed patients at both 2 weeks and 6 months after discharge.

In contrast, CBT was associated with moderate to large improvements in natural killer cell count and activity, inflammatory mediators, number of infectious illness episodes, and depressive symptoms.

At 6 months none of the CBT-treated patients remained clinically depressed, whereas three of eight patients in the usual care group met diagnostic criteria for major depression and another had minor depression.

Although the study size was far too small to draw definitive conclusions, the results suggest CBT holds promise for treatment of post-CABG depression as well as for immune enhancement in this immunologically compromised population, she said.

Spinal surgery patients exposed to increased sunlight in their hospital rooms used 22% less pain medication per hour than those not exposed to the additional sunlight, said Jeffrey M. Walch of the University of Pittsburgh and his colleagues.

In the prospective study, 44 patients were situated on the bright side and 45 patients on the dim side of the same hospital unit. Their mean age was 59 years, and the mean length of stay was 3.5 days (Psychosom. Med. 2005;67:156–63).

Patients on the bright side of the unit received 46% more natural light than the patients on the dim side. The colors of the hospital rooms and the patients' gowns were alike, so they were not confounding factors.

Patients exposed to additional sunlight spent 21% less on pain medication, compared with the other patients. Upon discharge from the hospital, those patients who were from the bright side also reported significantly less perceived stress and slightly less pain, although the difference in reported pain was not statistically significant.

“An optimal therapeutic hospital design may maximize sunlight exposure for patients with high use of analgesic medication,” Mr. Walch and his associates noted. A reduction in opioid use, they added, could improve the dose-dependent side effects common in postoperative patients.

Spinal surgery patients exposed to increased sunlight in their hospital rooms used 22% less pain medication per hour than those not exposed to the additional sunlight, said Jeffrey M. Walch of the University of Pittsburgh and his colleagues.

In the prospective study, 44 patients were situated on the bright side and 45 patients on the dim side of the same hospital unit. Their mean age was 59 years, and the mean length of stay was 3.5 days (Psychosom. Med. 2005;67:156–63).

Patients on the bright side of the unit received 46% more natural light than the patients on the dim side. The colors of the hospital rooms and the patients' gowns were alike, so they were not confounding factors.

Patients exposed to additional sunlight spent 21% less on pain medication, compared with the other patients. Upon discharge from the hospital, those patients who were from the bright side also reported significantly less perceived stress and slightly less pain, although the difference in reported pain was not statistically significant.

“An optimal therapeutic hospital design may maximize sunlight exposure for patients with high use of analgesic medication,” Mr. Walch and his associates noted. A reduction in opioid use, they added, could improve the dose-dependent side effects common in postoperative patients.

Spinal surgery patients exposed to increased sunlight in their hospital rooms used 22% less pain medication per hour than those not exposed to the additional sunlight, said Jeffrey M. Walch of the University of Pittsburgh and his colleagues.

In the prospective study, 44 patients were situated on the bright side and 45 patients on the dim side of the same hospital unit. Their mean age was 59 years, and the mean length of stay was 3.5 days (Psychosom. Med. 2005;67:156–63).

Patients on the bright side of the unit received 46% more natural light than the patients on the dim side. The colors of the hospital rooms and the patients' gowns were alike, so they were not confounding factors.

Patients exposed to additional sunlight spent 21% less on pain medication, compared with the other patients. Upon discharge from the hospital, those patients who were from the bright side also reported significantly less perceived stress and slightly less pain, although the difference in reported pain was not statistically significant.

“An optimal therapeutic hospital design may maximize sunlight exposure for patients with high use of analgesic medication,” Mr. Walch and his associates noted. A reduction in opioid use, they added, could improve the dose-dependent side effects common in postoperative patients.

BOSTON – A test measuring somatization can predict which patients with chronic headaches will benefit from outpatient care and which ones won't–and will instead require intensive inpatient therapy, according to a new study.

The next step is to explore whether it is possible to calculate an exact cutoff score that would signal which patients should skip outpatient care and go directly to inpatient therapy, Dana Brendza, Psy.D., and associates suggested in a poster presented at the annual meeting of the American Pain Society.

Dr. Brendza and associates at the Cleveland Clinic studied the medical records of 213 patients enrolled in the multidisciplinary treatment program of an outpatient neurology headache clinic. Neurologists had referred the patients, predominantly white women aged 17–85, for psychological evaluation. All patients filled out the 344-item Personality Assessment Inventory (PAI), a tool used for assessing personality and psychopathology.

As a group, the patients' scores on the Somatic Complaints subscale were significantly elevated (two standard deviations above normal). Individually, the scores of more than half (51.6%) were considered clinically elevated.

The researchers took a closer look at the patients who failed outpatient treatment and required referral to the inpatient pain program. Their scores on the Somatic Complaints scale were significantly higher than the scores of patients who did not fail outpatient therapy.

Elevated scores on another measure (the Physical Symptoms subscale of the Depression scale) showed they were also more likely to be tuned in to physical symptoms.

The findings are consistent with a common belief among chronic headache patients that their malady is rooted in physical causes, not primarily psychological ones, coauthor Kathleen Ashton, Ph.D., explained in an interview.

The results also reinforce previous research suggesting that disability is often more intractable in headache patients who suffer from anxiety and mood disorders.

“The PAI Somatic Complaints scale may be useful in identifying patients who are most likely to be referred to an intensive, inpatient chronic pain treatment program after failure to improve in traditional outpatient treatment for their headache disorders,” the researchers concluded.

In patients with high scores, “there is probably an underlying emotional component to this pain that's not being addressed in outpatient therapy,” Dr. Ashton suggested. In addition, headache patients scoring lower on the Somatic Complaints scale are probably more amenable to psychological therapy, she said.

BOSTON – A test measuring somatization can predict which patients with chronic headaches will benefit from outpatient care and which ones won't–and will instead require intensive inpatient therapy, according to a new study.

The next step is to explore whether it is possible to calculate an exact cutoff score that would signal which patients should skip outpatient care and go directly to inpatient therapy, Dana Brendza, Psy.D., and associates suggested in a poster presented at the annual meeting of the American Pain Society.

Dr. Brendza and associates at the Cleveland Clinic studied the medical records of 213 patients enrolled in the multidisciplinary treatment program of an outpatient neurology headache clinic. Neurologists had referred the patients, predominantly white women aged 17–85, for psychological evaluation. All patients filled out the 344-item Personality Assessment Inventory (PAI), a tool used for assessing personality and psychopathology.

As a group, the patients' scores on the Somatic Complaints subscale were significantly elevated (two standard deviations above normal). Individually, the scores of more than half (51.6%) were considered clinically elevated.

The researchers took a closer look at the patients who failed outpatient treatment and required referral to the inpatient pain program. Their scores on the Somatic Complaints scale were significantly higher than the scores of patients who did not fail outpatient therapy.

Elevated scores on another measure (the Physical Symptoms subscale of the Depression scale) showed they were also more likely to be tuned in to physical symptoms.

The findings are consistent with a common belief among chronic headache patients that their malady is rooted in physical causes, not primarily psychological ones, coauthor Kathleen Ashton, Ph.D., explained in an interview.

The results also reinforce previous research suggesting that disability is often more intractable in headache patients who suffer from anxiety and mood disorders.

“The PAI Somatic Complaints scale may be useful in identifying patients who are most likely to be referred to an intensive, inpatient chronic pain treatment program after failure to improve in traditional outpatient treatment for their headache disorders,” the researchers concluded.

In patients with high scores, “there is probably an underlying emotional component to this pain that's not being addressed in outpatient therapy,” Dr. Ashton suggested. In addition, headache patients scoring lower on the Somatic Complaints scale are probably more amenable to psychological therapy, she said.

BOSTON – A test measuring somatization can predict which patients with chronic headaches will benefit from outpatient care and which ones won't–and will instead require intensive inpatient therapy, according to a new study.

The next step is to explore whether it is possible to calculate an exact cutoff score that would signal which patients should skip outpatient care and go directly to inpatient therapy, Dana Brendza, Psy.D., and associates suggested in a poster presented at the annual meeting of the American Pain Society.

Dr. Brendza and associates at the Cleveland Clinic studied the medical records of 213 patients enrolled in the multidisciplinary treatment program of an outpatient neurology headache clinic. Neurologists had referred the patients, predominantly white women aged 17–85, for psychological evaluation. All patients filled out the 344-item Personality Assessment Inventory (PAI), a tool used for assessing personality and psychopathology.

As a group, the patients' scores on the Somatic Complaints subscale were significantly elevated (two standard deviations above normal). Individually, the scores of more than half (51.6%) were considered clinically elevated.

The researchers took a closer look at the patients who failed outpatient treatment and required referral to the inpatient pain program. Their scores on the Somatic Complaints scale were significantly higher than the scores of patients who did not fail outpatient therapy.

Elevated scores on another measure (the Physical Symptoms subscale of the Depression scale) showed they were also more likely to be tuned in to physical symptoms.

The findings are consistent with a common belief among chronic headache patients that their malady is rooted in physical causes, not primarily psychological ones, coauthor Kathleen Ashton, Ph.D., explained in an interview.

The results also reinforce previous research suggesting that disability is often more intractable in headache patients who suffer from anxiety and mood disorders.

“The PAI Somatic Complaints scale may be useful in identifying patients who are most likely to be referred to an intensive, inpatient chronic pain treatment program after failure to improve in traditional outpatient treatment for their headache disorders,” the researchers concluded.

In patients with high scores, “there is probably an underlying emotional component to this pain that's not being addressed in outpatient therapy,” Dr. Ashton suggested. In addition, headache patients scoring lower on the Somatic Complaints scale are probably more amenable to psychological therapy, she said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.

Psychological stress either at work or at home raises the risk of myocardial infarction across all ethnic groups, all geographic regions, and both genders, reported Annika Rosengren, M.D., of Sahlgrenska University Hospital, Göteborg, Sweden, and her associates.

They assessed preexisting psychosocial stressors in 11,119 patients who had experienced acute MI and 13,648 controls matched for age, sex, and geographic location who were free of heart disease. The subjects, recruited at 262 medical centers in 52 countries over a 4-year period, were questioned about how often and how strongly they had experienced stress in the preceding year at home and at work. Internal stressors included feeling irritable, anxious, or depressed or having difficulty sleeping. External stressors included experiencing major adverse life events or serious financial distress, or having little control over life circumstances (Lancet 2004;364:953–62).

After the data were adjusted to account for cardiovascular risk factors, the MI patients showed consistently higher levels of stress and for a longer period than did controls. The size of this effect makes stress a much more important risk factor than is commonly recognized and a likely contributor to the incidence of MI, they said.

VANCOUVER, B.C. – Panic symptoms affect many patients with diabetes and are linked to depression and diabetes-related disability, Evette Ludman, Ph.D., and her associates reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Like other forms of anxiety, panic symptoms in diabetic patients are often associated with depression as well as poor diabetes-related functional and clinical indicators.

“Clinicians treating diabetic patients should be alert for panic symptoms as well as depressive symptoms. Panic episodes may be mistaken for hypoglycemia,” said Dr. Ludman, senior research associate at the Center for Health Studies, Group Health Cooperative (GHC), Seattle.

In a National Institute of Mental Health-supported study–the first to look specifically at panic symptoms in diabetic patients–surveys were sent to 9,063 individuals in a population-based diabetes registry from nine primary care clinics of GHC, a large HMO in western Washington. Complete data were available for 4,385, of whom 4.4% met criteria for panic disorder, defined as answering “yes” both when asked if they'd had “spells of panic or fear” during the past 2 weeks, and when asked if these feelings “forced you to change what you were doing at the time.”

Respondents who answered yes to both questions were significantly more likely to be female than were those who reported no panic symptoms (63.7% vs. 48.1%), to be employed (53.3% vs. 41.9%), and to also have a diagnosis of major depression (54.9% vs. 10.0%); they were also significantly younger (55.4 years vs. 63.7 years). Overall, 2.0% of the patients had panic but no major depression, 2.4% had both panic and major depression, and 9.5% had major depression without panic symptoms, Dr. Ludman and her associates reported.

Independent of depression, symptoms of panic were associated with higher hemoglobin A_1c values, a greater number of diabetes complications, higher levels of disability (using World Health Organization criteria), and lower social functioning. Unlike depression, panic was not associated with smoking or body mass index.

“Treatment for panic episodes is likely to positively impact diabetes symptoms, self-care, and quality of life among patients with diabetes,” Dr. Ludman said.

VANCOUVER, B.C. – Panic symptoms affect many patients with diabetes and are linked to depression and diabetes-related disability, Evette Ludman, Ph.D., and her associates reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Like other forms of anxiety, panic symptoms in diabetic patients are often associated with depression as well as poor diabetes-related functional and clinical indicators.

“Clinicians treating diabetic patients should be alert for panic symptoms as well as depressive symptoms. Panic episodes may be mistaken for hypoglycemia,” said Dr. Ludman, senior research associate at the Center for Health Studies, Group Health Cooperative (GHC), Seattle.

In a National Institute of Mental Health-supported study–the first to look specifically at panic symptoms in diabetic patients–surveys were sent to 9,063 individuals in a population-based diabetes registry from nine primary care clinics of GHC, a large HMO in western Washington. Complete data were available for 4,385, of whom 4.4% met criteria for panic disorder, defined as answering “yes” both when asked if they'd had “spells of panic or fear” during the past 2 weeks, and when asked if these feelings “forced you to change what you were doing at the time.”

Respondents who answered yes to both questions were significantly more likely to be female than were those who reported no panic symptoms (63.7% vs. 48.1%), to be employed (53.3% vs. 41.9%), and to also have a diagnosis of major depression (54.9% vs. 10.0%); they were also significantly younger (55.4 years vs. 63.7 years). Overall, 2.0% of the patients had panic but no major depression, 2.4% had both panic and major depression, and 9.5% had major depression without panic symptoms, Dr. Ludman and her associates reported.

Independent of depression, symptoms of panic were associated with higher hemoglobin A_1c values, a greater number of diabetes complications, higher levels of disability (using World Health Organization criteria), and lower social functioning. Unlike depression, panic was not associated with smoking or body mass index.

“Treatment for panic episodes is likely to positively impact diabetes symptoms, self-care, and quality of life among patients with diabetes,” Dr. Ludman said.

VANCOUVER, B.C. – Panic symptoms affect many patients with diabetes and are linked to depression and diabetes-related disability, Evette Ludman, Ph.D., and her associates reported in a poster presentation at the annual meeting of the American Psychosomatic Society.

Like other forms of anxiety, panic symptoms in diabetic patients are often associated with depression as well as poor diabetes-related functional and clinical indicators.

“Clinicians treating diabetic patients should be alert for panic symptoms as well as depressive symptoms. Panic episodes may be mistaken for hypoglycemia,” said Dr. Ludman, senior research associate at the Center for Health Studies, Group Health Cooperative (GHC), Seattle.

In a National Institute of Mental Health-supported study–the first to look specifically at panic symptoms in diabetic patients–surveys were sent to 9,063 individuals in a population-based diabetes registry from nine primary care clinics of GHC, a large HMO in western Washington. Complete data were available for 4,385, of whom 4.4% met criteria for panic disorder, defined as answering “yes” both when asked if they'd had “spells of panic or fear” during the past 2 weeks, and when asked if these feelings “forced you to change what you were doing at the time.”

Respondents who answered yes to both questions were significantly more likely to be female than were those who reported no panic symptoms (63.7% vs. 48.1%), to be employed (53.3% vs. 41.9%), and to also have a diagnosis of major depression (54.9% vs. 10.0%); they were also significantly younger (55.4 years vs. 63.7 years). Overall, 2.0% of the patients had panic but no major depression, 2.4% had both panic and major depression, and 9.5% had major depression without panic symptoms, Dr. Ludman and her associates reported.

Independent of depression, symptoms of panic were associated with higher hemoglobin A_1c values, a greater number of diabetes complications, higher levels of disability (using World Health Organization criteria), and lower social functioning. Unlike depression, panic was not associated with smoking or body mass index.

“Treatment for panic episodes is likely to positively impact diabetes symptoms, self-care, and quality of life among patients with diabetes,” Dr. Ludman said.