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ABSTRACT: BACKGROUND: This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure. METHOD: This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets-Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n=940,058). RESULTS: States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos. CONCLUSIONS: Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.
Drug and alcohol dependence 05/2013; · 3.60 Impact Factor
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ABSTRACT: AIMS: To examine the association between military deployment of a parent and use of alcohol and drugs among children of deployed military personnel. DESIGN: Observational and cross-sectional study. SETTING: Data from the 2010 Iowa [USA] Youth Survey, a statewide survey of 6th, 8th, and 11th graders, were analyzed during 2011. PARTICIPANTS: Of all 6th, 8th, and 11th grade students enrolled in Iowa in 2010, 69% (n=78,240) completed the survey. MEASUREMENTS: Ever drink more than a few sips of alcohol and past 30-day: binge drinking, marijuana consumption, other illegal drug use, and prescription drug misuse. FINDINGS: The odds of using alcohol (OR=1.44, 99.91%CI=1.21-1.70), binge drinking (OR=2.02, 99.91%CI=1.63-2.50), using marijuana (OR=2.22, 99.91%CI=1.69-2.92), using other illegal drugs (OR=3.73, 99.91%CI=2.81-4.94), and misusing prescription drugs (OR=2.51, 99.91%CI=2.00-3.16) are greater for children of currently or recently deployed parents than for children of parents who are not in the military. The magnitude of the effects is consistent across 6th, 8th, and 11th grades. Disrupted living arrangements further accentuate increased substance use, with the largest effect seen in children with a deployed parent who was not living with a parent or relative. CONCLUSIONS: Children of deployed military personnel should be considered at higher risk for substance use than children of non-military citizens.
Addiction 02/2013; · 4.31 Impact Factor
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ABSTRACT: Surveillance system indicators of morbidity, mortality, or behaviors are used to provide regional information for ever-smaller areas, most recently for ranking counties. These rankings are thought to provide information about the relative standing of regions and provide information about problem areas and the success of programs. We investigate the ability of such rankings to reliably assess health. We assess the reliability of several ranked health indices used at the county level and the consistency of an index's quality across different states. Reliability is assessed using an index of reliability, simulations, and the ability of an index to consistently identify the top 10 % (worst) counties within a state. There is marked variability across measures to provide consistent ranks, across states, and, many times, across states for a particular measure. A few health measures do consistently well, e.g., Teen Birth, Chlamydia, and Years of Potential Life Lost rates. While a few health rankings appear worthy of use for policy and in the identification of local problems, in general, they are not consistent across regions.
Prevention Science 02/2013; · 2.63 Impact Factor
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ABSTRACT: Evidence-based health indicators are vital to needs-based programming and epidemiological planning. Agencies frequently make programming funds available to local jurisdictions based on need. The use of objective indicators to determine need is attractive but assumes that selection of communities with the highest indicators reflects something other than random variability from sampling error.
The authors compare the statistical performance of two heterogeneity measures applied to community differences that provide tests for randomness and measures of the percentage of true community variation, as well as estimates of the true variation. One measure comes from the meta-analysis literature and the other from the simple Pearson chi-square statistic. Simulations of populations and an example using real data are provided.
The measure based on the simple chi-square statistic seems superior, offering better protection against Type I errors and providing more accurate estimates of the true community variance.
The heterogeneity measure based on Pearson's χ2 should be used to assess indices. Methods for improving poor indices are discussed.
Population Health Metrics 02/2011; 9(1):3. · 2.11 Impact Factor
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ABSTRACT: Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability.
To examine the effect of escitalopram on cognitive outcome. We hypothesized that patients who received escitalopram would show improved performance in neuropsychological tests assessing memory and executive functions than patients who received placebo or underwent Problem Solving Therapy.
Randomized trial.
Stroke center.
One hundred twenty-nine patients were treated within 3 months following stroke. The 12-month trial included 3 arms: a double-blind placebo-controlled comparison of escitalopram (n = 43) with placebo (n = 45), and a nonblinded arm of Problem Solving Therapy (n = 41).
Change in scores from baseline to the end of treatment for the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail-Making, Controlled Oral Word Association, Wechsler Adult Intelligence Scale-III Similarities, and Stroop tests.
We found a difference among the 3 treatment groups in change in RBANS total score (P < .01) and RBANS delayed memory score (P < .01). After adjusting for possible confounders, there was a significant effect of escitalopram treatment on the change in RBANS total score (P < .01, adjusted mean change in score: escitalopram group, 10.0; nonescitalopram group, 3.1) and the change in RBANS delayed memory score (P < .01, adjusted mean change in score: escitalopram group, 11.3; nonescitalopram group, 2.5). We did not observe treatment effects in other neuropsychological measures.
When compared with patients who received placebo or underwent Problem Solving Therapy, stroke patients who received escitalopram showed improvement in global cognitive functioning, specifically in verbal and visual memory functions. This beneficial effect of escitalopram was independent of its effect on depression. The utility of antidepressants in the process of poststroke recovery should be further investigated. Trial Registration clinicaltrials.gov Identifier: NCT00071643.
Archives of general psychiatry 02/2010; 67(2):187-96. · 12.26 Impact Factor
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ABSTRACT: As the use of atypical antipsychotics in children and adolescents has increased, concerns have been raised about their long-term safety. We aimed to investigate the association between risperidone-induced weight gain, leptin concentration, and the leptin gene (LEP) -2548G/A variants in youths.
Medically healthy 7- to 17-year-old children and adolescents, in extended naturalistic treatment with risperidone, were recruited through pediatric psychiatry clinics. Anthropometric measures and laboratory testing were conducted. Growth and medication history was obtained from the medical record. The effect of the LEP genotypes on leptin concentration and on the slopes of the weight and body mass index (BMI) Z-score curves before and after the onset of risperidone treatment was investigated .
In 74 individuals, chronically treated with risperidone, the A allele was associated with higher leptin concentration at low weight and BMI Z-scores. There was no effect of the LEP genotypes on weight or BMI Z-scores before risperidone was started. Afterwards, however, the A-allele carriers showed a steeper rate of increase in weight and BMI Z-scores. As a result, the GG-genotype carriers were 2.5 times less likely to be overweight/obese (i.e. having a BMI above the 85th percentile). This genetic effect on risperidone-associated weight gain did not extend to weight loss related to psychostimulants.
The LEP - 2548G/A variants seem to moderate the weight-altering effect of risperidone but not psychostimulants. This may be related to genetic differences in tissue sensitivity to leptin, resulting in differential body composition.
Psychiatric genetics 12/2009; 19(6):320-7. · 2.33 Impact Factor
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ABSTRACT: The aim of this study was to investigate the prevalence of clinical and laboratory metabolic abnormalities during long-term risperidone treatment in children and adolescents.
Medically healthy 7- to 17-year-old children chronically treated, in a naturalistic setting, with risperidone were recruited through child psychiatry clinics. Anthropometric measurements and laboratory testing were conducted. Developmental and medication histories were obtained from medical records.
In 99 patients treated with risperidone for an average of 2.9 years, a significant increase in age- and gender-adjusted weight and body mass index (BMI) (i.e., z-scores) was observed. Concomitant treatment with psychostimulants did not attenuate this weight gain. Risperidone-associated weight gain was negatively correlated with the BMI z-score obtained at the onset of risperidone treatment. Compared to lean children, overweight and obese children had higher odds of metabolic abnormalities, including increased waist circumference, hypertriglyceridemia, and low high-density lipoprotein cholesterol (HDL-C). They also tended to have a higher insulin level and homeostasis model assessment insulin resistance (HOMA-IR) index. As a result, upon recruitment in the study, children with excessive weight were 12 times more likely to have at least one laboratory metabolic abnormality and seven times more likely to have at least one criterion of the metabolic syndrome compared to lean subjects. In contrast to excessive weight status, gaining > or =0.5 BMI z-score point during risperidone treatment was not associated with a significantly higher occurrence of metabolic disturbances.
The long-term use of risperidone, especially when weight is above normal, is associated with a number of metabolic abnormalities but a low prevalence of the metabolic syndrome phenotype. Future studies should evaluate the stability of these abnormalities over time.
Journal of child and adolescent psychopharmacology 04/2009; 19(2):101-9. · 2.59 Impact Factor
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ABSTRACT: To investigate the association between hyperprolactinemia and variants of the dopamine D2 receptor (DRD2) gene in children and adolescents in long-term treatment with risperidone.
Medically healthy 7 to 17-year-old patients chronically treated with risperidone but receiving no other antipsychotics were recruited in a cross-sectional study. Four DRD2 variants were genotyped and prolactin concentration was measured. Medication history was obtained from the medical records. The effect of the TaqIA variants of the DRD2 on the risk of risperidone-induced hyperprolactinemia was the primary outcome measure.
Hyperprolactinemia was present in 50% of 107 patients (87% males) treated with risperidone for an average of 2.9 years. Age, stage of sexual development, and the dose of risperidone independently predicted a higher prolactin concentration, whereas the dose of psychostimulants was negatively correlated with it. However, these four predictors became nonsignificant when risperidone serum concentration was entered into the model. Adverse events potentially related to hyperprolactinemia were more common in participants with elevated prolactin concentration and in girls (45%) compared with boys (10%). After controlling for risperidone concentration and the dose of psychostimulants, the TaqIA A1 and the A-241G alleles were associated with higher prolactin concentration, whereas the -141C Ins/Del and C957T variants had no significant effect. In addition, adverse events potentially related to hyperprolactinemia were four times more common in TaqIA A1 allele carriers.
Prolactin concentration is closely related to central DRD2 blockade, as reflected by risperidone serum concentration. Furthermore, the TaqIA and A-241G variants of the DRD2 gene could be useful in predicting the emergence of hyperprolactinemia and its potential adverse events.
Pharmacogenetics and Genomics 04/2009; 19(5):373-82. · 3.48 Impact Factor
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ABSTRACT: A consecutive series of 79 patients with probable Alzheimer's disease were assessed with a structured psychiatric evaluation, and diagnoses of apathy and depression were made using standardized criteria. Three-dimensional MRI scans were obtained from all patients, and images were segmented into gray matter, white matter, and CSF. White matter hyperintensities were edited on segmented images, and lobar assignments (frontal, temporal, parietal, and occipital) were made based on Talairach coordinates. Patients with apathy showed a significantly larger volume of frontal white matter hyperintensities than patients without apathy. Patients with depression had a significantly larger volume of right parietal white matter hyperintensities than patients without depression. However, neither apathy nor depression was significantly associated with lobar gray or white matter atrophy. Frontal and right parietal white matter hyperintensities are the strongest brain structural correlates of apathy and depression in Alzheimer's disease.
The Journal of neuropsychiatry and clinical neurosciences 01/2009; 21(3):259-65. · 2.34 Impact Factor
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ABSTRACT: Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.
To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication.
A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups: a double-blind placebo-controlled comparison of escitalopram (n = 59) with placebo (n = 58), and a nonblinded problem-solving therapy group (n = 59).
The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressive-like episode or minor depression (ie, research criteria).
Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 minor cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4-8.2; P < .001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4-3.5; P < .001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2-3.9; P = .007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8-1.5; P = .51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.
In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.
clinicaltrials.gov Identifier: NCT00071643.
JAMA The Journal of the American Medical Association 05/2008; 299(20):2391-400. · 30.03 Impact Factor
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ABSTRACT: The term vascular depression (VD) has been used to describe late-life depressive disorders in patients with clinical evidence of cerebrovascular disease. Preliminary data on poststroke depression suggest that repetitive transcranial magnetic stimulation (rTMS) might also be effective among patients with VD.
To examine the efficacy and safety of rTMS to treat VD.
Prospective, randomized, sham-controlled study.
University hospital.
After discontinuation of antidepressant therapy, 92 patients with clinically defined VD were randomly assigned to receive active or sham rTMS of the left dorsolateral prefrontal cortex. Approximately half of the patients met criteria for magnetic resonance imaging-defined VD. In experiment 1, we administered a total cumulative dose (TCD) of 12 000 pulses (TCD-12K); in experiment 2, 18,000 pulses (TCD-18K). Sham stimulation was performed using a sham coil.
In experiment 1, the sham group showed a 13.6% decrease in the 17-item Hamilton Depression Rating Scale (HAMD-17) scores compared with a 33.1% decrease in the TCD-12K group (P = .04). Response rates were 6.7% in the sham group and 33.3% in the active-stimulation group (P = .08); remission rates were 6.7% and 13.3%, respectively (P = .50). In experiment 2, the sham group showed a 17.5% decrease in the 17-item Hamilton Depression Rating Scale scores compared with a 42.4% decrease observed in the TCD-18K group (P < .001). Response rates were 6.9% in the sham group and 39.4% in the active-stimulation group (P = .003); remission rates were 3.5% and 27.3%, respectively (P = .01). Response rates to rTMS were negatively correlated with age and positively correlated with higher frontal gray matter volumes.
To our knowledge, this is the first controlled trial that demonstrates the efficacy of rTMS among geriatric patients with VD. Older age and smaller frontal gray matter volumes were associated with a poorer response to rTMS.
Archives of general psychiatry 04/2008; 65(3):268-76. · 12.26 Impact Factor
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ABSTRACT: Recent evidence from clinical studies and animal models of traumatic brain injury (TBI) suggest that neuronal and glial loss might progress after the initial insult in selectively vulnerable regions of the brain such as the hippocampus. There is also evidence that hippocampal dysfunction plays a role in the pathogenesis of mood disorders. We examined the relationship between hippocampal damage and mood disorders after TBI and the effect of hippocampal atrophy on the outcome of TBI patients.
The study group consisted of 37 patients with closed head injury who were evaluated at baseline and at 3, 6, and 12 months after trauma. Psychiatric diagnosis was made with a structured clinical interview and DSM-IV criteria. Quantitative magnetic resonance imaging scans were obtained at 3-months follow-up.
Patients with moderate to severe head injury had significantly lower hippocampal volumes than patients with mild TBI. Patients who developed mood disorders had significantly lower hippocampal volumes than patients without mood disturbance. Furthermore, there was a significant interaction between mood disorders diagnosis and severity of TBI, by which patients with moderate to severe TBI who developed mood disorders had significantly smaller hippocampal volumes than patients with equivalent severe TBI who did not develop mood disturbance. Finally, reduced hippocampal volumes were associated with poor vocational outcome at 1-year follow-up.
Our findings are consistent with a "double-hit" mechanism by which neural and glial elements already affected by trauma are further compromised by the functional changes associated with mood disorders (e.g., the neurotoxic effects of increased levels of cortisol or excitotoxic damage resulting from overactivation of glutaminergic pathways). Finally, patients with greater hippocampal damage were less likely to return to a productive life 1 year after trauma.
Biological Psychiatry 09/2007; 62(4):332-8. · 8.28 Impact Factor
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ABSTRACT: Effect sizes (ES) tell the magnitude of the difference between treatments and, ideally, should tell clinicians how likely their patients will benefit from the treatment. Currently used ES are expressed in statistical rather than in clinically useful terms and may not give clinicians the appropriate information. We restrict our discussion to studies with two groups: one with n patients receiving a new treatment and the other with m patients receiving the usual or no treatment. The standardized mean difference (e.g. Cohen's d) is a well-known index for continuous outcomes. There is some intuitive value to d, but measuring improvement in standard deviations (SD) is a statistical concept that may not help a clinician. How much improvement is a half SD? A more intuitive and simple-to-calculate ES is the probability that the response of a patient given the new treatment (X) is better than the one for a randomly chosen patient given the old or no treatment (Y) (i.e. P(X > Y), larger values meaning better outcomes). This probability has an immediate identity with the area under the curve (AUC) measure in procedures for receiver operator characteristic (ROC) curve comparing responses to two treatments. It also can be easily calculated from the Mann-Whitney U, Wilcoxon, or Kendall tau statistics. We describe the characteristics of an ideal ES. We propose P(X > Y) as an alternative index, summarize its correspondence with well-known non-parametric statistics, compare it to the standardized mean difference index, and illustrate with clinical data.
Statistics in Medicine 03/2006; 25(4):591-602. · 1.88 Impact Factor
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ABSTRACT: The number of older people with substance abuse problems is expected to increase over the next decade. Given the expected growth in the number of elderly clients needing substance abuse treatment, the authors provide a description of admissions of patients age 55 years and over to facilities receiving some public funds.
The Treatment Episode Data Set (TEDS), a public-use data-set, contained information on 58,073 admissions to substance treatment (age 55+) and 1,043,910 admissions age 30-54 years.
Older admissions listed only one substance-daily use of alcohol. Admission record notations indicated that these admissions were more frequently associated with income, insurance, and marriage or divorce than younger admissions. As in younger admissions, criminal justice was a major source of referral to treatment. Older patients' admissions records indicated fewer previous treatment experiences. Older male and female admissions were similar in many regards, but differed in their treatment history. The current treatment admission was more often the first for female admissions. Older female admissions were likely to be more educated than their male counterparts, with a later age at onset.
Older admissions to substance abuse treatment differed in important ways from younger adult admissions. The older admissions tended to come from a more stable environment (income, insurance, marriage). Despite their very high frequency and amount of drinking, few of these admissions were referred to treatment by healthcare workers.
American Journal of Geriatric Psychiatry 06/2005; 13(5):385-92. · 3.64 Impact Factor
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ABSTRACT: Depression has a significant impact on poststroke recovery and mortality. There are a proportion of patients with poststroke depression (PSD) who do not respond to antidepressants. Repetitive Transcranial Magnetic Stimulation (rTMS) might be a safe and effective alternative in these refractory cases.
We conducted a randomized, parallel, double-blind study of active versus sham left prefrontal rTMS in patients with refractory PSD. After discontinuing antidepressants, patients were randomly assigned to receive 10 sessions of active (10 Hz, 110% of the motor threshold, 20 trains of 5 seconds duration) or sham left prefrontal rTMS. Efficacy measures included HAM-D scores, response and remission rates. Patients completed a neuropsychological battery at baseline and after completing the protocol.
When compared with sham stimulation, 10 sessions of active rTMS of the left dorsolateral prefrontal cortex were associated with a significant reduction of depressive symptoms. This reduction was not influenced by patient's age, type or location of stroke, volume of left frontal leukoaraiosis or by the distance of the stimulating coil to the prefrontal cortex. However, there was a significant positive correlation between the percentage of reduction of Ham-D scores and frontal gray and white matter volumes. There were no significant changes in cognitive functioning between the active and the sham stimulation groups. In addition, there were few and mild adverse effects that were equally distributed among groups.
Taken together, these preliminary findings suggest that rTMS may be an effective and safe treatment alternative for patients with refractory depression and stroke.
Biological Psychiatry 03/2004; 55(4):398-405. · 8.28 Impact Factor
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ABSTRACT: Context
Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.Objective
To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication.Design, Setting, and Participants
A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups: a double-blind placebo-controlled comparison of escitalopram (n = 59) with placebo (n = 58), and a nonblinded problem-solving therapy group (n = 59).Main Outcome Measures
The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressive-like episode or minor depression (ie, research criteria).Results
Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 minor cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4-8.2; P < .001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4-3.5; P < .001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2-3.9; P = .007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8-1.5; P = .51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.Conclusions
In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.Trial Registration
clinicaltrials.gov Identifier: NCT00071643
Figures in this Article
Prevention is a goal to which every field of medicine aspires because it reduces morbidity, may alleviate suffering, and reduces the cost of health care. Although the Commission on Chronic Illness proposed the classification of primary, secondary, and tertiary prevention1 in 1957, the Institute of Medicine Committee on Prevention of Mental Disorders recommended a new terminology2 in 1995. According to the new terminology, preventive intervention is defined as an intervention before the patient receives a diagnosis. Alternatively, treatment is an intervention for patients already with a diagnosis, and maintenance is the care of patients with chronic illnesses including relapse prevention. Furthermore, preventive interventions are categorized as (1) indicated, addressing high-risk individuals with premorbid signs or symptoms; (2) selective, for select individuals with demonstrated increased risk of developing illness; and (3) universal, for a whole population in a group with all levels of risk.
Although the ultimate goal of preventive intervention in mental disorders is universal, the major problem is identifying a population at sufficiently high risk to justify the expense and risk of pharmacological or psychological intervention.
The annual incidence of stroke (ischemic and hemorrhagic cerebral infarction), which exceeds 700 000 in the United States,3 represents a major public health problem. Patients who survive acute stroke may constitute a particularly good population for preventive intervention for depression because of their high risk of developing depression. Among combined studies of 2178 patients hospitalized for acute stroke or rehabilitation, 22% were diagnosed with major depression and 17% were diagnosed with minor depression.4- 9 Furthermore, among patients without depression during the acute stroke period, 14% developed major depression and 23% developed minor depression during the first 2 years following stroke.9 Thus, approximately 37% of stroke survivors developed depression after the acute stroke period and represent a sizeable population in which to assess a selective preventive intervention strategy.
Several investigators have previously attempted to prevent the development of poststroke depression without success.10- 12 Palomäki et al10 conducted a randomized placebo-controlled study of 100 patients younger than 71 years who were admitted to the hospital for acute ischemic stroke. Patients received either mianserin (60 mg/d) or placebo for 1 year and were examined at 2, 6, 12, and 18 months follow-up. At no time during the 18-month follow-up did the prevalence rate for major depression according to the Diagnostic and Statistical Manual of Mental Disorders, (Third Edition, Revised) differ between treatment groups. Rasmussen et al,12 using double-blind methods and random assignment, treated 137 patients without depression over 12 months following acute stroke with sertraline (mean dose 63 mg/d; n = 70) or placebo (n = 67). The depression occurrence rate over the 12 months, based on a Hamilton-17 Depression Rating Scale13 score of greater than 18, was 8.2% for sertraline (90% confidence interval [CI], 2.4%-13.9%; 3 of 35 completers) vs 22.8% for placebo (90% CI, 13.7%-32.0%; 7 of 32 completers). Based on the number of completers, the power of this study to find significant intergroup differences was 0.44, which indicates that the study was underpowered.
The most recent report was by Almeida et al11 in which 111 patients within 2 weeks following stroke were randomized to treatment with sertraline (50 mg/d; n = 55) or placebo (n = 56) in a 24-week double-blind clinical trial. Results demonstrated no significant intergroup difference in the prevalence of scores of 8 or greater on the Hospital Depression and Anxiety Scale during the 24 weeks of treatment. Among sertraline-treated patients, 8 out of 48 (16.7%) developed depression compared with 11 out of 51 placebo-treated patients (21.6%) (rate ratio, 0.8; 95% CI, 0.3-2.1; P = .59). A recent meta-analysis, however, reported significant effect of antidepressants across 10 studies with duration of treatment ranging from 4 to 52 weeks. Some studies, however, were designed for prophylaxis while other studies were acute treatment studies in which nondepressed patients were assessed for measurement of recovery.14
Although 3 double-blind trials failed to show a significant effect of active treatment in preventing poststroke depression, we undertook the current preventive treatment study to assess the efficacy of escitalopram or psychological problem-solving therapy. Our rationale included larger numbers of patients to increase statistical power, multisite enrollment to achieve a more varied sample, and comparison of both psychological and pharmacological interventions to prevent poststroke depression. Problem-solving therapy was selected because it had been developed for use in elderly patients with depression15 and cognitive behavioral therapy had been shown to be unsuccessful in treating poststroke depression.16 We hypothesized that both escitalopram and problem-solving therapy would constitute effective preventive interventions.
JAMA The Journal of the American Medical Association 299(20):2391-2400. · 30.03 Impact Factor
