[Show abstract][Hide abstract] ABSTRACT: Background
Little is known about the demographic and clinical differences between early- and late-onset depressions (EOD and LOD, respectively) in Chinese patients. This study examined the demographic and clinical profile of EOD (<=25 years) compared to LOD (>25 years) in China.
A consecutively recruited sample of 1178 patients with MDD was assessed in 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide. The cross-sectional data of patients׳ demographic and clinical characteristics and prescriptions of psychotropic drugs including antidepressants, mood stabilizers, antipsychotics and benzodiazepines were recorded using a standardized protocol and data collection procedure.
Two hundred and seventy five (23.3%) of the 1178 patients fulfilled criteria for EOD. In multiple logistic regression analyses, compared to LOD patients their EOD counterparts were more likely to be unmarried and unemployed, had more atypical and psychotic depressive episodes, had bipolar features, while they had more lifetime depressive episodes.
The demographic and more severe clinical features of EOD in Chinese patients were basically consistent with those found in Western populations. The association between socio-cultural factors and development of EOD warrants further studies.
Journal of Affective Disorders 01/2015; 170:266–269. · 3.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness.
Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N=88) were randomized to receive six months of facilitation (enhanced REP) or continued standard REP. Site-level uptake was defined as percentage of patients (N=1,531) with updated documentation or with whom contact was attempted.
Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p=.01). Total REP facilitation time was 7.3 hours per site for six months.
Added facilitation improved short-term uptake of a national mental health program.
[Show abstract][Hide abstract] ABSTRACT: Background
Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy.Methods
One mental health provider from each U.S. VA site (N¿=¿158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N¿=¿89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N¿=¿40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N¿=¿49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization.ResultsPatients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR¿=¿2.13; 95% CI: 1.09¿4.19, P¿=¿0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites.Conclusions
Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes.Trial registrationISRCTN: ISRCTN21059161.
[Show abstract][Hide abstract] ABSTRACT: Background
Lithium has been reported in some, but not all, studies to be associated with reduced risk of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate.MethodsA propensity score-matched cohort study was conducted of Veterans Health Administration patients (n¿=¿21,194/treatment) initiating lithium or valproate from 1999¿2008.ResultsMatching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p¿=¿0.003). No significant differences in suicide death were observed over 0¿365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p¿=¿0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 0.46, 1.61; p¿=¿0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p¿=¿0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p¿=¿0.015).Conclusions
In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0¿180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.
[Show abstract][Hide abstract] ABSTRACT: This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.
Administration and Policy in Mental Health and Mental Health Services Research 10/2014; · 3.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.Methods/DesignThis study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N¿=¿1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ¿3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.DiscussionThis study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.Trial registrationClinicalTrials.gov identifier: NCT02151331.
[Show abstract][Hide abstract] ABSTRACT: Background
Persons with serious mental illnesses (SMI) are more likely to die earlier than the general population, primarily due to increased medical burden, particularly from cardiovascular disease (CVD). Life Goals Collaborative Care (LG-CC) is designed to improve health outcomes in SMI through self-management, care management, and provider support. This single-blind randomized controlled effectiveness study will determine whether patients with SMI receiving LG-CC compared to usual care (UC) experience improved physical health in 12 months.
Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or UC. LG-CC included five self-management sessions covering mental health symptom management reinforced through health behavior change; care coordination and health monitoring via a registry, and provider feedback. The primary outcome is change in physical health-related quality of life score (VR-12) from baseline to 12 months. Secondary outcomes include changes in mental health-related quality of life, CVD risk factors (blood pressure, BMI), and physical activity from baseline to 12 months later.
Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N = 284); the mean age was 55.2 (SD = 10.9; range 28–75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean ± SD = 33.3 ± 6.3). Baseline VR-12 physical health component score was below population norms (50.0 ± SD = 10) at 33.4 ± 11.0.
Findings from this trial may inform initiatives to improve physical health for SMI patient populations.
[Show abstract][Hide abstract] ABSTRACT: This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.
Current Psychiatry Reports 09/2014; 16(9):485. · 3.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This evaluation compared the effectiveness of MOVE!, a U.S. Veterans Health Administration (VHA) weight management program, among veterans with posttraumatic stress disorder (PTSD), other mental conditions, or no mental health diagnoses.
[Show abstract][Hide abstract] ABSTRACT: People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.
[Show abstract][Hide abstract] ABSTRACT: The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam-era veterans. The CIDI and the Clinician-Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3-week interval. Forty-five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past-year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past-year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.Traditional and Simplified Chinese Abstracts by AsianSTSS標題：女越南戰事退役軍中綜合國際診斷會見(CIDI 3.0) 的診斷準確性撮要：世界衛生組織(WHO)綜合國際診斷會見(CIDI)創傷後壓力症(PTSD)單元被廣泛應用於PTSD流行學研究，但只有少數研究其相關診斷效用。本研究在女性越南戰事退役軍中評定CIDI 3.0 PTSD單元的診斷效能。這是160名女士的分層和過度採樣現有PTSD的樣本，然後獨立地施行CIDI 和醫生施行PTSD量表(CAPS)。在三週內使用評估其終生PTSD和現有(過去一年)PTSD。總數45.0%符合CAPS終生PTSD診斷準則，和21.9%為CAPS過去一年PTSD診斷準則。以CAPS為診斷標準，CIDI 正確判別78.8% 終生PTSD個案(K= .56)和82.0% 過去一年PTSD 個案(K= .51) 。利用CAPS為標準估計CIDI的診斷表現，終生PTSD的靈敏度為.61和特異性為.091，而過往一年PTSD的靈敏度是.71 和特異性是.85。結果確認CIDI對辨識PTSD有高效用，但對比CAPS在終生PTSD方面卻是較保守的指標。标题：女越南战事退役军中综合国际诊断会见(CIDI 3.0) 的诊断准确性撮要：世界卫生组织(WHO)综合国际诊断会见(CIDI)创伤后压力症(PTSD)单元被广泛应用于PTSD流行学研究，但只有少数研究其相关诊断效用。本研究在女性越南战事退役军中评定CIDI 3.0 PTSD单元的诊断效能。这是160名女士的分层和过度采样现有PTSD的样本，然后独立地施行CIDI 和医生施行PTSD量表(CAPS)。在三周内使用评估其终生PTSD和现有(过去一年)PTSD。总数45.0%符合CAPS终生PTSD诊断准则，和21.9%为CAPS过去一年PTSD诊断准则。以CAPS为诊断标准，CIDI 正确判别78.8% 终生PTSD个案(K= .56)和82.0% 过去一年PTSD 个案(K= .51) 。利用CAPS为标准估计CIDI的诊断表现，终生PTSD的灵敏度为.61和特异性为.091，而过往一年PTSD的灵敏度是.71 和特异性是.85。结果确认CIDI对辨识PTSD有高效用，但比对CAPS在终生PTSD方面却是较保守的指标。
Journal of Traumatic Stress 04/2014; 27(2). · 2.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.
American journal of epidemiology 01/2014; · 4.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Depression is a frequent yet overlooked occurrence in primary health care clinics worldwide. Depression and related health screening instruments are available but are rarely used consistently. The availability of technologically based instruments in the assessments offers novel approaches for gathering, storing, and assessing data that includes self-reported symptom severity from the patients themselves as well as clinician recorded information. In a suburban primary health care clinic in Quito, Ecuador, we tested the feasibility and utility of computer tablet-based assessments to evaluate clinic attendees for depression symptoms with the goal of developing effective screening and monitoring tools in the primary care clinics. We assessed individuals using the 9-item Patient Health Questionnaire, the Quick Inventory of Depressive Symptoms-Self-Report, the 12-item General Health Questionnaire, the Clinical Global Impression Severity, and a DSM-IV checklist of symptoms. We found that 20% of individuals had a PHQ9 of 8 or greater. There was good correlation between the symptom severity assessments. We conclude that the tablet-based PHQ9 is an excellent and efficient method of screening for depression in attendees at primary health care clinics and that one in five people should be assessed further for depressive illness and possible intervention.
International journal of family medicine. 01/2014; 2014:845397.
[Show abstract][Hide abstract] ABSTRACT: Mood disorders represent the most expensive mental disorders for employer-based commercial health plans. Collaborative care models are effective in treating chronic physical and mental illnesses at little to no net healthcare cost, but to date have primarily been implemented by larger healthcare organizations in facility-based models. The majority of practices providing commercially insured care are far too small to implement such models. Health plan-level collaborative care treatment can address this unmet need. The goal of this study is to implement at the national commercial health plan level a collaborative care model to improve outcomes for persons with mood disorders.
A randomized controlled trial of a collaborative care model versus usual care will be conducted among beneficiaries of a large national health plan from across the country seen by primary care or behavioral health practices. At discharge 344 patients identified by health plan claims as hospitalized for unipolar depression or bipolar disorder will be randomized to receive collaborative care (patient phone-based self-management support, care management, and guideline dissemination to practices delivered by a plan-level care manager) or usual care from their provider. Primary outcomes are changes in mood symptoms and mental health-related quality of life at 12 months. Secondary outcomes include rehospitalization, receipt of guideline-concordant care, and work productivity.
This study will determine whether a collaborative care model for mood disorders delivered at the national health plan level improves outcomes compared to usual care, and will inform a business case for collaborative care models for these settings that can reach patients wherever they receive treatment.
ClinicalTrials.gov Identifier: NCT02041962; registered January 3, 2014.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES. Bipolar disorder is often misdiagnosed as major depressive disorder. Such misdiagnosis partly depends on the type of treatment setting. This study compared general hospital psychiatric units with psychiatric hospitals in China with respect to basic demographic and clinical characteristics of patients with unrecognised bipolar disorder who are treated for major depressive disorder. METHODS. Patients treated for major depressive disorder were consecutively examined in 13 health centres (6 general hospital psychiatric units and 7 psychiatric hospitals) in China. Their socio-demographic and clinical features were recorded using a standardised protocol and data collection procedure. The DSM-IV diagnoses were established using the Mini-International Neuropsychiatric Interview. RESULTS. Of the 1487 patients included in the study, 309 (20.8%) were diagnosed with bipolar disorder. There was no significant difference between general hospital psychiatric units and psychiatric hospitals in the ratio of all types of unrecognised bipolar disorders (χ2 = 0.008, degrees of freedom = 1, p = 0.9) and bipolar II disorders (χ2 = 3.1, degrees of freedom = 1, p = 0.08). The proportions of unrecognised bipolar I disorders (χ2 = 4.1, degrees of freedom = 1, p = 0.04) differed significantly between the 2 types of study site. Multivariate analyses showed that patients with bipolar I disorders with more seasonal depressive episodes were more likely to receive treatment in general hospital psychiatric units (odds ratio = 3.3, 95% confidence interval = 1.1-9.8). CONCLUSION. Patients with bipolar I disorders receiving treatment in general hospital psychiatric units had different clinical characteristics compared to their counterparts treated in psychiatric hospitals in China.
East Asian archives of psychiatry : official journal of the Hong Kong College of Psychiatrists = Dong Ya jing shen ke xue zhi : Xianggang jing shen ke yi xue yuan qi kan. 12/2013; 23(4):139-43.
[Show abstract][Hide abstract] ABSTRACT: Persons with serious mental illness are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage.Methods/design: This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services.
Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site's uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies.Trial registration: Current Controlled Trials ISRCTN21059161.