Helena C Kraemer

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (512)3031.57 Total impact

  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: In Reply I wholeheartedly agree with the main point made by Meinlschmidt et al that well-justified, well-designed, and well-executed (non–poorly justified, designed, or executed [PJDE]) randomized clinical trials warrant dissemination—statistically significant or not. Crucial is whether a randomized clinical trial advances knowledge. It is the responsibility of reviewers and readers to evaluate the quality and value of every study (exploratory or hypothesis testing, statistically significant or not) before making decisions.
    No preview · Article · Dec 2015 · JAMA Psychiatry
  • [Show abstract] [Hide abstract] ABSTRACT: Background: We found a benefit of citalopram for agitation in the Citalopram for Agitation in Alzheimer's Disease study (CitAD), and wondered if this was mediated by a sedative effect. CitAD was a randomized, placebo-controlled, double-blind, parallel group trial conducted at 8 academic centers in the United States and Canada from August 2009 to January 2013. One hundred sixty-two participants with probable Alzheimer's disease (AD) and clinically significant agitation were analyzed in this study. Participants received a psychosocial intervention and were randomized to receive either citalopram or placebo (approximately half assigned to each group). Participants were rated on the Neurobehavioral Rating Scale Agitation subscale and measures of sedation (i.e., fatigue and somnolence). Methods: Using the MacArthur Foundation procedures for documenting a mediator effect, we performed a secondary analysis examining whether sedation mediates the effect of treatment on agitation outcome. Results: We found a statistically significant mediating effect of sedation on agitation outcomes, but the magnitude of the effect was small, only explaining 11% of the variance in agitation, with a significant, but modest effect size of 0.16 (95% CI: 0.08 to 0.22). Conclusions: The benefit of citalopram was partly due to sedation but largely due to other mechanisms of action.
    No preview · Article · Dec 2015 · Journal of Psychiatric Research
  • Vyjeyanthi S Periyakoil · Eric Neri · Helena Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: Objective: The study objective was to empirically identify barriers reported by multiethnic patients and families in receiving high-quality end-of-life care (EOLC). Methods: This cross-sectional, mixed-methods study in Burmese, English, Hindi, Mandarin, Tagalog, Spanish, and Vietnamese was held in multiethnic community centers in five California cities. Data were collected in 2013-2014. A snowball sampling technique was used to accrue 387 participants-261 women, 126 men, 133 Caucasian, 204 Asian Americans, 44 African Americans, and 6 Hispanic Americans. Measured were multiethnic patient-reported barriers to high-quality EOLC. A development cohort (72 participants) of responses was analyzed qualitatively using grounded theory to identify the six key barriers to high-quality EOLC. A new validation cohort (315 participants) of responses was transcribed, translated, and back-translated for verification. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 315 validation cohort transcripts were coded for presence or absence of the six barriers. Results: In the validation cohort, 60.6% reported barriers to receiving high-quality EOLC for persons in their culture/ethnicity. Primary patient-reported barriers were (1) finance/health insurance barriers, (2) doctor behaviors, (3) communication chasm between doctors and patients, (4) family beliefs/behaviors, (5) health system barriers, and (6) cultural/religious barriers. Age (χ(2) = 9.15, DF = 1, p = 0.003); gender (χ(2) = 6.605, DF = 1, p = 0.01); and marital status (χ(2) = 16.11 DF = 3, p = 0.001) were associated with reporting barriers; and women <80 years were most likely to report barriers to receiving high-quality EOLC. Individual responses of reported barriers were analyzed and only the participant's level of education (Friedman statistic = 2.16, DF = 10, p = 0.02) significantly influenced choices. Conclusion: Multiethnic patients report that high-quality EOLC is important to them; but unfortunately, a majority state that they have encountered barriers to receiving such care. Efforts must be made to rapidly improve access to culturally competent EOLC for diverse populations.
    No preview · Article · Nov 2015 · Journal of palliative medicine
  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: This Viewpoint argues that a valid diagnosis of mental health disorders is a developing process based on accumulating evidence rather than a fixed goal, and a physician should use all resources available: both dimensional and categorical, both DSM and Research Domain Criteria.The distinction between the approaches represented by the DSM and Research Domain Criteria (RDoC) does not lie in the choice between categorical and dimensional diagnosis.1 Every dimensional diagnosis can be converted to a corresponding categorical one by judiciously applying some dichotomization rule. Every categorical diagnosis can be converted to a corresponding dimensional one, for example, by requiring multiple assessments and using the percentage positive.2
    No preview · Article · Nov 2015 · JAMA Psychiatry
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    Helena Chmura Kraemer
    Preview · Article · Aug 2015 · Medical Decision Making
  • Helena Chmura Kraemer
    No preview · Article · Aug 2015 · JAMA Psychiatry
  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: How well will this treatment work for patients like me” is the question that research evaluating interventions is meant to answer for clinicians and their patients. Randomized clinical trials (RCTs) are the “gold standard” against which different research approaches to answering this question are judged. Here discussed are the basic principles underlying RCTs and consideration of a few alternatives to RCTs. Strategies used to satisfy these principles are discussed with focus on areas in which errors are currently most likely to occur, concluding with consideration of the general context in which such evaluations are optimally meant to take place.
    No preview · Chapter · Jul 2015
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    Vyjeyanthi S Periyakoil · Eric Neri · Helena Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: Though most patients wish to discuss end-of-life (EOL) issues, doctors are reluctant to conduct end-of-life conversations. Little is known about the barriers doctors face in conducting effective EOL conversations with diverse patients. This mixed methods study was undertaken to empirically identify barriers faced by doctors (if any) in conducting effective EOL conversations with diverse patients and to determine if the doctors’ age, gender, ethnicity and medical sub-specialty influenced the barriers reported.
    Preview · Article · Apr 2015 · PLoS ONE
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    [Show abstract] [Hide abstract] ABSTRACT: High levels of high-frequency heart rate variability (HF-HRV), related to parasympathetic-nervous-system functioning, have been associated with longer survival in patients with myocardial infarction and acute trauma and in patients undergoing palliative care. From animal studies linking higher vagal activity with better immune system functioning and reduced metastases, we hypothesized that higher HF-HRV would predict longer survival in patients with metastatic or recurrent breast cancer (MRBC). Eighty-seven patients with MRBC participated in a laboratory task including a 5-minute resting baseline electrocardiogram. HF-HRV was computed as the natural logarithm of the summed power spectral density of R-R intervals (0.15-0.50 Hz). In this secondary analysis of a study testing whether diurnal cortisol slope predicted survival, we tested the association between resting baseline HF-HRV on survival using Cox proportional hazards models. A total of 50 patients died during a median follow-up of 7.99 years. Higher baseline HF-HRV predicted significantly longer survival, with a hazard ratio of 0.75 (95% confidence interval = 0.60-0.92, p = .006). Visceral metastasis status and baseline heart rate were related to both HF-HRV and survival. However, a combination of HF-HRV and heart rate further improved survival prediction, with a hazard ratio of 0.64 (95% confidence interval = 0.48-0.85, p = .002). Vagal activity of patients with MRBC strongly predicted their survival, extending the known predictive window of HF-HRV in cancer beyond palliative care. Vagal activity can be altered by behavioral, pharmacological, and surgical interventions and may be a promising target for extending life expectancy in patients with metastasizing cancer.
    Full-text · Article · Apr 2015 · Psychosomatic Medicine
  • Vyjeyanthi Periyakoil · Eric Neri · Helena Kraemer
    No preview · Article · Feb 2015 · Journal of Pain and Symptom Management
  • No preview · Article · Nov 2014 · Sleep Medicine
  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: Does the McFarlane et al study1 provide a model for practical trials? Unfortunately, not. The methodological problems are here reviewed and used as a springboard to set out methodological criteria that might define such a model.
    No preview · Article · Oct 2014 · Schizophrenia Bulletin
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    [Show abstract] [Hide abstract] ABSTRACT: Objective To compare the outcome of donepezil treatment in ethnically diverse Alzheimer Disease (AD) patients to ethnically diverse AD patients who did not receive donepezil. Design: Patients meeting NINCDS-ADRA criteria for probable or possible AD from a consortium of California sites were systematically followed for at least one year in this prospective, observational study. Their treatment regimens, including prescription of donepezil, were determined by their individual physician according to his or her usual criteria. Patients self-identified their ethnicity. Results: The 64 ethnically diverse AD patients who completed the study and received donepezil treatment had an average one year decline of 2.30 points (3.9 SD) on the 30-point MMSE compared with a 1.70 point (4.2 SD) decline in the 74 ethnically diverse completers who received no donepezil or other anti-AD drugs during the study period. This difference was not statistically significant. The overall Cohen effect size of this treatment-associated difference was estimated at – 0.15. After using propensity analyses and other techniques to assess factors that could bias prescribing decisions, the lack of benefits associated with donepezil treatment remained. The lack of donepezil benefits also remained when more traditional analyses were applied to these data. Conclusion: California ethnically diverse AD patients in this study apparently did not benefit from one year of donepezil treatment. These unpromising results are in contrast to modest benefits of donepezil treatment measured in a directly comparable California study involving white non-Latino AD patients.
    Full-text · Article · Sep 2014 · American Journal of Geriatric Psychiatry
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    [Show abstract] [Hide abstract] ABSTRACT: Separate bodies of literature report that elevated pro-inflammatory cytokines and cortisol negatively affect hippocampal structure and cognitive functioning, particularly in older adults. Although interactions between cytokines and cortisol occur through a variety of known mechanisms, few studies consider how their interactions affect brain structure. In this preliminary study, we assess the impact of interactions between circulating levels of IL-1Beta, IL-6, IL-8, IL-10, IL-12, TNF-alpha, and waking cortisol on hippocampal volume. Twenty-eight community-dwelling older adults underwent blood draws for quantification of circulating cytokines and saliva collections to quantify the cortisol awakening response. Hippocampal volume measurements were made using structural magnetic resonance imaging. Elevated levels of waking cortisol in conjunction with higher concentrations of IL-6 and TNF-alpha were associated with smaller hippocampal volumes. In addition, independent of cortisol, higher levels of IL-1beta and TNF-alpha were also associated with smaller hippocampal volumes. These data provide preliminary evidence that higher cortisol, in conjunction with higher IL-6 and TNF-alpha, are associated with smaller hippocampal volume in older adults. We suggest that the dynamic balance between the hypothalamic-pituitary adrenal axis and inflammation processes may explain hippocampal volume reductions in older adults better than either set of measures do in isolation.
    Full-text · Article · Jul 2014 · Frontiers in Aging Neuroscience
  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: To understand the process by which a treatment (T) achieves an effect on outcome (O) and thus to improve the effect of T on O, it is vital to detect mediators, to compare the impact of different mediators, and to develop hypotheses about the causal factors (all mediators) linking T and O. An index is needed to facilitate interpretation of the potential clinical importance of a mediator (M) of choice of T on treatment O in randomized clinical trials (RCTs). Ideally such a mediator effect size should (1) be invariant under any rescaling of M and O consistent with the model used, and (2) reflect the difference between the overall observed effect of T on O and what the maximal effect of T on O could be were the association between T and M broken. A mediator effect size is derived first for the traditional linear model, and then more generally for any categorical (ordered or non-ordered) potential mediator. Issues such as the problem of multiple treatments, outcomes and mediators, and of causal inferences, and the correspondence between this approach and earlier ones, are discussed. Illustrations are given of the application of the approach. Copyright © 2014 John Wiley & Sons, Ltd.
    No preview · Article · Jun 2014 · International Journal of Methods in Psychiatric Research
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    Vyjeyanthi S Periyakoil · Eric Neri · Ann Fong · Helena Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: High-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.
    Preview · Article · May 2014 · PLoS ONE
  • [Show abstract] [Hide abstract] ABSTRACT: Background: Poor sleep, prevalent among cancer survivors, is associated with disrupted hormonal circadian rhythms and poor quality of life. Using a prospective research design, this study aimed to clarify the relationship between objective measures of sleep efficiency and sleep disruption with survival among women with advanced breast cancer. Method: We examined sleep quality and duration via wrist-worn actigraphy and sleep diaries for 3 days among 97 women in whom advanced breast cancer was diagnosed (age = 54.6 ± 9.8 years). Sleep efficiency was operationalized using actigraphy as the ratio of total sleep time to total sleep time plus wake after sleep onset. Results: As hypothesized, better sleep efficiency was found to predict a significant reduction in overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.98; P < 0.001) at median 6 y follow-up. This relationship remained significant (HR, 0.94; 95% CI, 0.91-0.97; P < 0.001) even after adjusting for other known prognostic factors (age, estrogen receptor status, cancer treatment, metastatic spread, cortisol levels, and depression). Secondary hypotheses were also supported (after adjusting for baseline prognostic factors) showing that less wake after sleep onset (HR, 0.41; 95% CI, 0.25-0.67; P < 0.001), fewer wake episodes, (HR, 0.93; 95% CI, 0.88-0.98; P = 0.007); and shorter wake episode duration (HR, 0.29; 95% CI, 0.14-0.58; P < 0.001) also contributed to reductions in overall mortality. Conclusions: These findings show that better sleep efficiency and less sleep disruption are significant independent prognostic factors in women with advanced breast cancer. Further research is needed to determine whether treating sleep disruption with cognitive behavioral and/or pharmacologic therapy could improve survival in women with advanced breast cancer.
    No preview · Article · May 2014 · Sleep
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    Helena Chmura Kraemer · Robert Freedman
    Preview · Article · Feb 2014 · American Journal of Psychiatry
  • Helena Chmura Kraemer
    [Show abstract] [Hide abstract] ABSTRACT: Reliability of clinical diagnosis is essential for good clinical decision making as well as productive clinical research. The current review emphasizes the distinction between a disorder and a diagnosis and between validity and reliability of diagnoses, and the relationships that exist between them. What is crucial is that reliable diagnoses are essential to establishing valid diagnoses. The present review discusses the theoretical background underlying the evaluation of diagnoses, possible designs of reliability studies, estimation of the reliability coefficient, the standards for assessment of reliability, and strategies for improving reliability without compromising validity. Expected final online publication date for the Annual Review of Clinical Psychology Volume 10 is March 20, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
    No preview · Article · Jan 2014 · Annual Review of Clinical Psychology
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    [Show abstract] [Hide abstract] ABSTRACT: Despite depressive disorders being very common there has been little research to guide primary care physicians on the choice of treatment for patients with mild to moderate depression. To evaluate the efficacy of interpersonal counselling compared with selective serotonin reuptake inhibitors (SSRIs), in primary care attenders with major depression and to identify moderators of treatment outcome. A randomised controlled trial in nine centres (DEPICS, Australian New Zealand Clinical Trials Registry number: ACTRN12608000479303). The primary outcome was remission of the depressive episode (defined as a Hamilton Rating Scale for Depression score ≤7 at 2 months). Daily functioning was assessed using the Work and Social Adjustment Scale. Logistic regression models were used to identify moderators of treatment outcome. The percentage of patients who achieved remission at 2 months was significantly higher in the interpersonal counselling group compared with the SSRI group (58.7% v. 45.1%, P = 0.021). Five moderators of treatment outcome were found: depression severity, functional impairment, anxiety comorbidity, previous depressive episodes and smoking habit. We identified some patient characteristics predicting a differential outcome with pharmacological and psychological interventions. Should our results be confirmed in future studies, these characteristics will help clinicians to define criteria for first-line treatment of depression targeted to patients' characteristics.
    Full-text · Article · Dec 2013 · The British journal of psychiatry: the journal of mental science

Publication Stats

36k Citations
3,031.57 Total Impact Points


  • 2001-2015
    • University of Pittsburgh
      • Department of Psychiatry
      Pittsburgh, Pennsylvania, United States
  • 1963-2015
    • Stanford University
      • • Department of Psychiatry and Behavioral Sciences
      • • Department of Medicine
      • • Department of Computer Science
      Stanford, California, United States
  • 2012
    • Norfolk and Norwich University Hospitals NHS Foundation Trust
      Norwich, England, United Kingdom
  • 2007
    • Johns Hopkins University
      Baltimore, Maryland, United States
    • University of Rochester
      • Department of Radiation Oncology
      Rochester, New York, United States
    • VA Palo Alto Health Care System
      Palo Alto, California, United States
  • 2000-2007
    • Columbia University
      • Department of Psychiatry
      New York, New York, United States
    • Cornell University
      • Department of Psychiatry
      Итак, New York, United States
    • University of Oregon
      Eugene, Oregon, United States
    • University of California, Berkeley
      Berkeley, California, United States
  • 2006
    • Tel Aviv University
      Tell Afif, Tel Aviv, Israel
    • University of Louisville
      • Department of Psychological and Brain Sciences
      Louisville, Kentucky, United States
  • 2005
    • Fairfield University
      • Graduate School of Education and Allied Professions
      Феърфилд, Connecticut, United States
  • 2002
    • University of Wisconsin, Madison
      • Department of Psychiatry
      Madison, MS, United States
    • University of California, Los Angeles
      Los Ángeles, California, United States
  • 1999-2000
    • Harvard University
      Cambridge, Massachusetts, United States
    • University of Texas Southwestern Medical Center
      • Department of Psychiatry
      Dallas, Texas, United States
  • 1982-1999
    • Stanford Medicine
      • Laboratory for the Study of Behavioral Medicine
      Stanford, California, United States
  • 1991
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
  • 1986
    • Santa Clara Valley Medical Center
      San Jose, California, United States