JAMA Internal Medicine: Psychiatry Topic Collection

Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression CODIACS Vanguard Randomized Controlled Trial CODIACS Vanguard RCT

Davidson KW, Bigger J, Burg MM, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Controversy remains about whether depression can be successfully managed after acute coronary syndrome (ACS) and the costs and benefits of doing so.

Objective

To determine the effects of providing post-ACS depression care on depressive symptoms and health care costs.

Design

Multicenter randomized controlled trial.

Setting

Patients were recruited from 2 private and 5 academic ambulatory centers across the United States.

Participants

A total of 150 patients with elevated depressive symptoms (Beck Depression Inventory [BDI] score ≥10) 2 to 6 months after an ACS, recruited between March 18, 2010, and January 9, 2012.

Interventions

Patients were randomized to 6 months of centralized depression care (patient preference for problem-solving treatment given via telephone or the Internet, pharmacotherapy, both, or neither), stepped every 6 to 8 weeks (active treatment group; n = 73), or to locally determined depression care after physician notification about the patient's depressive symptoms (usual care group; n = 77).

Main Outcome Measures

Change in depressive symptoms during 6 months and total health care costs.

Results

Depressive symptoms decreased significantly more in the active treatment group than in the usual care group (differential change between groups, −3.5 BDI points; 95% CI, −6.1 to −0.7; P = .01). Although mental health care estimated costs were higher for active treatment than for usual care, overall health care estimated costs were not significantly different (difference adjusting for confounding, −$325; 95% CI, −$2639 to $1989; P = .78).

Conclusions

For patients with post-ACS depression, active treatment had a substantial beneficial effect on depressive symptoms. This kind of depression care is feasible, effective, and may be cost-neutral within 6 months; therefore, it should be tested in a large phase 3 pragmatic trial.

Trial Registration

clinicaltrials.gov Identifier: NCT01032018

Benefits and Costs of Improving Depression Treatment in People With Heart Disease Comment on “Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression” Depression Treatment in People With Heart Disease

Simon GE. — Mon, 10 Jun 2013 00:00:00 GMT

In this issue of JAMA Internal Medicine, Davidson et al describe the benefits of an organized depression care program for outpatients experiencing significant symptoms of depression after acute coronary syndrome (ACS). Patients were screened 2 to 6 months after hospitalization for ACS, and those with significant depressive symptoms were randomly assigned to either a systematic depression treatment program or continued usual care (which might include depression treatment from local medical or mental health providers). The Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) treatment program included the essential elements proven effective in previous collaborative care or depression care management programs: availability of antidepressant pharmacotherapy and structured psychotherapy, systematic assessment of outcomes, a stepped care algorithm for treatment adjustment or intensification, and organized supervision by consulting mental health specialists. Those offered the organized depression treatment program experienced significantly greater improvement (both statistically and clinically) over 6 months. This finding adds to the substantial evidence for the clinical benefit of depression screening and systematic treatment among people with varying stages of heart disease ranging from outpatients with poorly controlled cardiovascular risk factors to patients discharged after revascularization.

Extent and Reporting of Patient Nonenrollment in Influential Randomized Clinical Trials, 2002 to 2010

Humphreys K, Maisel NC, Blodgett JC, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Because they assign patients to treatment conditions, randomized clinical trials (RCTs) offer unparalleled internal validity for drawing inferences about the efficacy of a medical treatment. Whether such inferences can be generalized is not always clear because many RCTs enroll a low and unrepresentative proportion of all patients. The challenges of judging the clinical utility of clinical trial results are increased by poor reporting. The study by Gross et al of trials published in leading medical journals from 1999 through 2000 found that only 28% reported the proportion of screened patients who were enrolled. These deficiencies may have been ameliorated in the past decade because the CONSORT statement was revised in 2001 to require more complete information on the enrollment process in reports of clinical trials, and because many treatment research fields have been showing greater concern about generating knowledge that better informs clinical practice. Accordingly, the present study assessed the extent to which low enrollment rates are still characteristic of widely cited clinical trials, and whether reporting of enrollment information has improved.

Radiation Safety in Nuclear Cardiology—Current Knowledge and Practice: Results From the 2011 American Society of Nuclear Cardiology Member Survey

Einstein AJ, Tilkemeier P, Fazel R, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Nuclear stress testing is well recognized as an effective technique for diagnosing coronary disease, predicting patient outcomes, and guiding management. Numerous evidence-based appropriate indications and practice guideline recommendations have been published regarding accepted uses of nuclear stress tests (NSTs) across a wide spectrum of patients with known or suspected coronary disease. However, the approximate 10 million NSTs performed annually account for greater than 10% of the entire ionizing radiation burden to the US population. One recent study, while pointing out that cancer risk from a single NST is small, projected on a population level that NSTs may result in thousands of radiation-attributable cancers annually, partially offsetting their benefits.

Association Between Hypoglycemia and Dementia in a Biracial Cohort of Older Adults With Diabetes Mellitus Hypoglycemia and Dementia in Older Adults With DM

Yaffe K, Falvey CM, Hamilton N, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Hypoglycemia commonly occurs in patients with diabetes mellitus (DM) and may negatively influence cognitive performance. Cognitive impairment in turn can compromise DM management and lead to hypoglycemia.

Objective

To prospectively evaluate the association between hypoglycemia and dementia in a biracial cohort of older adults with DM.

Design and Setting

Prospective population-based study.

Participants

We studied 783 older adults with DM (mean age, 74.0 years; 47.0% of black race/ethnicity; and 47.6% female) who were participating in the prospective population-based Health, Aging, and Body Composition Study beginning in 1997 and who had baseline Modified Mini-Mental State Examination scores of 80 or higher.

Main Outcome Measures

Dementia diagnosis was determined during the follow-up period from hospital records indicating an admission associated with dementia or the use of prescribed dementia medications. Hypoglycemic events were determined during the follow-up period by hospital records.

Results

During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycemic event had a 2-fold increased risk for developing dementia compared with those who did not have a hypoglycemic event (34.4% vs 17.6%, P < .001; multivariate-adjusted hazard ratio, 2.1; 95% CI, 1.0-4.4). Similarly, older adults with DM who developed dementia had a greater risk for having a subsequent hypoglycemic event compared with participants who did not develop dementia (14.2% vs 6.3%, P < .001; multivariate-adjusted hazard ratio, 3.1; 95% CI, 1.5-6.6). Further adjustment for stroke, hypertension, myocardial infarction, and cognitive change scores produced similar results.

Conclusion and Relevance

Among older adults with DM, there seems to be a bidirectional association between hypoglycemia and dementia.

Glucose Control in Older Adults With Diabetes Mellitus—More Harm Than Good? Comment on “The Association Between Hypoglycemia and Dementia in a Biracial Cohort of Older Adults With Diabetes Mellitus” Glucose Control in Older Adults With DM

Lipska KJ, Montori VM. — Mon, 10 Jun 2013 00:00:00 GMT

Ms Andrews, your 83-year-old patient, is proud. She walks daily, watches her diet, and never misses her appointments. Her glycated hemoglobin (HbA_1c) level is 6.9%. As she readies to leave, you notice her bruised arm. It is from one of her fainting spells, she says. After asking a few more questions, you realize she has been having hypoglycemic episodes, including at least 1 last week in which she lost consciousness and needed her son's assistance. Perhaps not all is as it seems. Based on multiple performance metrics, her care has been exemplary. But has your treatment caused more harm than good?

Use of Acute Care Services Among Older Homeless Adults

Brown RT, Kiely DK, Bharel M, et al. — Mon, 10 Jun 2013 00:00:00 GMT

The median age of homeless single adults in the United States has increased from approximately 35 years in 1990 to nearly 50 years in 2010, yet little is known about health care utilization among older homeless adults. Homeless adults 50 years or older have unique medical problems, including high rates of chronic illnesses and geriatric conditions. A better understanding of the health care use by this vulnerable population would help to target strategies to improve their care. Thus, we prospectively observed a cohort of older homeless adults to describe and identify modifiable factors associated with emergency department (ED) visits and hospitalizations during a 1-year period.

Regarding “Time to Rethink Screening for Abdominal Aortic Aneurysm?”

Cardneau JD, Chang RW, Okuhn SP. — Mon, 10 Jun 2013 00:00:00 GMT

We would like to address the Invited Commentary by Harris et al, which we believe fails to back its assertions with relevant data. The authors suggest a concept of “harm” in screening for abdominal aortic aneurysm (AAA). They imply that the diagnosis of a small aneurysm will never cause physical harm (rupture) or require repair, leaving the patient only with anxiety. The literature to support this is conflicting and not supportive.