Comorbid Medical Illness Research Articles

Sexuality in older adults: Clinical and psychosocial dilemmas

The present review aims to throw some light on the various aspects of sexuality in older adults and the challenges faced by medical professionals working in this area. Keyword searches using the terms sexuality, sexual dysfunction, geriatric, old age, and others in combination were carried out on PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews. Relevant clinical trials, case studies, and review papers were selected. This was further supplemented with the clinical experience of the authors, who work with older patients in a psychiatric outpatient setting with a dedicated sexual disorders clinic. Sexuality is a lifelong phenomenon and its expression a basic human right across all ages. However, the construct of normalcy for sex in aging is blurred, with agism playing a distinct role. Older adults face much stigma when expressing sexual desires or concerns, both from their own families and the health-care system. Sexual dysfunctions due to comorbid medical illnesses and medications are often treatable. Evidence-based treatments for sexual dysfunction in the elderly, lesbian, gay, bisexual, transgender, and queer, and other orientations are especially underrepresented in research; available research has several limitations. Sexuality in people with dementia and sexual rights in nursing homes are gray areas. Medical training, treatment guidelines, and health-care facilities all need to be stepped up in terms of awareness and quality of care provided to the elderly with concerns related to sexuality.

Combination of Serum C-reactive Protein and D-lactate: Predictors of Strangulation in Intestinal Obstruction

ABSTRACT Introduction Serum C-reactive protein (CRP) and D-lactate have been proposed as markers of intestinal ischemia. The purpose of this prospective observational study is to find whether serum CRP and serum D-lactate can help in predicting strangulation in cases of acute intestinal obstruction. Materials and methods A total of 50 consecutive patients were included in the study after excluding patients of comorbid medical illness and patients with findings other than obstruction or strangulation. The serum values of CRP and D-lactate were measured and compared between obstruction with strangulation and obstruction without strangulation. Receiver operating characteristic (ROC) curve was drawn and cutoff values for the diagnosis of strangulation were calculated along with calculation of sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs). Results A total of 14 patients who were diagnosed with strangulated bowel obstruction had significantly higher values of serum CRP and D-lactate when compared with 36 patients with simple bowel obstruction (116 vs 40 mg/L and 5.4 vs 2.7 mmol/L respectively, p < 0.05). Using ROC analysis, the area under the curve of serum CRP and D-lactate was found to be 0.785 and 0.775 respectively, for bowel strangulation. Using a cutoff value of 60 mg/L for CRP, the sensitivity, specificity, PPV, and NPV were 87.5, 58.3, 48.3, 91.3% respectively. Using a cutoff value of 4.5 mmol/L for D-lactate, the sensitivity, specificity, PPV, and NPV were 75.0, 69.4, 52.7, 86.2% respectively. Conclusion Serum CRP and D-lactate can be useful and reasonable markers for predicting strangulation in cases of acute intestinal obstruction in an emergency setting. How to cite this article Pal AK, Ansari MM, Islam N. Combination of Serum C-reactive Protein and D-lactate: Predictors of Strangulation in Intestinal Obstruction. Panam J Trauma Crit Care Emerg Surg 2016;5(3):134-139.

Sinus Node Dysfunction Is Associated With Higher Symptom Burden and Increased Comorbid Illness: Results From the ORBIT-AF Registry.

ABSTRACTBackgroundPatients with sinus node dysfunction (SND) have increased risk of atrial tachyarrhythmias, including atrial fibrillation (AF). To date, treatment patterns and outcomes of patients with SND and AF have not been well described.HypothesisPatients with SND and AF have higher risk of adverse cardiovascular outcomes.MethodsSinus node dysfunction was defined clinically, based on treating physician. Treatment patterns were described and logistic regression analysis performed to assess outcomes.ResultsOverall, 1710 (17.7%) out of 9631 patients had SND at enrollment. Patients with SND and AF had increased comorbid medical illnesses, more severe symptoms (European Heart Rhythm Association class IV: 17.5% vs 13.9%; P = 0.0007), and poorer quality of life (median 12‐month Atrial Fibrillation Effect on Quality of Life score: 79.6 vs 85.2; P = 0.0008). There were no differences in AF management strategy between patients with SND and those without (rate control, 69.7% vs 67.7%; rhythm control, 30.0% vs 32.0%; P = 0.11). After adjustment, patients with SND were more likely than those without SND to progress from paroxysmal AF at baseline to persistent or permanent AF at any follow‐up, or persistent AF at baseline to permanent AF at any follow‐up (odds ratio: 1.23, 95% confidence interval: 1.01‐1.49, P = 0.035). However, there was no association between SND and major risk‐adjusted outcomes.ConclusionsSinus node dysfunction is present in 1 of 6 patients with AF and is associated with increased comorbidities and higher symptom burden. However, SND is not associated with an increase in major risk‐adjusted outcomes.

Psikiyatri Hastalarının Tedaviye Uyumu

Purpose: Although medical treatments develop day by day, there have been no changes in the treatment adherence ratios in psychiatric patients in the past years. In this study, we aimed to determine the causes for treatment nonadherence and present possible solutions. Materials and Methods: In this retrospective study, clinical records of 230 patients who have been hospitalized in the inpatient clinic of Cukurova University Faculty of Medicine Psychiatry Department were analyzed initially. Axis I psychiatric disorders of patients which were diagnosed by using DSM-IV-TR criteria and associated characteristics of disorders have been completed in the socio-demographic data form. According to our retrospective adherence scale which was based on Morisky Adherence Scale, patients’ adherence to the appointments at the first and third months after discharging from hospital and taking their medication as recommended were checked. Results: The results of this study have shown that the rate of non-adherence with treatment changes between 16.7 % - 68.8 % according to disorder. According to the current study, the reasons have effects on the patients’ adherence were Axis I and Axis II psychiatric disorders according to DSM-IV, number of daily medications taken, presence of comorbid medical illnesses, family history of psychiatric illnesses and presence of insight. Conclusion: Although medical treatments and drug industry develop day by day, there have been no changes in the treatment adherence ratios in the past years. To generate possible solutions, treatment adherence should be assessed in all clinical interviews and if patient is non-adherent this issue should be handled seriously.

Acute experimental changes in mood state regulate immune function in relation to central opioid neurotransmission: a model of human CNS-peripheral inflammatory interaction

Although evidence shows depressed moods enhance risk for somatic diseases, molecular mechanisms underlying enhanced somatic susceptibility are ill-defined. Knowledge of these molecular mechanisms will inform development of treatment and prevention strategies across comorbid depressive and somatic illnesses. Existing evidence suggests that interleukin-18 (IL-18; an IL-1 family cytokine) is elevated in depression and implicated in pathophysiology underlying comorbid medical illnesses. We previously identified strong associations between baseline IL-18 and μ-opioid receptor availability in major depressive disorder (MDD) volunteers. Combined with the evidence in animal models, we hypothesized that experimental mood induction would change IL-18, the extent proportional to opioid neurotransmitter release. Using the Velten technique in a [11C]carfentanil positron emission tomography neuroimaging study, we examined the impact of experimentally induced mood (sad, neutral) on plasma IL-18 and relationships with concurrent changes in the central opioid neurotransmission in 28 volunteers (healthy, MDD). Results showed mood induction impacted IL-18 (F2,25=12.2, P<0.001), sadness increasing IL-18 (T27=2.6, P=0.01) and neutral mood reducing IL-18 (T27=−4.1, P<0.001). In depressed volunteers, changes in IL-18 were more pronounced (F2,25=3.6, P=0.03) and linearly proportional to sadness-induced μ-opioid activation (left ventral pallidum, bilateral anterior cingulate cortices, right hypothalamus and bilateral amygdala). These data demonstrate that dynamic changes of a pro-inflammatory IL-1 superfamily cytokine, IL-18, and its relationship to μ-opioid neurotransmission in response to experimentally induced sadness. Further testing is warranted to delineate the role of neuroimmune interactions involving IL-18 in enhancing susceptibility to medical illness (that is, diabetes, heart disease and persistent pain states) in depressed individuals.

Cognitive Behavior Therapy With Mindfulness and Acceptance Skills for the Treatment of Older Adults

Cognitive behavior therapy (CBT) is a psychotherapy approach for the treatment of depression in older adult populations. This article discusses an extension of CBT to include mindfulness and acceptance skills for the treatment of depression in older adults with comorbid medical illness. Findings support that a brief intervention of 12 weeks was effective in producing a clinically significant change in depression and quality of life at the completion of therapy and at follow-up. This suggests that mindfulness and acceptance skills in addition to CBT skills may be an effective intervention for the treatment of depression of older adults with chronic medical illnesses.

Prior Depression and Health Insurance in Non-receipt of Needed Medical Services.

Rates of non-access to needed medical services are elevated among uninsured and sociodemographic subpopulations. Clinical depression is associated with comorbid medical illness and reduced treatment adherence. The purpose of this study was to examine whether prior depression predicts missed needed medical care independent of health insurance status and socioeconomic and demographic characteristics. Data were from a cross-sectional representative sample of adult New York City residents, surveyed through the 2009 (n=9,900) and 2010 (n=8,622) annual Community Health Survey. Logistic regression was used to evaluate the association of lifetime depression with missed needed medical care in the past year, with stratification by health insurance status and adjustment for socioeconomic characteristics. Analyses were performed in 2014. Prior depression was associated with missed needed medical care among both insured (OR=1.9, 95% CI=1.7, 2.2) and uninsured adults (OR=1.8, 95% CI=1.3, 2.4). Missed needed care report was associated with uninsured status (OR=3.6, 95% CI=3.1, 4.0), controlling for employment, income, and demographics. Prior depression corresponded to greater probability of missed needed medical care report in the previous year, independent of health insurance status, employment, income, and demographics.

Alterations of Mitochondrial DNA Copy Number and Telomere Length With Early Adversity and Psychopathology

BackgroundTelomere shortening and alterations of mitochondrial biogenesis are involved in cellular aging. Childhood adversity is associated with telomere shortening, and several investigations have shown short telomeres in psychiatric disorders. Recent studies have examined whether mitochondria might be involved in neuropsychiatric conditions; findings are limited and no prior work has examined this in relation to stress exposure. MethodsTwo-hundred ninety healthy adults provided information on childhood parental loss and maltreatment and completed diagnostic interviews. Participants were categorized into four groups based upon the presence or absence of childhood adversity and the presence or absence of lifetime psychopathology (depressive, anxiety, and substance use disorders). Telomere length and mitochondrial DNA (mtDNA) copy number were measured from leukocyte DNA by quantitative polymerase chain reaction. ResultsChildhood adversity and lifetime psychopathology were each associated with shorter telomeres (p < .01) and higher mtDNA copy numbers (p < .001). Significantly higher mtDNA copy numbers and shorter telomeres were seen in individuals with major depression, depressive disorders, and anxiety disorders, as well as those with parental loss and childhood maltreatment. A history of substance disorders was also associated with significantly higher mtDNA copy numbers. ConclusionsThis study provides the first evidence of an alteration of mitochondrial biogenesis with early life stress and with anxiety and substance use disorders. We replicate prior work on telomere length and psychopathology and show that this effect is not secondary to medication use or comorbid medical illness. Finally, we show that early life stress and psychopathology are each associated with these markers of cellular aging.

Clinical Characteristics of the Suicide Attempters Who Refused to Participate in a Suicide Prevention Case Management Program.

Case management interventions for suicide attempters aimed at helping adjust their social life to prevent reattempts have high nonparticipation and dropout rates. We analyzed the clinical characteristics of the group who refused to participate in the suicide prevention program in Korea. A total of 489 patients with a suicide attempt who visited Uijeongbu St. Mary's Hospital, the Catholic University of Korea, from December 2009 to December 2013 were analyzed. All patients were divided into the participation group (n = 262) and the refusal group (n = 227) according to their participation in the case management program. Demographic and clinical characteristics of each group were examined. Results showed that the refusal group had low risks for suicide in terms of risk factors related with psychopathologies and presenting suicide behavior. That is, the refusal group had less patients with co-morbid medical illnesses and more patients with mild severity of depression compared to the participation group. However, the refusal group had more interpersonal conflict, more isolation of social integrity, and more impaired insight about suicide attempt. The results suggest that nonparticipation in the case management program may depend upon the patient's impaired insight about the riskiness of suicide and lack of social support.

Association of sociodemographical features, antiviral treatment, and necroinflammatory activity with depression and anxiety in chronic hepatitis B patients

Objective: Psychiatric disorders like depression and anxiety are known to be more prevalent in patients with chronic hepatitis B than healthy individuals. This increased prevalence may be due to multiple factors such as psychological distress associated with having a chronic disease, necroinflammatory activity in liver, side effects of treatment with antiviral agents or interferons, and/or direct effect of hepatitis viruses on central nervous system. Purpose of this study was to evaluate several risk factors that may be associated with anxiety and depression in patients with chronic hepatitis B. Methods: This study included 195 chronic hepatitis B patients. A psychiatrist made clinical interviews with the patients and filled Sociodemographic Data Form, Hamilton Anxiety Rating Scale (HARS), and Hamilton Depression Rating Scale (HDRS). Needle biopsies were performed to 175 patients who met biopsy criteria of American Association for the Study of Liver Diseases. Knodell Histological Activity Index was used to evaluate biopsy materials. HBV DNA and ALT levels were measured from patients’ sera. Findings: In the study sample, 119 patients were males and 76 were females. Mean HARS score was 7.3±6.2 and mean HDRS score was 8.8±6.6. Both HARS and HDRS scores were higher in females than males. HARS score was higher in patients with a family history of chronic hepatitis and both HARS and HDRS scores were higher in patients with comorbid medical illness. Alanine aminotransferase, HBV DNA levels, and level of fibrosis in liver biopsy didn’t affect HARS or HDRS scores. Also, there wasn’t a difference in HARS or HDRS scores according to patients’ usage of pegylated interferon, or oral antiviral therapy. Conclusion: Multiple factors affect the relation between chronic hepatitis and psychiatric disorders like anxiety and depression. Results of our study suggest that female sex, presence of a family history for chronic hepatitis B, comorbidity of other medical diseases, and ethnic origin affect more than the level of necro-inflammatory activity and cellular damage in the liver or antiviral treatments.

Understanding of Antipsychotics in Elderly Patients with Dementia

Behavioral and psychological symptoms are often apparent and major issues in elderly patients with dementia, and are potentially the cause of the caregiver’s stress, thus leading these patients to nursing homes. Aging is a major risk factor for dementia, and using antipsychotics due to behavioral psychological symptoms in dementia (BPSD) present a challenge task in geriatric psychopharmacology, which is complicated not only by the effects of normal aging but by co-morbid medical illness. Elderly patients often present with subclinical syndromes or symptoms that are modified by co-morbid disease or partial treatment. Antipsychotics were and are frequently used for the treatment of BPSD. However, in recent years, the use of antipsychotics (both conventional and atypical) has been widely debated for their efficacy in treating behavioral disturbances and the possible serious adverse events in elderly patients with dementia.1-3 In the past, using conventional antipsychotics in the elderly patients with BPSD was strongly limited by their severe adverse events,4,5 whereas atypical antipsychotics were believed to have a far milder adverse effect profile than their older counterparts. However, several recent studies have raised questions about this belief.1,2 In 2002, trials with risperidone and olanzapine in elderly psychotic patients with dementia isUnderstanding of Antipsychotics in Elderly Patients with Dementia

Management and Outcomes of Hospitalized Patients With Primary Neuroendocrine Tumor and Non-Neuroendocrine Tumor Appendiceal Cancers in the United States.

BackgroundThe incidence of appendiceal cancers continues to rise at a very rapid pace. Although surgery has a central role in the management of appendiceal tumors, literature is lacking regarding the pattern and predictors of surgical treatment for patients with appendiceal cancers. We aimed to describe the surgical treatment for patients with appendiceal cancers, with emphasis on utilization based on histology.MethodsHospitalized patients with appendiceal cancer in the US between 2006 and 2010 were included in the study. The Nationwide Inpatient Sample database maintained by the Agency for Health Care Research and Quality was employed for univariate and multivariate testing to identify factors significantly associated with patient outcome.ResultsA total of 3,799 patient discharges were identified over the 5-year period covered by the study. Neuroendocrine tumor (NET) was the diagnosis in 291 (7.66%) patients and non-NET in 3,508 (92.34%) patients. The mean age was 56.8 years (± SD 14.6), with female predominance (54.73% vs. 45.27%). NET patients were younger than those with non-NET (50.7 vs. 57.4 years; P < 0.001). NET patients were more commonly treated with appendectomy compared to non-NET (OR: 1.59; 95% CI: 1.23 - 2.07; P < 0.001). Hyperthermic intraperitoneal chemotherapy (HIPEC) was used in 8.5% of all the cases, mostly in non-NET histology (91% vs. 8%). Majority of the patients treated with HIPEC had no co-morbid medical illness (60%), and received care at high volume hospitals located in urban areas. There was a very low incidence of in-hospital mortality (2.5%).ConclusionsThe described surgical utilization pattern should prompt more research focusing on barriers to appropriate surgical debulking and HIPEC utilization in non-NET appendiceal cancers.

Treating complexity: Collaborative care for multiple chronic conditions

Individuals with co-morbid chronic medical illness and psychiatric illness are a costly and complex patient population, at high risk for poor outcomes. Health-risk behaviours (e.g. smoking, poor diet, and sedentary lifestyle), side effects from psychiatric medications, and poor quality medical care all contribute to poor outcomes. Individuals with major depression die, on average, 5 to 10 years before their age-matched counterparts. For individuals with severe mental illness such as bipolar disorder or schizophrenia, life expectancy may be up to 20 years shorter. As the majority of this premature mortality is due to cardiovascular disease, there is a critical need to engage these individuals around the care of chronic medical illness.

English

OBJECTIVES: To determine the ECG changes in a group of out-patients on antipsychotics medication, and the association, if any, with factors such as gender, age, co-morbid illness and the use of concomitant medication. METHODS: Study subjects included patients 18 years and older attending the outpatient departments of Basaveshwar Teaching and General Hospitals. The subject's demographic and clinical characteristics were obtained and a resting ECG was recorded. RESULTS: Eighty patients were included in the study. The mean age of the subjects was 45.4 (standard deviation (SD) =18.2) years, with a minimum age of 18 and a maximum of 85 years. Fifty-four subjects (67.5%) had evidence of some ECG abnormalities. There was no significant difference between the occurrence of ECG abnormalities and the different age groups (p > 0.05), gender (p > 0.05), and different race groups (p > 0.05). Sixty-one subjects (76.3%) had no co-morbid medical illness and were on psychotropic medication only; of these patients 43 (70.5%) had abnormal ECG tracings (p >0.05). The ECG abnormalities recorded included abnormal rate (28.8%), abnormal ST segment (20.5%), abnormal QRS complex (17.8%), abnormal T wave (15.4%), prolonged or borderline corrected QT interval (8.2%), irregular rhythm (5.5%) and prolonged PR interval (2.7%). There was a significant positive correlation between the corrected QT interval and age (r = 0.43, p 0.05). CONCLUSION: The use of psychotropic drugs is associated with ECG changes in ordinary doses. However, this study serves to strengthen previous evidence that, although common, most of these changes are of a benign nature.

Outcomes of Implantable Cardioverter-Defibrillator Use in Patients With Comorbidities: Results From a Combined Analysis of 4 Randomized Clinical Trials

ObjectivesThe aim of this study was to determine if the benefit of implantable cardioverter-defibrillators (ICDs) is modulated by medical comorbidity. BackgroundPrimary prevention ICDs improve survival in patients at risk for sudden cardiac death. Their benefit in patients with significant comorbid illness has not been demonstrated. MethodsOriginal, patient-level datasets from MADIT I (Multicenter Automatic Defibrillator Implantation Trial I), MADIT II, DEFINITE (Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation), and SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) were combined. Patients in the combined population (N = 3,348) were assessed with respect to the following comorbidities: smoking, pulmonary disease, diabetes, peripheral vascular disease, atrial fibrillation, ischemic heart disease, and chronic kidney disease. The primary outcome was overall mortality, using the hazard ratio (HR) of time to death for patients receiving an ICD versus no ICD by extent of medical comorbidity, and adjusted for age, sex, race, left ventricular ejection fraction, use of antiarrhythmic drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. ResultsOverall, 25% of patients (n = 830) had <2 comorbid conditions versus 75% (n = 2,518) with significant comorbidity (≥2). The unadjusted hazard of death for patients with an ICD versus no ICD was significantly lower, but this effect was less for patients with ≥2 comorbidities (unadjusted HR: 0.71; 95% confidence interval: 0.61 to 0.84) compared with those with <2 comorbidities (unadjusted HR: 0.59; 95% confidence interval: 0.40 to 0.87). After adjustment, the benefit of an ICD decreased with increasing number of comorbidities (p = 0.004). ConclusionsPatients with extensive comorbid medical illnesses may experience less benefit from primary prevention ICDs than those with less comorbidity; implantation should be carefully considered in sick patients. Further study of ICDs in medically complex patients is warranted.

Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey

ObjectivePosttraumatic stress disorder (PTSD) is associated with higher rates of many medical conditions and higher use of medical health care services. Growing evidence suggests that comorbid medical illness in PTSD may in turn be associated with greater use of mental health treatment. However, no study to date has examined the impact of cumulative medical illness burden on PTSD service utilization. MethodData come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions. PTSD was assessed via structured interview, and cumulative medical illness burden was assessed via a survey of medical conditions. Logistic regression modeling examined associations between cumulative medical illness burden and odds of receiving PTSD treatment. ResultsIn the final sample of 1599 individuals with current PTSD, controlling for demographic characteristics, insurance status, psychiatric comorbidity and PTSD symptom count, higher levels of past-year medical illness were associated with increased odds of receiving past-year treatment for PTSD (odds ratio=1.10, 95% confidence interval=1.01–1.20, P=.029). ConclusionsGreater levels of medical illness are associated with increased odds of PTSD service utilization. Greater medical comorbidity may increase the need for PTSD care by exacerbating symptoms or increase contact with medical services promoting PTSD detection and treatment.

Enregistrement magnéto-encéphalographique (MEG) de réminiscences du trauma chez des femmes souffrant de stress post-traumatique : une étude pilote

The experiment studied the effects of a short duration exposure to traumatic memories using magneto-encephalography (MEG). Nine right-handed DSM-4 PTSD patients were recruited from a unit for anxiety disorders and an organisation supporting victims of violence. In order to have a homogeneous sample, we included only women who suffered from civilian PTSD. Exclusion criteria were co-morbid major medical illness, metallic dental prostheses that would interfere in the magnetic measurement, and current drug treatment. All participants were free from neurological disease and had normal hearing. They signed a written informed consent form. An ethics committee accepted the study. A tape-recorded voice administered a script-driven imagery. The patients had to imagine, successively, a neutral image, a traumatic memory and rest, while MEG measured brain activities across delta, theta, alpha and beta bands. Each condition lasted three minutes. Heart rate (HR), anxiety and the vividness of mental images were recorded at the end of each phase. MEG power analysis was carried out with Statistical Parametric Mapping (SPM) 8. The signals were averaged for each of the three conditions of threeminutes duration. The dependent variable was a subtracted value: (trauma - rest) - (neutral - rest). The significance threshold was set at P<0.01. Anxiety and HR significantly increased during the trauma condition and returned to the neutral level during rest. The vividness of the mental imagery remained stable across the three conditions. The left-brain demonstrated a statistically significant power decrease in the secondary visual cortex (BA 18-19) in the delta band, the insula (BA13) in the beta band, the insula (BA13), premotor cortex (BA 6), Broca area (BA 44), and BA 43, in the alpha band. The symptom provocation protocol was successful in eliciting subjective anxiety and HR response in relation to traumatic memories. Our MEG results are in keeping with previous neuro-imagery studies showing decreased activities in the insula and Broca area during PTSD symptom provocation. However, we did not replicate the activation in the amygdala and the cingulate and prefrontal cortex found in some studies. Moreover, the within-group design, the small sample, and the inclusion of only female patients with milder dissociative symptoms limit our conclusions. The MEG protocol we used may also explain some partial discrepancies with previous MEG studies. However, our aim was to provoke a specific autobiographic recall of a traumatic event unfolding several sequential mental images along three minutes as in exposure therapy for PTSD. Despite its limitations, this pilot study is the first to provide MEG data during trauma recall. It suggests that recalling a specific traumatic event along three minutes results in hypo-activations of the brain regions regulating language and emotions. This paves the way to recording whole sessions of specific therapies for PTSD, with MEG using the millisecond resolution. MEG might be of interest to study the suppression of traumatic memories and their activation and habituation through prolonged graduated exposure in imagination across several sessions. MEG could also be used to study the effects of medication on PTSD symptoms. A controlled replication in a larger sample including male and female patients with various traumatic experiences is needed.

Posttraumatic stress disorder: Beyond best practices.

Traditional therapies for posttraumatic stress disorder (PTSD) and the many neuropsychiatric conditions associated with abuse, stress, and combat are effective in only half of patients, despite best efforts and practices. The 50% of patients who do not improve by responding to usual standards of care are labeled treatment resistant. I propose that comorbid medical illnesses and injuries affecting mental state and general health and the failures of the systems that treat them contribute to the so-called “resistance” of chronic PTSD, depression, and anxiety. Military veterans and victims of torture often manifest treatment-resistant PTSD, depression, and anxiety. Many are debilitated by sleep disturbances, anxiety, depression, postconcussion syndrome, hypothyroidism, pain, and degenerative arthritis. Current practices lack an effective model for integrating these medical illnesses and injuries into the diagnosis and treatment of treatment-resistant PTSD, depression, and anxiety. A working model that integrates these components would involve comprehensive and integrated diagnosis and treatment. Current treatment approaches also often fail to track meaningful measures of recovery, most notably quality of life. The application of general systems theory provides a framework to address these deficits by focusing on the complex interplay between the psychological and physiological, recognizing the cumulative and synergistic effects of the psychiatric, neurological, metabolic, and pain problems— both clinical and subclinical—that contribute to treatment-resistant PTSD, depression, and anxiety.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

ObjectiveThe objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans. MethodsData came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care. ResultsOnly 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07–10.31). ConclusionsAlthough individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Randomized Trial of an Electronic Personal Health Record for Patients With Serious Mental Illnesses

The authors evaluated the effect of an electronic personal health record on the quality of medical care in a community mental health setting. A total of 170 individuals with a serious mental disorder and a comorbid medical condition treated in a community mental health center were randomly assigned to either a personal health record or usual care. One-year outcomes assessed quality of medical care, patient activation, service use, and health-related quality of life. Patients used the personal health record a mean of 42.1 times during the 1-year intervention period. In the personal health record group, the total proportion of eligible preventive services received increased from 24% at baseline to 40% at the 12-month follow-up, whereas it declined in the usual care group, from 25% to 18%. In the subset of patients with one or more cardiometabolic conditions (N=118), the total proportion of eligible services received improved by 2 percentage points in the personal health record group and declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups. There was an increase in the number of outpatient medical visits, which appeared to explain many of the significant differences in the quality of medical care. Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients. Personal health records could provide a relatively low-cost scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses.