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BackgroundNatural disasters are associated with increased mental health disorders and suicidal ideation; however, associations with suicide deaths are not well understood. We explored how Hurricane Florence, which made landfall in September 2018, may have impacted suicide deaths in North Carolina (NC).MethodsWe used publicly available NC death records data to estimate associations between Hurricane Florence and monthly suicide death rates using a controlled, interrupted time series analysis. Hurricane exposure was determined by using county-level support designations from the Federal Emergency Management Agency. We examined effect modification by sex, age group, and race/ethnicity.Results8363 suicide deaths occurred between January 2014 and December 2019. The overall suicide death rate in NC between 2014 and 2019 was 15.53 per 100 000 person-years (95% CI 15.20 to 15.87). Post-Hurricane, there was a small, immediate increase in the suicide death rate among exposed counties (0.89/100 000 PY; 95% CI −2.69 to 4.48). Comparing exposed and unexposed counties, there was no sustained post-Hurricane Florence change in suicide death rate trends (0.02/100 000 PY per month; 95% CI −0.33 to 0.38). Relative to 2018, NC experienced a statewide decline in suicides in 2019. An immediate increase in suicide deaths in Hurricane-affected counties versus Hurricane-unaffected counties was observed among women, people under age 65 and non-Hispanic black individuals, but there was no sustained change in the months after Hurricane Florence.ConclusionsAlthough results did not indicate a strong post-Hurricane Florence impact on suicide rates, subgroup analysis suggests differential impacts of Hurricane Florence on several groups, warranting future follow-up.

Background Prescription records, manual chart review, and patient self-report are each imperfect measures of depression treatment in HIV-infected adults. Methods We compared antidepressant prescription records in an electronic data warehouse with antidepressant treatment and psychotherapy identified via manual chart review and self-report for patients at 6 academic HIV treatment centers. We examined concordance among these three sources, and used latent class analysis (LCA) to estimate sensitivity and specificity of each measure. Results In our charts sample (n = 586), 59% had chart indication of “any depression treatment” and 46% had a warehouse prescription record. Antidepressant use was concordant between charts and data warehouse for 77% of the sample. In our self-report sample (n = 677), 52% reported any depression treatment and 43% had a warehouse prescription record. Self-report of antidepressant treatment was consistent with prescription records for 71% of the sample. LCA estimates of sensitivity and specificity for “any depression treatment” were 67% and 90% (warehouse), 87% and 75% (self-report), and 96% and 77% (chart). Limitations There is no gold standard to measure depression treatment. Antidepressants may be prescribed to patients for conditions other than depression. The results may not be generalizable to patient populations in non-academic HIV clinics. Regarding LCA, dependence of errors may have led to overestimation of sensitivity and specificity. Conclusions Prescription records were largely concordant with self-report and chart review, but there were discrepancies. Studies of depression in HIV-infected patients would benefit from using multiple measures of depression treatment or correcting for exposure misclassification.

Numerous guidelines have been developed over the past decade regarding treatments for Posttraumatic stress disorder (PTSD). However, given differences in guideline recommendations, some uncertainty exists regarding the selection of effective PTSD therapies. The current manuscript assessed the efficacy, comparative effectiveness, and adverse effects of psychological treatments for adults with PTSD. We searched MEDLINE, Cochrane Library, PILOTS, Embase, CINAHL, PsycINFO, and the Web of Science. Two reviewers independently selected trials. Two reviewers assessed risk of bias and graded strength of evidence (SOE). We included 64 trials; patients generally had severe PTSD. Evidence supports efficacy of exposure therapy (high SOE) including the manualized version Prolonged Exposure (PE); cognitive therapy (CT), cognitive processing therapy (CPT), cognitive behavioral therapy (CBT)-mixed therapies (moderate SOE); eye movement desensitization and reprocessing (EMDR) and narrative exposure therapy (low-moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., Cohen's d ~-1.0 or more compared with controls). Numbers needed to treat (NNTs) were

Context Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD. Evidence acquisition The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012. Evidence synthesis Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings. Conclusions Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Objective The purpose of this study was to evaluate whether co-prescription of benzodiazepine when initiating antidepressant treatment is associated with better antidepressant adherence than initiating treatment with antidepressants alone among patients with anxiety disorders. Methods We conducted a retrospective observational cohort study using MarketScan Commercial Claims and Encounters database (Thomson Reuters). We identified patients aged 18–64 with anxiety disorders (including generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive–compulsive disorder, and post-traumatic stress disorder), who were newly receiving a selective serotonin reuptake inhibitor or serotonin–norepinephrine reuptake inhibitor between July 1, 2005 and June 30, 2007. We compared those who were co-prescribed a benzodiazepine at antidepressant initiation with those who begun on an antidepressant alone. The outcome measure was antidepressant adherence rate measured as the proportion of days covered (PDC) on antidepressant treatment. Patients with PDC ≥80% were considered adherent. We used propensity score matching to balance measurable confounders. Logistic regression models were used to measure adherence. Results Our study included 6949 patients who were co-prescribed benzodiazepines and antidepressants, and 6949 patients receiving antidepressants alone after matching for propensity scores. Before adjusting covariates, patients in the co-prescribed benzodiazepine group had lower adherence to antidepressants (PDC: 0.52 vs. 0.60, p Conclusion This is the largest analysis with an observational study design to date. Our study results showed that patients with anxiety who are co-prescribed benzodiazepines when initiating treatment with antidepressants are less likely to adhere to antidepressants than those who begin treatment with antidepressants alone. Further research should clarify whether co-prescribing benzodiazepines with antidepressant initiators is a preferred clinical strategy for those with anxiety disorders.

Background In high-income countries, depression is prevalent in HIV patients and is associated with lower medication adherence and clinical outcomes. Emerging evidence from low-income countries supports similar relationships. Yet little research has validated rapid depression screening tools integrated into routine HIV clinical care. Methods Using qualitative methods, we adapted the Patient Health Questionnaire-9 (PHQ-9) depression screening instrument for use with Cameroonian patients. We then conducted a cross-sectional validity study comparing an interviewer-administered PHQ-9 to the reference standard Composite International Diagnostic Interview in 400 patients on antiretroviral therapy attending a regional HIV treatment center in Bamenda, Cameroon. Results The prevalence of major depressive disorder (MDD) in the past month was 3% ( n =11 cases). Using a standard cutoff score of ≥10 as a positive depression screen, the PHQ-9 had estimated sensitivity of 27% (95% confidence interval: 6–61%) and specificity of 94% (91–96%), corresponding to positive and negative likelihood ratios of 4.5 and 0.8. There was little evidence of variation in specificity by gender, number of HIV symptoms, or result of a dementia screen. Limitations The low prevalence of MDD yielded very imprecise sensitivity estimates. Although the PHQ-9 was developed as a self-administered tool, we assessed an interviewer-administered version due to the literacy level of the target population. Conclusion The PHQ-9 demonstrated high specificity but apparently low sensitivity for detecting MDD in this sample of HIV patients in Cameroon. Formative work to define the performance of proven screening tools in new settings remains important as research on mental health expands in low-income countries.

Depression affects 20-30% of people living with HIV/AIDS (PLWHA) in the U.S. and predicts greater sexual risk behaviors, lower antiretroviral (ARV) medication adherence, and worse clinical outcomes. Yet little experimental evidence addresses the critical clinical question of whether depression treatment improves ARV adherence and clinical outcomes in PLWHA with depression. The Strategies to Link Antidepressant and Antiretroviral Management at Duke, UAB, and UNC (SLAM DUNC) Study is a randomized clinical effectiveness trial funded by the National Institute for Mental Health. The objective of SLAM DUNC is to test whether a depression treatment program integrated into routine HIV clinical care affects ARV adherence. PLWHA with depression (n=390) are randomized to enhanced usual care or a depression treatment model called Measurement-Based Care (MBC). MBC deploys a clinically supervised Depression Care Manager (DCM) to provide evidence-based antidepressant treatment recommendations to a non-psychiatric prescribing provider, guided by systematic and ongoing measures of depressive symptoms and side effects. MBC has limited time requirements and the DCM role can be effectively filled by a range of personnel given appropriate training and supervision, enhancing replicability. In SLAM DUNC, MBC is integrated into HIV care to support HIV providers in antidepressant prescription and management. The primary endpoint is ARV adherence measured by unannounced telephone-based pill counts at 6 months with follow-up to 12 months and secondary endpoints including viral load, health care utilization, and depressive severity. Important outcomes of this study will be evidence of the effectiveness of MBC in treating depression in PLWHA and improving HIV-related outcomes.

To examine whether prescriber specialty and guideline-concordant follow-up visits were associated with antidepressant treatment completion among patients with major depressive disorder (MDD).This study analyzed medical and prescription claims from a large national health plan. Patients were grouped based on initial prescriber specialty. Receipt of guideline-concordant follow-ups was defined as havingor =3 visits during the treatment phase. Completion of acute phase (first 90 days) and continuation phase (Days 91-270) was defined by adherenceor = 80% without significant gaps in treatment. Logistic regressions were used to examine factors associated with treatment completion.Forty-seven percent of the 4102 newly diagnosed patients completed the acute phase, 45% of whom also completed the continuation phase. Among those initially prescribed by primary care providers (PCPs), patients with guideline-concordant follow-ups were more likely (13.1 percentage points, P.0001) to complete acute phase than patients without guideline-concordant follow-ups. Receipt of guideline-concordant follow-ups increased the probability of acute phase completion by an additional 6.8 percentage points if initially treated by psychiatrists. Patients prescribed by psychiatrists were less likely to complete acute phase treatment (-4.6 percentage points, P=.04) if they did not have guideline-concordant follow-ups.A large gap remains between guideline recommendations and actual antidepressant treatment. Frequent follow-up corresponds with better antidepressant adherence.

Background Comorbid panic symptoms may complicate depression treatment. However, most research focuses on specialty care, and the evidence in primary care is mixed. Methods We analyzed data from a randomized trial investigating Selective Serotonin Reuptake Inhibitor (SSRI) Treatment, a longitudinal effectiveness study comparing 3 SSRIs for the treatment of depression in primary care ( n = 573). Depression at month 6 was measured using the Symptom Checklist-20; remission was defined as a score ≤ 0.5; partial response was defined as ≥ 50% improvement but not to a level of ≤ 0.5. Nonresponse, the referent level for all analyses, was defined as patients who do not meet either of these criteria. Panic symptoms (yes/no) were measured using a screening question. Results Rates of remission vs. nonresponse [OR = 1.06 (95% confidence interval 0.67, 1.67)] or partial response vs. nonresponse [OR = 0.92 (95% CI 0.54, 1.57)] were similar among patients with baseline panic symptoms, adjusting for baseline depression severity. However, patients with persistent panic symptoms were less likely to experience remission (OR = 0.38, 95% CI 0.18, 0.81), while the lower likelihood of partial response did not achieve statistical significance (0.66, 95% CI 0.33, 1.33). Results were similar using complete case, last observation carried forward, and multiple imputation methods, and were robust to varying the sensitivity and specificity of the panic screening question. Conclusion Panic symptoms that persist are associated with worse depression outcomes in the maintenance phase. Consequently, improvement in panic symptoms may be important for improved depression outcomes and primary care physicians should be attuned to the presence of panic symptoms when making treatment decisions.

Background Individuals with diabetes mellitus (DM) are two to four times more likely to be diagnosed with major depressive disorder (MDD). However, few controlled studies have examined the impact of DM on the treatment of MDD. Understanding the effect of DM on depressed patients could provide valuable clinical information toward adjusting current treatment modalities to produce a more effective treatment for depressed patients with DM. Methods This study was conducted using an evaluable sample of 2876 outpatient participants enrolled in the Sequenced Treatment Alternatives to Relieve Depression study. Sociodemographic and clinical characteristics and treatment characteristics with the selective serotonin reuptake inhibitor (SSRI) citalopram, as well as remission rates for MDD and time to remission, were compared between participants with DM and participants without DM. Results The odds of remission were lower in participants with DM than in those without DM prior to adjustment [odds ratio (OR)=0.68; 95% confidence interval (95% CI)=(0.49, 0.94); P=.0184]. These differences were no longer present after adjustment [OR=0.92; 95% CI=(0.64, 1.32); P=.6399]. Participants with DM reported fewer side effects than participants without DM despite similar dosing. Conclusions Depressed patients with DM and depressed patients without DM appear to have similar rates of MDD remission, indicating that a diagnosis of DM per se has no impact on MDD remission. The findings of fewer side effects and psychiatric serious adverse events in participants with DM imply that depressed patients with DM may be excellent candidates for more aggressive SSRI dosing. This lower prevalence of side effects reported by depressed participants with DM warrants further exploration.

Objetivo Habitualmente, los medicos formulan preguntas a los pacientes con trastorno depresivo mayor (TDM) no psicotico sobre los antecedentes familiares de suicidio. Sin embargo, se desconoce si los pacientes con un familiar que consumo el suicidio difieren de los que no. Metodo Se recluto a los pacientes para el ensayo multicentrico STAR*D. En el periodo basal, se solicito a los pacientes que refirieran si algun familiar en primer grado habia fallecido por suicidio. Se evaluaron las diferencias en las caracteristicas demograficas y clinicas de pacientes con y sin antecedentes familiares de suicidio. Resultados Entre los pacientes con antecedentes familiares de suicidio (142/4.001; 3,5%), fue mas probable identificar antecedentes familiares de TDM, trastorno bipolar o cualquier trastorno del humor y trastorno familiar por consumo de sustancias, pero no pensamientos suicidas, comparado con aquellos sin dichos antecedentes. El grupo con antecedentes de suicidio de un familiar manifesto una vision mas pesimista del futuro y el TDM se inicio a una edad mas temprana. No se detectaron otras diferencias significativas en los sintomas depresivos, gravedad, recurrencia, subtipo depresivo o funcion diaria. Conclusiones Los antecedentes de suicidio consumado en un miembro de la familia se asociaron con diferencias clinicas minimas en la presentacion transversal de pacientes ambulatorios con TDM. Las limitaciones del presente estudio incluyen la ausencia de informacion sobre familiares que hubieran intentado suicidarse, al igual que la edad de los probandos cuando fallecio el miembro de la familia. Las evaluaciones STAR*D se limitaron a las necesarias para determinar el diagnostico y la respuesta al tratamiento y no incluyeron una variedad mas amplia de medidas psicologicas.

Background Patients with major depressive disorder (MDD) have high rates of medical comorbidities which can impair MDD treatment. Yet little is known regarding associations between the presence of a serious comorbidity and MDD treatment. The purpose of this study was to examine the baseline sociodemographic and clinical characteristics of MDD outpatients with and without diabetes mellitus to evaluate possible associations between these characteristics and the presence of comorbid diabetes. Methods We gathered baseline sociodemographic and clinical data for 4041 participants with non-psychotic MDD who enrolled in the STAR ⁎ D, a large-scale depression treatment protocol, and made comparisons between participants with and without diabetes. Results Participants with diabetes were more likely to be male, older, black, Hispanic, unemployed, and have less education, a lower income, higher mental functioning, lower physical functioning, atypical features, increased appetite, psychomotor slowing and leaden paralysis, and were less likely to have concurrent alcohol abuse/dependence, mood reactivity or problems with concentration. We found no significant differences between groups regarding depression severity. Limitations The primary limitation is the lack of a clinical diagnosis of diabetes. Conclusions We found no difference in depression severity between participants with and without diabetes. Diabetes was associated with physical symptoms of depression. Thus treatments for these participants should be directed toward these symptoms.

We report on the prevalence of self-reported depressive symptoms and associated factors among women employed in a poultry processing plant and a community comparison group of other employed women in northeastern North Carolina in the southern United States. The rural area is poor and sparsely populated with an African American majority. The largest employer of women in the area is a poultry processing plant. The goals of the analyses were 1) to evaluate whether women employed in poultry processing had a higher prevalence of depressive symptoms than other working women from the same geographic area, and 2) to evaluate factors which might be associated with depression among all of these working women, including specific characteristics of their work environment. Recruitment of participants (n=590) and data collection were by community-based staff who were also African American women. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Work organization factors were measured with the Job Content Questionnaire (JCQ). Log-binomial regression was used to calculate crude and adjusted prevalence ratios. The prevalence of depressive symptoms, based on a CES-D measure of sixteen or more, was 47.8% among the poultry workers and 19.7% among the other working women (prevalence ratio=2.3). After adjusting for socioeconomic variables, health-related quality of life and coping style, the prevalence of depressive symptoms remained 80% higher among the poultry workers. The prevalence of symptoms was also higher among those who perceived low social support at work, hazardous work conditions, job insecurity, and high levels of isometric load. These factors were all more common among the women employed in the poultry plant. The concentration of this low-wage industry in economically depressed rural areas illuminates how class exploitation and racial discrimination may influence disparities in health among working women.

No study has directly compared the clinical features of depression for patients entering clinical trials using identical enrollment criteria at primary care (PC) and specialty care (SC) settings. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (http://www.star-d.org) provides a unique opportunity to provide this comparison for patients with a major depressive disorder (MDD) requiring treatment.We report baseline data for the first 1500 patients enrolled in this trial involving 41 clinic sites (18 PC, 23 SC). Broadly inclusive eligibility criteria required that patients have a DSM-IV diagnosis of nonpsychotic MDD, have not failed an adequate medication trial during their current episode and scoreor=14 on the 17-item Hamilton Rating Scale for Depression (HAM-D17). Primary outcomes included the 30-item Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C30) and the HAM-D17.Specialty care and PC patients had equivalent degrees of depressive severity (IDS-C30=35.8; HAM-D17=20.4). Specialty care patients were almost twice as likely to report a prior suicide attempt than PC patients (21% vs. 12%, P.0001) and slightly less likely to endorse suicidal ideation in the past week (45.0% vs. 50.8%, P=.006). The only other distinguishing core symptoms were a slightly lower likelihood of PC patients endorsing depressed mood (95.2% vs. 97.7%, P=.032) or anhedonia (66.3% vs. 70.7%, P=.042, IDS-C30) and a lower likelihood of PC patients endorsing weight loss (IDS-C30). HAM-D17 results were identical.Depressive severity was not different, and symptomatic presentations did not differ substantially. Major depressive disorder is more similar than different among patients at SC and PC settings. Thus, similar clinical and research methods for screening, detecting and measuring treatment outcomes can be applied in both settings.

Psychosocial factors, as appreciated within the context of the biopsychosocial model, are necessary for understanding the clinical expression of irritable bowel syndrome (IBS) by virtue of their key roles in the development, precipitation and perpetuation of IBS. Addressing psychosocial factors in assessment and management leads to improvement in the clinical outcome for IBS patients. Pertinent management components include adopting a ‘care’ approach within an ongoing collaborative treatment relationship; offering any psychological or psychiatric intervention as part of a multi-disciplinary treatment approach; providing education and reassurance; and using mental health professionals when indicated.