Primary prevention-psychosocial aspects

Psychosocial risk factors like low socio-economic status, social isolation and lack of social support, chronic work or family stress, depression, and hostility contribute significantly to the development and adverse outcome of coronary heart disease (CHD). The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Methods to assess psychosocial risk factors are single item questions to be included in the cardiologist clinical interview and/or standardized questionnaires. Recommended interventions include an appropriate physician-patient interaction, multimodal, behavioral interventions with face to face or group counselling, and, in case of clinically significant depression, psychotherapy and medication.     

The Time Has Come for Physicians to Take Notice: The Impact of Psychosocial Stressors on the Heart

A rapidly growing body of evidence supports a relationship between psychosocial factors and cardiovascular disease. In this article, a review of the epidemiologic and clinical research investigating this relationship concludes that psychosocial stressors can be both a cause and a consequence of cardiovascular disease events. Furthermore, recent data have shown that stress management might reduce future cardiac events in patients with cardiovascular disease. Unfortunately, the influence of psychosocial risk factors on cardiovascular disease remains underrecognized compared with traditional cardiac risk factors. Physicians and their associates should screen for psychosocial stressors and recognize potential symptoms. Consideration should be given to developing improved liaison relationships with psychologic or behavioral specialists to facilitate more specialized interventions when appropriate. A variety of interventions conducted by appropriately trained mental health professionals have successfully improved stress in patients with cardiovascular disease and other chronic diseases. The time has come for physicians to recognize the impact of psychosocial stressors on cardiovascular disease.     

Psychosocial screening in coronary heart disease: 5 decisive questions

There is overwhelming convincing evidence linking psychosocial factors to outcome of patients with coronary heart disease. Thus, assessment of psychosocial variables should be an integrated part of risk stratification. To facilitate psychosocial assessment in clinical practice and to identify a subset of patients possibly benefitting from extended psychological measures, a new semistandardized interview instrument is presented, called LIPS ("Lübecker halbstandardisiertes Interview zum Psychosozialen Screening"). Beside the well-known and relevant domains social support, emotional stress/vital exhaustion, anxiety and depression, a score for the global psychosocial impairment can be documented. LIPS requires no specialized psychological training, its time requirement is five to ten minutes and it is easily integrated into routine physical and psychosocial assessment. The presentation includes the original instrument in addition to its validation on standardized self-administered questionnaires.     

AUDIT-C as a brief screen for alcohol misuse in primary care

BACKGROUND: The Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questions have been previously validated as a 3-item screen for alcohol misuse and implemented nationwide in Veterans Affairs (VA) outpatient clinics. However, the AUDIT-C's validity and optimal screening threshold(s) in other clinical populations are unknown. METHODS: This cross-sectional validation study compared screening questionnaires with standardized interviews in 392 male and 927 female adult outpatients at an academic family practice clinic from 1993 to 1994. The AUDIT-C, full AUDIT, self-reported risky drinking, AUDIT question #3, and an augmented CAGE questionnaire were compared with an interview primary reference standard of alcohol misuse, defined as a Diagnostic and Statistical Manual, 4th ed. alcohol use disorder and/or drinking above recommended limits in the past year. RESULTS: Based on interviews with 92% of eligible patients, 128 (33%) men and 177 (19%) women met the criteria for alcohol misuse. Areas under the receiver operating characteristic curves (AUROCs) for the AUDIT-C were 0.94 (0.91, 0.96) and 0.90 (0.87, 0.93) in men and women, respectively (p=0.04). Based on AUROC curves, the AUDIT-C performed as well as the full AUDIT and significantly better than self-reported risky drinking, AUDIT question #3, or the augmented CAGE questionnaire (p-values <0.001). The AUDIT-C screening thresholds that simultaneously maximized sensitivity and specificity were > or =4 in men (sensitivity 0.86, specificity 0.89) and > or =3 in women (sensitivity 0.73, specificity 0.91). CONCLUSIONS: The AUDIT-C was an effective screening test for alcohol misuse in this primary care sample. Optimal screening thresholds for alcohol misuse among men (> or =4) and women (> or =3) were the same as in previously published VA studies.     

Psychosocial variables in relation to various risk factors in patients with stable angina pectoris

OBJECTIVES: To evaluate relationships between psychosocial variables and common risk factors such as age, concomitant diseases (hypertension, diabetes mellitus, myocardial infarction, heart failure) and smoking habits in patients with stable angina pectoris. SETTING: University Hospital. SUBJECTS: Participants in the Angina Prognosis Study in Stockholm (APSIS), which comprised 809 patients (248 females) <70 years of age, with chronic stable angina pectoris, of whom 767 (236 females) participated in the present report. Patients with angina pectoris occurring only at rest constituted one group, patients with angina pectoris on effort with or without angina at rest were stratified according to signs of marked ischaemia on exercise and/or clinical signs of heart failure. METHODS: Psychosomatic symptoms, job strain, Type-A behaviour, sleep disturbances and overall life satisfaction were evaluated by a structured interview, which also included questions regarding how the patients usually felt, and health related problems, according to a standardized check-list. RESULTS: Age correlated with several psychosomatic symptoms and tendency to worry. When adjusted for age and sex, patients with previous myocardial infarction and heart failure described more psychosomatic symptoms, but worried less about the future than patients without these diseases. In the group with angina pectoris at rest only there were fewer smokers than amongst other groups, regardless of risk stratification. CONCLUSIONS: Smoking habits and concomitant diseases influence psychosocial variables in patients with stable angina pectoris. The severity of angina pectoris does not seem to relate to life satisfaction and attitudes towards the future.     

Psychosocial risk factors and asthma among adults in Puerto Rico

Objective: Asthma and psychosocial stressors are common among Puerto Rican adults living in the United States. We estimated the prevalence of current asthma, and examined potential psychosocial risk factors and current asthma, among adults in Puerto Rico. Methods: Cross-sectional study of 3,049 Puerto Ricans aged 18–64 years living in Puerto Rico between May 2014 and June 2016. A structured interview was conducted to obtain information on demographics, lifestyle, mental disorders, and respiratory health. Current asthma was defined as self-reported physician-diagnosed asthma and still having asthma. Multivariable logistic regression was used to examine psychosocial risk factors and current asthma. Results: The estimated prevalence of current asthma was 10.2%. In a multivariable analysis, exposure to violence (odds ratio [OR] for each 1-point increment in a validated scale = 1.14, 95% confidence interval [CI] = 1.07 to 1.21) and a lifetime history of at least one suicide attempt (OR = 3.01, 95% CI = 1.80 to 5.01) were significantly associated with current asthma, independently of major depressive disorder. Moreover, a lifetime history of at least one suicide attempt was associated with co-existing asthma and chronic obstructive pulmonary disease (i.e., asthma-COPD overlap syndrome or ACOS (OR = 9.05, 95% CI = 3.32–24.67). Conclusions: Our findings suggest that asthma is a major health problem among adults in Puerto Rico, with psychosocial risk factors playing a significant role in asthma and ACOS. Addressing chronic stressors and mental illness should be part of comprehensive strategies to reduce asthma burden in this population.     

Schlafapnoescreening kardiovaskul?rer Patienten im klinischen Alltag

Sleep apnea syndromes (SAS) are highly prevalent in cardiovascular patients. Because diagnostics are cost and labor intensive, these patients often remain undiagnosed. For this reason, simple screening methods for SAS in daily clinical practice are very important. Standardized questionnaires are one way to screen patients, i.e., simple standardized questionnaires have been shown to be highly predictive in OSA, but not in CSA patients. Simple ambulatory screening devices use oxymetry and/or nasal flow to determine the apnea-hypopnea index (AHI). These devices have been shown to be highly effective in screening for OSA and CSA. In addition, algorithms that calculate the electrocardiography (ECG)-derived AHI using heart rate variability and/or QRS morphology from Holter ECG recordings are also promising. Especially the latter method could become a simple tool for cardiologists to screen for SAS in clinical routine.     

Screening for depression and diabetes‐related distress in a diabetes outpatient clinic

Aims To investigate: (1) the willingness of patients with diabetes to participate in a screening programme; (2) the extent to which patients with diabetes who screen positive endorse need for psychosocial care; (3) the rate of referral to psychosocial care during screening vs. usual care. Methods Four hundred and ninety‐nine patients with diabetes were invited to complete the Center for Epidemiologic Studies Depression and the Problem Areas in Diabetes questionnaires. Patients screening positive on either instrument were invited for an interview. One year after screening was withdrawn, rates of referral to psychosocial care were assessed from physician reports of patient referrals. Results In total, 349/499 (70%) patients with diabetes completed the questionnaire. Patients who did not take up the screening were younger, smoked more often and had higher HbA_1c values. ‘No‐shows’ for clinical appointments accounted for 74% of non‐participation. Of the 104 (30% of 349) patients screening positive, 45 accepted an invitation for an interview. Finally, 36/104 (35%) would like a referral for psychological care. Seven per cent of patients were referred to psychological care during screening compared with 1% when screening was withdrawn. Conclusions Results raise questions as to whether screening is the most efficient way to identify patients with psychological problems. Many patients did not take up the screening, especially those with low adherence to diabetes care in general. Furthermore, few patients screening positive wanted to be referred. Screening should be evaluated in the context of consideration of alternative ways to identify at‐risk patients, including providing resources to deal with patients with already known adjustment and adherence problems.     

Practice Constraints,Behavioral Problems,and Dementia Care: Primary Care Physicians’ Perspectives

Objectives To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. Design Cross-sectional qualitative interview study of primary care physicians. Setting Physicians’ offices. Participants Forty primary care physicians in Northern California. Measurements Open-ended interviews lasted 30–60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. Results Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, “reactive” as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. Conclusion Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.     

Needle Sharing: a Longitudinal Study of Female Injection Drug Users

The objective of this study was to examine the psychosocial risk and protective factors related to needle-sharing behavior among female intravenous drug users (IDUs) positive (N = 96) and negative (N = 128) for human immunodeficiency virus (HIV). Participants in this longitudinal study were interviewed individually at two points in time, with a 6-month interval between interviews. The interviewers used a structured questionnaire, which included psychosocial measures and questions about drug and sexual risk behaviors. Data were analyzed using Pearson correlations and hierarchical regression analyses. The findings supported a developmental model in which the psychosocial domains and HIV status predicted T1 (initial) needle-sharing behavior, which in turn was related to T2 (follow-up) needle-sharing behavior. In addition, the relationship between personality and peer risk factors and T2 needle sharing was buffered by family-related protective factors. While HIV-positive status had a direct effect on T1 needle sharing with strangers, its effect was mediated by all of the psychosocial variables in its relation to T1 needle sharing with familiar people. Comparisons of these results were made with a companion study of male IDUs. The results suggest several intervention and treatment approaches that can be implemented at different points in the developmental pathways leading to risky needle-sharing practices among female IDUs.     

Psychosocial Risk Factors for Hospitalisation and Death from Chronic Obstructive Pulmonary Disease: A Prospective Cohort Study

Only a few smaller studies have addressed the effect of psychosocial factors on risk of chronic obstructive pulmonary disease (COPD) in spite of the potential for psychosocial stress to affect development of the disease through immunological and behavioural pathways. The aim of this study is to determine the relation between various psychosocial risk factors, individually and accumulated, and COPD hospitalisation and deaths. A total of 8728 women and men free of asthma and COPD participating in the Copenhagen City Heart Study, were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, economic hardship, and sleep medication in 1991–1993 and followed in nationwide registers until 2009, with <2% loss to follow-up. During follow-up, 461 women and 352 men were hospitalized with or died from COPD. Major life events in adult life and vital exhaustion were both associated with a higher risk of COPD in an exposure-dependent manner, with high vital exhaustion being associated with a hazard ratio [HR] of 2.31 (95% CI 1.69–3.16) for women and 2.48 (1.69–3.64) for men. A higher risk of COPD was also found in participants who experienced economic hardship or had a dysfunctional social network. Furthermore, the accumulation of psychosocial risk factors was associated with a higher risk of COPD in both women (HR = 2.40, 1.78–3.22) and men (HR = 1.93, 1.33–2.80). Psychosocial vulnerability may be important to consider both in clinical practice and when planning future preventive strategies against COPD.     

Evidence for Psychosocial Risk Factors and Behavioral Interventions in Cardiovascular Disease

Over nearly a half century, epidemiologic studies have shown a strong relationship between several psychosocial variables and the risk of coronary heart disease. Key factors include negative thought patterns and emotions, specifically depressive syndromes, anxiety syndromes, hostility and anger, worry and pessimism. Chronic stress factors include work stress, social isolation, and low socioeconomic status. Positive psychological factors include optimism, social support and sense of purpose. Clinical trials involving behavioral interventions such as those focusing on type A behavior or depression, have had mixed results. Simple psychosocial evaluation recommended includes an inventory for assessing depression given its predominance as a psychosocial factor consistently associated with cardiovascular disease risk. Screening for other factors of psychosocial stress as well as carefully planned multidisciplinary management is also recommended to maximize the likelihood of adherence.     

Use of assessment instruments in clinical settings

In recent years, increased emphasis has been placed in the field of geriatric medicine on the need for multidimensional assessment of elderly patients. There is an increasing tendency to use standardized structured assessment instruments or questionnaires in this process. Frequently, the exact question or set of questions to be answered by the instrument has not been carefully analyzed. Although comprehensive structured multidimensional instruments allow the collection of large amounts of data in multiple domains (physical, social, psychologic, economic), these instruments may require excess data collection and may not be reliable in clinical settings. Clinicians considering using a variety of assessment instruments should carefully consider their goals for data collection and carefully review the validity, reliability, and population sampled for any assessment instruments under consideration. Also, the clinical setting in which the instrument is to be used can have a negative impact on either instrument validity or reliability.     

Psychosocial and behavioral correlates of depression among HIV-infected pregnant women

This study addressed two aims: (1) to assess the level of depressive symptoms among pregnant, HIV-infected racial and ethnic minority women and (2) to identify potentially modifiable factors associated with prenatal depression in order to foster proactive clinical screening and intervention for these women. Baseline interview data collected from HIV-infected women participating in the Perinatal Guidelines Evaluation Project were analyzed. Participants were from prenatal clinics in four areas representative of the U. S. HIV/AIDS epidemic among women. Of the final sample (n = 307), 280 were minorities (218 blacks [African American and Caribbean], 62 Hispanic). Standardized interviews assessed potential psychosocial factors associated with pregnancy-related depression and psychological distress (life stressors, inadequate social support, and ineffective coping skills) in a population for whom little work has been done. Depressive symptomatology was considerable, despite excluding somatic items in order to avoid confounding from prenatal or HIV-related physical symptoms. The psychosocial factors significantly predicted the level of prenatal depressive symptoms beyond the effects of demographic and health-related factors. Perceived stress, social isolation, and disengagement coping were associated with greater depression, positive partner support with lower depression. These findings demonstrate that psychosocial and behavioral factors amenable to clinical intervention are associated with prenatal depression among women of color with HIV. Routine screening to identify those currently depressed or at risk for depression should be integrated into prenatal HIV-care settings to target issues most needing intervention.     

Diagnostic utility of reflux disease symptoms

Symptom assessment, by structured interview or questionnaire, is central to the diagnosis of gastro-oesophageal reflux disease (GORD). However, empiric support for the diagnostic utility of reflux symptom measures is lacking. Reliable reflux symptom questionnaires have been developed with content validity. These questionnaires need to be evaluated in terms of diagnostic accuracy, support for application of specific treatment, and improved outcomes resulting from their use. The impact on clinical outcomes of GORD diagnosis by valid questionnaires or structured interview has not been studied.     

Illness behavior and psychosocial factors in diffuse upper limb pain disorder: a case-control study

OBJECTIVE: To compare behavioral and other psychosocial factors in patients with diffuse upper limb pain disorder (ULPD) and patients with carpal tunnel syndrome (CTS). METHODS: We compared 37 hospital outpatients with diffuse ULPD with 36 hospital outpatients with CTS, matched by sex, pain intensity, and duration of illness. We assessed psychiatric morbidity by a standardized interview, and both symptoms and personality by self-rated questionnaires. We measured illness behavior by assessing financial benefits and compensation, coping strategies, illness beliefs, treatments received, and 24 hours of monitoring movements of the most affected arm and the body as a whole. RESULTS: There were no significant differences in the prevalence of either current or premorbid psychiatric disorders, personality scores, symptom amplification, disability, or treatments received. Subjects with ULPD had significantly lower self-rated scores for depression, somatic distress, sleep disturbance, and physical fatigue than subjects with CTS, although there were more than normal levels of anxiety, fatigue, and sleep disturbance in both groups. There were no significant differences in the numbers of arm or body movements by day and night. Significantly more ULPD subjects had been involved in litigation, but litigating patients were a minority. CONCLUSION: The primary etiology of endemic diffuse ULPD, presenting in secondary care, is no more psychiatric, psychological, behavioral, or related to personality than is the case with a similarly chronic and painful condition of known pathology. We cannot exclude either a specific role for psychosocial factors at work, or a more general role for psychosocial factors in maintaining disability in patients with chronic pain.     

Optimizing screening for depression among adults with asthma

Objective: The Beck Depression Inventory II (BDI-II) is one of the most frequently used tools to screen for depression in patients with chronic diseases such as cardiovascular disease and asthma. However, its original cut-off score has not been validated in adult asthmatics. The present study aimed to determine the optimal BDI-II cut-off score and to verify the impact of various patient sociodemographic and clinical characteristics on performance accuracy of the BDI-II. Methods: A total of 801 adult asthmatic outpatients (mean ± SD, age 49 ± 14 years, 60% female) completed the BDI-II and a structured psychiatric interview (used as the standard referent to determine presence of major depressive disorder [MDD]). The sensitivity and specificity of the BDI-II were computed to determine the optimal cut-off score for identifying MDD. The optimal cut-off scores were also verified across covariate subgroups (e.g., sex, age, smoking status, asthma control levels). Results: According to the structured psychiatric interview, 108 (13%) patients had current MDD. The overall optimal BDI-II cut-off score was 12 (sensitivity = 85%, specificity = 79%). However, subgroup analyses revealed that this score could range from 11 to 15 depending on the characteristics of the individual. Conclusions: Results suggest that the BDI-II is an appropriate screening tool for MDD in asthma populations. However, the cut-off score is influenced by the sociodemographic and clinical characteristics of patients. These findings highlight the importance of validating generic questionnaires for depression in specific populations in order to improve the accuracy of their usage.     

Daily activities and survival at older ages

OBJECTIVE: This study tested the hypothesis that time spent on activities that are considered regenerative (e.g., resting), productive (e.g., housework), and consumptive (e.g., meeting friends) is associated with survival in persons aged 70 and older. METHODS: An observational study with mortality follow-ups was carried out in the former West Berlin, Germany. The sample was stratified by age and sex, and it consisted of 473 persons aged 70 to 103 years. Study participants lived in the community as well as in institutions. Activity measures were assessed from 1990 to 1993 by structured interviews in the participants' homes. Cox regression was used to model survival from time of interview. The main outcome measure was survival on August 1, 2003. RESULTS: Consumptive activities were related to survival (relative risk = 0.89, 95% confidence interval 0.83 to 0.97), after several confounding factors were controlled for. The effect diminished over time. DISCUSSION: Results support the idea that daily activities are linked to survival via a psychosocial pathway that might involve perceived quality of life. Consumptive activities (e.g., meeting friends, reading a novel) may contribute considerably to maintaining health and achieving longevity because they are performed on a daily basis and their effects may accumulate over the life course.     

Voluntary HIV Testing Among Adults with Severe Mental Illness: Frequency and Associated Factors

Adults with severe mental illness (SMI) are disproportionately affected by HIV/AIDS. This study describes the frequency and associated factors of HIV testing among psychiatric outpatients (N = 150) in a small Northeastern city. A structured clinical interview assessed demographic, psychosocial, behavioral, and psychiatric factors. In the past year, 41% of participants were HIV tested. A hierarchical linear regression model revealed the following multivariate correlates: lower educational attainment, HIV risk behavior, greater social support, homelessness, non-psychotic disorder, borderline personality disorder, and greater treatment utilization. Psychiatric factors remained significant correlates of HIV testing after accounting for psychosocial and behavioral factors. Although HIV testing occurred among a substantial proportion of participants, 45% of individuals who engaged in HIV risk behavior were not tested in the past year. Adults with SMI are in need of interventions promoting routine HIV testing and risk-reduction counseling.     

The influence of psychosocial difficulties on women's attrition in an HIV/STD prevention program

We examined attrition from an HIV/STD group counselling intervention in two ways: quantitative analyses of the entire sample (n=287) and structured interviews of a subset of 30 women with low attendance. In the interviews, the most common reasons for low attendance were time conflicts and enrolling primarily to obtain the monetary incentives given for completing research questionnaires. Latent class statistical analysis of the full sample identified two subgroups that differed from each other in the number of psychosocial problems recently experienced. Relative to the 'non-distressed' class, the 'distressed' class members had higher probabilities of psychological distress, low incomes, heavy substance use, sex for trade, relationship violence, and unstable housing. This group had higher HIV/STD risk, but lower intervention attendance. Members also had less education and less knowledge about HIV/STD. A higher proportion of the distressed group was African-American. Study findings suggest that in interventions for women at HIV/STD risk, it is not necessarily enough to ensure cultural relevance and to provide food, childcare, and transportation. To increase retention, interventionists should consider (1) the use of strategies to support attendance (such as monetary incentives and attention to group process factors) and (2) intervention formats that are brief, matched to participants' stage of change, population-specific, and/or maximally accessible.