Prevalence and Risk Factors for Depressive Symptoms in Persons with Chronic Obstructive Pulmonary Disease

Background  Although depression is a risk factor for adverse outcomes in chronic illness, little is known about the prevalence or risk factors for depressive symptoms in chronic obstructive pulmonary disease (COPD). Objective  To determine the prevalence of depressive symptoms in COPD as compared to other chronic illnesses and to identify risk factors for depressive symptoms in COPD. Design and Patients  Cross-sectional study of 18,588 persons (1,736 subjects with self-reported COPD), representing a sample of the US population aged ≥50 years who participated in the 2004 Health and Retirement Survey. Measurements  Presence of COPD and other chronic conditions was defined by self-report. Presence of depressive symptoms was assessed using the CES-D8 scale. Participants with a score ≥3 on CES-D8 were classified as having clinically significant depressive symptoms. Main Results  Of 1,736 participants with COPD, 40% had ≥3 depressive symptoms. Depressive symptoms were more common in COPD than in coronary heart disease, stroke, diabetes, arthritis, hypertension, and cancer. Risk factors for ≥3 depressive symptoms in COPD: younger age (OR 1.02/per year younger, 95% CI [1.02–1.03]), female gender (1.2 [1.1–1.3]), current smoking (1.5 [1.3–1.7]), marital status [divorced/separated (1.8 [1.6–2.1]), widowed (1.8 [1.6–2]), never married (1.4 [1.1–1.8]), ≤high school degree (1.6 [1.5–1.8]), dyspnea (2.3 [2.1–2.6]), difficulty walking (2.8 [2.5–3.2]), and co-morbid diabetes (1.2 [1.1–1.4]), arthritis (1.3 [1.2–1.5]) or cancer (1.2 [1.1–1.4]). Conclusions  Depressive symptoms are common in COPD and are more likely to occur in COPD than in other common chronic illnesses. The risk factors identified may be used for targeted depression screening in COPD patients. An erratum to this article can be found at     

Longitudinal predictors of depressive symptoms among low income injection drug users

Effects of changes in physical health status and drug use, and prior social support on depressive symptoms were assessed in low income injection drug users. Data are from participants (n = 503) enrolled at baseline (1994-1995) who remained at one-year follow-up (79%), of whom 37% were HIV-positive and 36% female. Physical health was measured by HIV symptoms, AIDS, CD4 count and functional limitation (IADLs). One-third scored high on depressive symptoms (CES-D > or = 16) at one-year follow-up, representing no statistically significant change from baseline (38%). In multiple logistic regression, after controlling for baseline depression scores (OR = 6.11, p < 0.001) and drug use (OR = 1.20, p = 0.192), baseline functional limitation (OR = 3.28, p < 0.001) and declining functioning (OR = 3.60, p < 0.001) were positively, and quitting drug use was negatively, associated with depressive symptoms at follow-up. Low social support at baseline (OR = 0.58, p < 0.10) was marginally predictive of depressive symptoms. Depressive symptoms did not differ by gender. For HIV-positive respondents, functional limitation was predictive of depressive symptoms, but HIV illness and drug use were not. Facilitating drug treatment and preventive medical care may aid in reducing depression in this population. For HIV-positive drug users, drug treatment prior to AIDS may help reduce depressive symptoms, with potential implications for HIV service utilization and medical adherence.     

Does fear of serious disease predict consulting behaviour amongst patients with dyspepsia in general practice?

BACKGROUND: There have been relatively few studies of health care utilization amongst patients with upper gastrointestinal (GI) complaints. We postulated that health care utilization amongst patients with dyspepsia is primarily driven by fear of serious disease. METHOD: Consecutive patients presenting to primary care with dyspepsia were questioned about their health care utilization over a 12-month pre-consultation period. The patients completed a questionnaire which included validated measures of GI symptoms (including symptom frequency, duration and severity), and the shortened neuroticism scale of the Eysenck Personality Questionnaire. In total, 614 patients were recruited into the study, and 596 patients provided details of their health care utilization. Previous health care utilization was defined as one or more primary care visits for upper GI symptoms in the 12 months prior to the index visit; frequent health care utilization was defined as six or more visits over the same period. RESULTS: Previous health care utilization was reported by 80% of patients, while frequent health care utilization was reported by 26% of patients. Fear of serious illness and fear of cancer were univariately associated with previous and frequent health care utilization (both P = 0.001). However, the only independent predictors of previous health care utilization were frequent dyspepsia (odds ratio (OR) = 2.17), pain-related anxiety (OR = 2.08-4.66) and higher neuroticism scores (OR = 1.12); independent predictors of frequent health care utilization were frequent dyspepsia (OR = 3.25), pain-related anxiety (OR = 1.74-6.08), female gender (OR = 1.73) and being a non-drinker (OR = 1.72). Health care utilization was not independently associated with symptom severity or duration, or with patients' characteristics, such as age, marital status, ethnicity, smoking status or the use of non-steroidal antiinflammatory drugs. CONCLUSIONS: Consulting behaviour amongst patients with dyspepsia is driven in part by psychological factors and, in particular, by symptom-related anxiety as well as by the frequency of dyspepsia, but not primarily by fear of serious disease. Anxiety may help sustain health care utilization once the behaviour has been established.     

Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life

BACKGROUND: Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD), but depression's impact on COPD outcomes has not been fully investigated. We evaluated the impact of comorbid depression on mortality, hospital readmission, smoking behavior, respiratory symptom burden, and physical and social functioning in patients with COPD. METHODS: In this prospective cohort study, 376 consecutive patients with COPD hospitalized for acute exacerbation were followed up for 1 year. The independent associations of baseline comorbid depression (designated as a Hospital Anxiety and Depression Scale score of > or =8) with mortality, hospital readmission, length of stay, persistent smoking, and quality of life (determined by responses to the St George Respiratory Questionnaire) were evaluated after adjusting for potential confounders. RESULTS: The prevalence of depression at admission was 44.4%. The median follow-up duration was 369 days, during which 57 patients (15.2%) died, and 202 (53.7%) were readmitted at least once. Multivariate analyses showed that depression was significantly associated with mortality (hazard ratio, 1.93; 95% confidence interval, 1.04-3.58), longer index stay (mean, 1.1 more days; P = .02) and total stay (mean, 3.0 more days; P = .047), persistent smoking at 6 months (odds ratio, 2.30; 95% confidence interval, 1.17-4.52), and 12% to 37% worse symptoms, activities, and impact subscale scores and total score on the St George Respiratory Questionnaire at the index hospitalization and 1 year later, even after controlling for chronicity and severity of COPD, comorbidities, and behavioral, psychosocial, and socioeconomic variables. CONCLUSIONS: Comorbid depressive symptoms in patients with COPD are associated with poorer survival, longer hospitalization stay, persistent smoking, increased symptom burden, and poorer physical and social functioning. Interventions that reduce depressive symptoms may potentially affect COPD outcomes.     

Illness intrusiveness in rheumatoid arthritis: differential impact on depressive symptoms over the adult lifespan.

Depressive symptoms in rheumatoid arthritis (RA) were hypothesized to derive from illness intrusiveness--illness-induced lifestyle disruptions. Differences over the adult lifespan were also investigated in 110 outpatients with RA, aged 24-78 years who completed standardized psychological tests. A significant Age x Illness Intrusiveness interaction indicated that depressive symptoms intensified more sharply among comparatively younger vs older individuals as the intrusiveness of RA increased. We conclude illness intrusiveness is an important determinant of depressive symptoms in RA. However, its impact may vary over the course of adult psychological development.     

Percutaneous transluminal angioplasty: association between depressive symptoms and diminished health status benefits

Depressive symptoms are known to compromise health status in cardiac disease, but this relationship has not been described in peripheral artery disease (PAD). Depressive symptoms (PHQ-9) and disease-specific health status (Peripheral Artery Questionnaire, PAQ) were assessed in 242 PAD patients undergoing percutaneous transluminal angioplasty (PTA) at baseline and 1 year. Patients were classified by baseline and follow-up depression status (moderate-severe depressive symptoms = PHQ ≥ 10). Changes were categorized as no depression/improvement of depression versus persistent/worsened depression. At baseline, 20% of patients were depressed; at 1 year, 17% of patients experienced persistent/worsened depression. Although this group improved on most PAQ subscales, they improved to a significantly lesser degree than those without depressive symptoms or those who improved by 1 year (p-values < 0.05). Baseline depressive symptoms (B(per 5-point increment) = -11.9, 95% CI -15.3, -8.5, p < 0.0001) and changes in depression were independently associated with a decrease in 1-year health status (B(per 5-point increment) = -11.7, 95% CI -14.3, -9.2, p < 0.0001). In conclusion, depressive symptoms are associated with less improvement in health status 1 year after undergoing a peripheral endovascular revascularization (PER) as compared with those having no depression or whose depressive symptoms improve. Efforts to improve depression detection and treatment among patients with PAD may improve the health status outcomes of these patients.     

Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction

OBJECTIVES: We sought to compare symptoms of depression and anxiety as predictors of incomplete recovery after a first myocardial infarction (MI). BACKGROUND: Depressive symptoms have been related to post-MI mortality and health care consumption, but little is known about the effect of anxiety. We wanted to examine the effect of emotional distress on health care consumption and whether depressive symptomatology is a better predictor of prognosis than anxiety. METHODS: Subjects were 318 men (mean age 58 years) who completed the depression, anxiety, and hostility scales from the 90-item symptom check list after they survived a first MI. RESULTS: After an average follow-up of 3.4 years, there were 25 cardiac events (fatal or non-fatal MI). Symptoms of both depression (hazard ratio [HR] 2.32, 95% confidence interval [CI] 1.04 to 5.18; p = 0.039) and anxiety (HR 3.01, 95% CI 1.20 to 7.60; p = 0.019) were associated with cardiac events, adjusting for age, left ventricular ejection fraction, and use of antidepressants. However, a multivariate analysis including all three negative emotions indicated that symptoms of anxiety (HR 2.79, 95% CI 1.11 to 7.03; p = 0.029) explained away the relationship between depressive symptoms and cardiac events. Regarding health care consumption, anxiety (OR 2.00, 95% CI 1.24 to 3.22; p = 0.005), but not depression/hostility, was a predictor of cardiac rehospitalization and frequent visits at the cardiac outpatient clinic. CONCLUSIONS: Symptoms of depression and anxiety were associated with cardiac events. Anxiety was an independent predictor of both cardiac events and increased health care consumption and accounted for the relationship between depressive symptoms and prognosis. Symptoms of anxiety need to be considered in the risk stratification and treatment of post-MI patients.     

Effect of smoking and sedentary behavior on the association between depressive symptoms and mortality from coronary heart disease

It has been suggested that one of the mechanisms linking depression with elevated mortality risk is the association between depressive symptoms and other established coronary artery disease (CAD) risk factors, such as smoking and failure to exercise. The present study examined this hypothesis using repeated assessments of smoking and exercise from patients with CAD in whom depressive symptoms had been shown to predict decreased survival. Initially, associations between depressive symptoms and the risk factors of smoking and sedentary behavior were assessed. Next, patterns of smoking and sedentary behavior were examined as mediators and/or moderators of the association between depressive symptoms and mortality. Depressive symptoms were positively related to smoking (p <0.01) and sedentary behavior (p <0.01). Depressive symptoms, smoking, and sedentary behavior were independent predictors of mortality. Results indicated that smoking and/or sedentary behavior may partially mediate the relation between depressive symptoms and mortality. No evidence for moderation was found.     

Depressive symptoms, inflammatory markers and body composition in elderly with and without chronic obstructive pulmonary disease (COPD)

Our aim was to assess the relationships between cortisol, interleukin-2 (Il-2) and tumor necrosis factor-α (TNF-α) levels in elderly with and without COPD presenting with or without depressive symptoms. Forty COPD patients and 53 elderly individuals with no COPD took part in the study. Depressive symptoms (Geriatric Depression Scale=GDS-15), IL-2 and TNF-α, serum cortisol, number of comorbidities, smoking habits and body composition were evaluated. The prevalence of depressive symptoms was higher in COPD group. The number of comorbidities was higher in patients with depressive symptoms. No differences were found between IL-2, TNF-α and cortisol levels, years of smoking and smoked pack-years in the groups. The COPD group obtained lower body mass index (BMI) and fat content and higher fat free mass index as well as greater nutritional depletion. Conclusions: Depressive symptoms as well as fat and lean body composition, due to preserved BMI in those with nutritional depletion, must be investigated.     

Depression in COPD �C management and quality of life considerations

Depression is common in COPD patients. Around 40% are affected by severe depressive symptoms or clinical depression. It is not easy to diagnose depression in COPD patients because of overlapping symptoms between COPD and depression. However, the six-item Hamilton Depression Subscale appears to be a useful screening tool. Quality of life is strongly impaired in COPD patients and patients’ quality of life emerges to be more correlated with the presence of depressive symptoms than with the severity of COPD. Nortriptyline and imipramine are effective in the treatment of depression, but little is known about the usefulness of newer antidepressants. In patients with milder depression, pulmonary rehabilitation as well as cognitive-behavioral therapy are effective. Little is known about the long-term outcome in COPD patients with co-morbid depression. Preliminary data suggest that co-morbid depression may be an independent protector for mortality.     

Risk Factors for Respiratory Syncytial Virus Illness Among Patients with Chronic Obstructive Pulmonary Disease

Abstract

Respiratory syncytial virus (RSV), although not typically considered an important pathogen in adults, may cause acute exacerbation of chronic obstructive pulmonary disease (COPD). It is unclear which COPD patients are at highest risk for developing serious RSV illness. Our objective was to identify risk factors for RSV illness among adult patients with COPD. We conducted a pooled analysis of data from COPD patients in 2 previously published longitudinal studies that examined RSV infection in high risk adults for ≤ 2 RSV seasons. Risk factors for RSV illness studied included age, sex, race, smoking status, exposure to children, home oxygen use, inhaled or oral steroid use, instrumental activities of daily living scores, and co-morbid conditions. Outcomes studied included symptomatic and medically attended RSV illness. Logistic regression was used to identify significant risk factors for RSV illness among older adults with COPD. Among 379 patients with COPD, the rate of symptomatic RSV illness was 11.1% (42/379); almost half (20/42) of whom required medical attention. In multivariable analyses, congestive heart failure (odds ratio [OR] = 4.18; 95% CI: 1.38, 12.69) and exposure to children (OR = 2.38; 95% CI: 1.03, 5.51) were risk factors for symptomatic RSV illness. Congestive heart failure (OR = 4.16; 95% CI: 1.02, 17.01) was the only significant risk factor for developing medically attended RSV illness. Exposure to children and congestive heart failure are risk factors for RSV illness among adult patients with COPD. Future prospective, well-designed studies are needed to corroborate these findings and examine other risk factors, including history of exacerbations.     

Depression in elderly hospitalized patients with medical illness

Depressive symptoms and disorders were identified by structured psychiatric interview in 130 consecutively admitted male inpatients aged 70 years and over. Major depression was found in 11.5% and other depressive syndromes in 23%. While depressive symptoms and syndromes are common among the medically ill, this study demonstrated the need for careful diagnostic assessment of older patients with depressive symptoms before initiating treatment that may itself convey significant risk. Sociodemographic and health characteristics of older men at higher risk for depression were also identified. Patients more likely to be depressed were over age 75 years, had less formal education, experienced cognitive dysfunction, suffered from more severe medical illness (particularly recent myocardial infarction), and had a history of psychiatric illness. Depressive symptoms were also common among patients with renal or neurologic diseases, those having a family history of psychiatric illness, the unmarried, and the more severely disabled. Given the impact of depression on recovery from medical illness, compliance with medical therapy, and costs of extended hospital stays, detection and treatment of this disorder are imperative.     

Clustering of psychosocial risk factors enhances the risk of depressive symptoms 12-months post percutaneous coronary intervention.

BACKGROUND: Psychosocial risk factors cluster together, but generally a single factor approach has been adopted when studying their influence on health outcomes in cardiac patients. We examined the impact of clustering (i.e. type D personality and anxiety) on depressive symptoms 12 months post percutaneous coronary intervention (PCI). DESIGN: Prospective study. METHODS: Consecutive patients (n=416), treated with PCI with drug-eluting stents, completed the type D Scale and the Hospital Anxiety and Depression Scale anxiety subscale at baseline, and the depression subscale at 12 months. RESULTS: Of all patients, 27% experienced depressive symptoms at 12 months. Depressive symptoms could not be attributed to cardiac events occurring during follow-up (P=0.76). The prevalence of depressive symptoms at 12 months was highest in patients with clustering (64%), followed by the single risk factors type D (45%) and anxiety (38%), with the lowest prevalence in the no risk factor group (neither anxiety nor type D) (13%; P<0.001). The single risk factors type D personality [odds ratio (OR): 5.82; 95% confidence interval (CI): 2.93-11.56] and anxiety (OR: 4.36; 95% CI: 2.23-8.55) and their co-occurrence (OR: 12.38; 95% CI: 6.11-25.09) remained independent significant predictors of depressive symptoms at 12 months compared with the no risk factor group, adjusting for baseline characteristics. CONCLUSION: Patients with the co-occurrence of type D personality and anxiety, two risk factors independently associated with adverse prognosis, had a considerably higher risk of depressive symptoms 12 months post PCI compared with patients with no or one risk factor. Further research is warranted to examine whether clustering of psychosocial risk factors also has deleterious effects on prognosis.     

Effect of Care Setting on Evidence-based Depression Treatment for Veterans with COPD and Comorbid Depression

Background Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients. Objective To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting. Design Retrospective cohort study. Patients A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder. Measurements and Main Results Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (≥3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only. Conclusions Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings. This study was funded by the VA Health Services Research & Development Service.     

Sex, depression, and risk of hospitalization and mortality in chronic obstructive pulmonary disease

BACKGROUND: We sought to determine whether depressive or anxiety symptoms are associated with chronic obstructive pulmonary disease (COPD) hospitalization or mortality. These data were collected as part of the National Emphysema Treatment Trial (NETT), a randomized controlled trial of lung volume reduction surgery vs continued medical treatment conducted at 17 clinics across the United States between January 29, 1998, and July 31, 2002. METHODS: Prospective cohort study among participants in the NETT with emphysema and severe airflow limitation who were randomized to medical therapy. Primary outcomes were 1- and 3-year mortality, as well as COPD or respiratory-related hospitalization or emergency department visit during the 1-year follow-up period. Of 610 patients randomized to medical therapy, complete data on hospitalization and mortality were available for 3 years of follow-up for 603 patients (98.9%). RESULTS: Depressive symptoms were assessed using the Beck Depression Inventory (BDI) questionnaire, and anxiety was assessed using the State-Trait Anxiety Inventory. Among 610 subjects, 40.8% had at least mild to moderate depressive symptoms. Patients in the highest quintile of BDI score (BDI score, >or=15) had an increased risk of respiratory hospitalization in unadjusted analysis compared with patients in the lowest quintile (BDI score, < 5) (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.30-3.93). After adjustment for disease severity, this relationship was no longer statistically significant. The adjusted risk of 3-year mortality was increased among those in the highest quintile of BDI score (OR, 2.74; 95% CI, 1.42-5.29) compared with those in the lowest quintile. Anxiety was not associated with hospitalization or mortality in this population. CONCLUSIONS: Depressive symptoms are common in patients with severe COPD and are treated in few subjects. Depressive symptoms are associated with increased risk for 3-year mortality but not 1-year mortality or hospitalization.     

Relationship between depressive symptoms and hypogonadism in men with COPD

The prevalence of depression in chronic obstructive pulmonary disease (COPD) is greater than in the general population, but the mechanism is unknown. Depression has been linked mechanistically to testosterone deficiency, and testosterone deficiency (hypogonadism) affects many men with COPD. Accordingly, we hypothesized that significant depressive symptoms would be associated with hypogonadism in men with COPD. The hypothesis was tested in a prospective cross-sectional investigation of 104 men (FEV1 = 43 ± 1% predicted (± SE)), 36 of whom had significant depressive symptoms (Geriatric Depression Scale score or GDS ≥ 11). Hypogonadism was present in 14 patients with GDS ≥ 11 (39%) and in 21 with GDS < 11 (31%; p = 0.41). The independent association between depressive symptoms and gonadal state was evaluated after adjusting for potential confounders: combined severity of lung disease and functional impairment (BODE-index), co-morbidities (Charlson co-morbidity-Index), age, active smoking, education, and marital status. After controlling for confounding variables, multivariable logistic-regression analysis revealed that only BODE-index (odds ratio 1.40; p = 0.003), lack of companion (2.73; p = 0.045) and younger age (0.93; p = 0.021) were independently associated with depressive symptoms. In a secondary analysis, patients were stratified into those with severe depressive symptoms (GDS ≥ 19) and those with mild depressive symptoms (GDS 11-18). Prevalence of hypogonadism was greater in first group than in the second (62% vs. 26%; p = 0.036). After controlling for confounders, however, gonadal state was not associated with severe depressive symptoms. Similarly, gonadal state was not associated with mood and motivation subscale scores of the GDS. In conclusion, presence of significant depressive symptoms was not associated with hypogonadism in men with COPD.     

Anxiety and depressive symptoms among patients infected with human immunodeficiency virus in South Korea

Patients infected with human immunodeficiency virus (HIV) may develop mental health problems such as anxiety and depression, which negatively impact of disease progression. We investigated factors associated with the prevalence of anxiety and depression symptoms among HIV-infected patients in Korea. A total of 840 HIV-infected patients who participated in the Korea HIV/AIDS Cohort Study from 2006 to 2012 were evaluated. Socio-demographic, epidemiologic, and clinical variables were obtained through standardized questionnaires. The State-Trait Anxiety Inventory and Beck Depression Inventory were used to assess the symptoms of anxiety and depression. Multiple logistic regression analyses were performed to identify factors associated with symptoms of anxiety and depression. The prevalence of anxiety and depressive symptoms among HIV-infected patients was 32% and 36%, respectively. Ex-smoker and persistent symptoms for more than one week within the past six months and diagnosis of HIV infection within one year were associated with increased anxiety symptoms (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.09–2.69; OR 1.52, 95% CI 1.09–2.11; OR 1.49, 95% CI 1.02–2.20) and current smoking and persistent symptoms were also associated with increased depressive symptoms (OR 2.10, 95% CI 1.31–3.30; OR 1.87, 95% CI 1.25–2.79). Marital status, current smoking, current drinking, and persistent symptoms were associated with both increased anxiety and depressive symptoms (OR 1.75, 95% CI 1.07–2.88; OR 1.66, 95% CI 1.06–2.61; OR 1.88, 95% CI 1.18–2.99). The prevalence of anxiety and depressive symptoms among HIV-infected patients is higher than those estimated for the general population. This study shows the necessity to evaluate symptoms of anxiety and depression and suggest psychological support for HIV-infected patients who smoke or have persistent symptoms or have sexual partner or drink.     

Clinical importance of HIV and depressive symptoms among veterans with HIV infection

OBJECTIVE: To compare the clinical importance (association with illness severity and survival) of depressive and HIV symptoms among veterans with HIV infection. DESIGN: Cross-sectional study; survival analysis. SETTING: Infectious Disease Clinics at 3 VA Medical Centers. PARTICIPANTS: HIV-infected patients (N = 881) and their health care providers from June 1999 through July 2000. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms were assessed using the 10-item Centers for Epidemiologic Studies Depression Scale (CES-D). Patient baseline survey included an HIV Symptom Index measuring the frequency and bother of 20 common symptoms. Providers were surveyed on patients' illness severity, and survival data were obtained from VA death records. Of 881 patients, 46% had significant depressive symptoms (CES-D >/=10). Increasing depression symptom severity was associated with increasing HIV symptom frequency (P <.001) and bother (P <.001). Multiple regression results revealed that having moderate or severe depressive symptoms was not associated with provider-reported illness severity or survival. However, HIV symptoms were significantly associated with provider-reported illness severity (P <.01) and survival (P =.05), after adjusting for moderate and severe depressive symptoms, CD4 cell count/mm3, viral load, age, race, and antiretroviral use. CONCLUSIONS: Depression, while common in this sample, was not associated with illness severity or mortality after adjusting for HIV symptoms. HIV symptoms are associated with severity of illness and survival regardless of patients' severity of depressive symptoms. This suggests that equal medical consideration should be given to HIV symptoms presented by HIV-infected patients regardless of their depression status, rather than automatically attributing medical complaints to depression.     

A randomized trial of two types of nurse-assisted home care for patients with COPD

STUDY OBJECTIVES: Whereas pulmonary rehabilitation reduces symptoms and improves the quality of life of patients with COPD and is recommended in management guidelines, few patients have access to rehabilitation services. The purpose of this study was to investigate the effectiveness of increasing access to selected components of pulmonary rehabilitation by providing nurse-assisted home care that was composed of patient education, efforts to improve patient self-management skills, and enhanced follow-up. DESIGN: We conducted a 6-month, randomized, controlled trial. SETTING: Primary care clinics associated with an urban academic health system. PATIENTS: Patients were > or = 45 years of age with a physician diagnosis of COPD, and had a > or = 20-pack-year smoking history, had experienced at least one respiratory symptom during the past 12 months, and had airflow obstruction (ie, FEV1/FVC ratio, < 70%; FEV1, < 80%). INTERVENTIONS: Four nurses were trained in the use of the Global Initiative for Chronic Obstructive Lung Disease guidelines, and two of the four nurses received additional training in collaborative management. Patients were randomly assigned to usual care (UC), nurse-assisted medical management (MM), or nurse-assisted collaborative management (CM). MEASUREMENTS: The main outcome measures were of generic (Medical Outcome Study 36-item short form [SF-36], illness intrusiveness) and disease-specific (St. George's respiratory questionnaire [SGRQ]) quality of life and self-reported health-care utilization. RESULTS: Overall, 151 patients (UC group, 51 patients; MM group, 49 patients; and CM group, 51 patients) completed the study, their average age was 69 years, and 56.9% were women. The average change in the SF-36 general health domain for the MM group vs the UC group was 1.1 (95% confidence interval [CI], -7.9 to 11.2), and for the CM group vs the UC group the average change was 2.5 (95% CI, -7.0 to 12.3). The corresponding changes in SGRQ total domain were -2.9 (95% CI, -9.8 to 4.1) and -2.6 (95% CI, -9.5 to 4.3). There was no change in the number of self-reported emergency department visits or hospitalizations, but the utilization of these services was infrequent. CONCLUSION: The findings of our investigation and those from the published literature suggest that interventions to enhance patient education, self-management skills, and follow-up among patients with COPD do not result in clinically meaningful improvements in health status or self-reported health-care utilization. Moreover, future studies of disease management programs for patients with COPD need to evaluate interventions that address associated comorbidities, exercise, and social support.     

Depressive symptoms and smoking among Hong Kong Chinese adolescents

AIMS: To examine associations among depressive symptoms, smoking, smoking trajectories and quitting smoking in Hong Kong. DESIGN: Prospective longitudinal design, with wave 1 at baseline (T1) and wave 2 (T2) 12 months later. SETTING AND PARTICIPANTS: Form 1 (equivalent to 7th grade in the United States) students, mean age = 12.7 years, n = 1894. MEASUREMENTS: Self-reported smoking status, attempts to quit and depressive symptoms. FINDINGS: At both waves, current as well as ex-smokers had higher depressive symptoms than never smokers. T1 smoking predicted T2 depressive symptoms among those with low baseline depressive symptoms. Depressive symptoms at T1 predicted smoking at T2 among non-smokers at T1. Trajectories were defined by separating participants who were never smokers at both waves ('non-smokers'), those who smoked at both waves ('persistent smokers'), those who smoked at one time but were not smoking at either wave ('past smokers), and those who had never smoked at T1 but reported smoking a year later ('new smokers'). Persistent, past and new smokers had higher depressive symptoms at both waves than non-smokers. Smokers who reported not wanting or trying to quit and those who had been unsuccessful at quitting had higher depressive symptoms at T2 than those who successfully quit. CONCLUSION: Our results suggest that depressive symptoms promote tobacco use in Asian adolescents by making it more likely that an adolescent will begin smoking and less likely that she or he will quit. These findings elucidate risk factors in Hong Kong for two important public health concerns for adolescents: smoking and depression.