Prevalence of Depression–PTSD Comorbidity: Implications for Clinical Practice Guidelines and Primary Care-based Interventions

BACKGROUND Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. OBJECTIVE To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). DESIGN Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. PARTICIPANTS Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. MEASUREMENTS The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. RESULTS Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. CONCLUSIONS PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.     

Why Do Nonsurvivors from Community-Acquired Pneumonia Not Receive Ventilatory Support?

Objective

We investigated rates and predictors of ventilatory support during hospitalization in seemingly not severely compromised nonsurvivors of community-acquired pneumonia (CAP).

Methods

We used the database from the German nationwide mandatory quality assurance program including all hospitalized patients with CAP from 2007 to 2011. We selected a population not residing in nursing homes, not bedridden, and not referred from another hospital. Predictors of ventilatory support were identified using a multivariate analysis.

Results

Overall, 563,901 patients (62.3 % of the whole population) were included. Mean age was 69.4 ± 16.6 years; 329,107 (58.4 %) were male. Mortality was 39,895 (7.1 %). A total of 28,410 (5.0 %) received ventilatory support during the hospital course, and 76.3 % of nonsurvivors did not receive ventilatory support (62.6 % of those aged <65 years and 78 % of those aged ≥65 years). Higher age (relative risk (RR) 0.48, 95 % confidence interval (CI) 0.44–0.51), failure to assess gas exchange (RR 0.18, 95 % CI 0.14–0.25) and to administer antibiotics within 8 h of hospitalization (RR 0.48, 95 % CI 0.39–0.59) were predictors of not receiving ventilatory support during hospitalization. Death from CAP occurred significantly earlier in the nonventilated group (8.2 ± 8.9 vs. 13.1 ± 14.1 days; p < 0.0001).

Conclusions

The number of nonsurvivors without obvious reasons for withholding ventilatory support is disturbingly high, particularly in younger patients. Both performance predictors for not being ventilated remain ambiguous, because they may reflect either treatment restrictions or deficient clinical performance. Elucidating this ambiguity will be part of the forthcoming update of the quality assurance program.     

What Constitutes “Success” in Addiction Treatment and How Do We Determine What Works Best?

This article attempts to address two questions: “What constitutes success in addiction treatment” and “How do we determine what works best in addition treatment.” Historical approaches to addiction treatment are contrasted with those used currently. Factors that complicate answering these questions are discussed, with a special focus on abstinence and claims by some for the superiority of evidence-based practices and the harm reduction model. An alternative ecological dysfunction model of addiction is proposed as an alternative to the “brain disease-only” model.     

What Do the 2011 American Heart Association Guidelines Tell Us About Prevention of Cardiovascular Disease in Women?

The 2011 Update of the American Heart Association's Cardiovascular Disease Prevention Guideline for Women is designed to help women and their physicians understand cardiovascular Disease (CVD) risks and undertake practical steps that are most effective in preventing heart disease and stroke. Defining a woman's risk status and improving her adherence to preventive lifestyle behaviors and medications is the best strategy to lower the burden of CVD in women.     

Guidelines 2.0: Do No Net Harm—The Future of Practice Guideline Development in Asthma and Other Diseases

Decisions are like double-edged swords: they always come with benefits and downsides. That is, any decision in life bears desirable and undesirable consequences, even if the latter only involves the time it takes to make or think about the decision, which can be considered the harm of decision making. Therefore, it is impossible to adhere to the Hippocratic Oath’s concept of “primum non nocere,” which is frequently interpreted as “never do harm.” The guiding principle for health care decision making should be to ensure that there is, in summary, more benefit than harm—in other words, “to do no net harm” (“primum non net nocere”). Practice guidelines support decision making and, as a consequence, would require the explicit consideration of both desirable and undesirable consequences, and assigning due considerations depending on the magnitude and importance of the consequences. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group () has made these considerations more explicit when developing health care recommendations. This article briefly summarizes the work of the GRADE working group based on examples of its application in the field of allergy and asthma, and provides an outlook for advances in the field of guideline development. These developments focus on funding of guidelines and handling conflict of interest, working with observational and diagnostic test accuracy studies, developing appropriate group processes, and the integration of values and preferences in the formulation of recommendations.     

Cardiac Resynchronization Therapy: Do Women Benefit More Than Men?

Gender and Resynchronization Therapy. Introduction: Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Whether there is a gender difference in the benefit derived from CRT has not been well studied. Methods: This study included 728 consecutive CRT recipients at our institution who met guidelines for placement of a CRT device. Clinical characteristics and echocardiographic parameters were collected at baseline and after CRT; Kaplan–Meier survival analysis was performed using a national death and location database. The effects and outcome of CRT were compared between women and men. Results: Of 728 patients, 166 were female (22.8%). Female patients were younger than male patients (66.0 ± 11.9 years vs 69.4 ± 10.9 years; P < 0.001) and more often had nonischemic cardiomyopathy (68% vs 36%; P < 0.001). Both female and male patients had significantly improved clinical and echocardiographic parameters after CRT. The magnitude of improvement was similar in women and men, except that improvement in New York Heart Association (NYHA) class was greater in women than in men (–0.79 ± 0.78 vs –0.56 ± 0.85; P = 0.009). Although women were at lower risk of death than men after CRT (hazard ratio, 0.51; 95% confidence interval, 0.35–0.75; P < 0.001, unadjusted), multivariate analysis indicated gender was not, but age at CRT placement, cardiomyopathy cause, NYHA class, and lead location were independent predictors of survival. Conclusion: Female CRT recipients seem to achieve greater survival benefit than male recipients. However, this benefit is majorly driven by nonischemic cardiomyopathy and other clinical factors. (J Cardiovasc Electrophysiol, Vol. 23, pp. 172‐178, February 2012)     

Do Women Differ from Men on Alcoholics Anonymous Participation and Abstinence? A Multi‐Wave Analysis of Treatment Seekers

Background: Given the widespread use of Alcoholics Anonymous (AA) and other similar groups in the United States and the increasing membership of women, this study compares women with men on their meeting attendance and AA‐prescribed behaviors, factors associated with that AA participation, and tests how these relate to women’s and men’s abstinence across time. Methods: All consecutive new admissions (age ≥ 18) from county‐wide public and private treatment programs representing the larger population of treatment seekers were approached to be in the study at treatment entry. Those consenting at baseline (n = 926) were sought for follow‐up interviews 1, 3, 5, and 7 years later. Generalized linear models were used to test whether various help‐seeking factors were associated with AA participation differentially by gender and, controlling for AA and other confounders, whether women differ from men on abstinence. Results: At each follow‐up interview, women and men attended AA at similar rates and similarly practiced specific AA behaviors, and they were alike on most factors associated with AA participation and abstention across time including abstinence goal, drink volume, negative consequences, prior treatment, and encouragement to reduce drinking. Relative to men, women with higher drug severity were less likely to participate in AA. Although higher AA participation was a predictor of abstinence for both genders, men were less likely to be abstinent across time. Men were also more likely to reduce their AA participation across time. Conclusions: These findings add to an emerging literature on how women compare with men on factors related to AA participation and subsequent drinking outcomes across time. Findings have clinical implications for service providers referring clients to such groups.