Positive psychological constructs and health behavior adherence in heart failure: A qualitative research study

Psychological well-being may play an important role in health behavior adherence and cardiovascular health, but there has been limited study of well-being in patients with heart failure. In this descriptive qualitative research study, we interviewed 30 patients with heart failure to explore their psychological experiences with heart failure and the perceived associations between positive psychological constructs and adherence to physical activity, diet, and medication recommendations. Interviews were transcribed, then coded in NVivo using directed and conventional content analysis, and the Consolidated Criteria for Reporting Qualitative Research checklist was applied to report our findings. Participants spontaneously reported positive psychological constructs both during an acute phase of illness and 3 months later. Participants most commonly experienced gratitude, acceptance, connectedness, and faith in the setting of heart failure. In contrast, pride, determination, and hope were identified most frequently as playing a role in health behavior adherence. Finally, participants reported a reinforcing relationship between positive constructs and health behavior engagement. These findings suggest that interventions to boost positive constructs have the potential to improve well-being and health behavior adherence in patients with heart failure.

Development of the State Optimism Measure

BACKGROUND

Optimism, or positive expectations about the future, is associated with better health. It is commonly assessed as a trait, but it may change over time and circumstance. Accordingly, we developed a measure of state optimism.

METHODS

An initial 29-item pool was generated based on literature reviews and expert consultations. It was administered to three samples: sample 1 was a general healthy population (n = 136), sample 2 was people with cardiac disease (n = 96), and sample 3 was persons recovering from problematic substance use (n = 265). Exploratory factor analysis and item-level descriptive statistics were used to select items to form a unidimensional State Optimism Measure (SOM). Confirmatory factor analysis (CFA) was performed to test fit.

RESULTS

The selected seven SOM items demonstrated acceptable to high factor loadings on a single dominant factor (loadings: 0.64-0.93). There was high internal reliability across samples (Cronbach's alphas: 0.92-0.96), and strong convergent validity correlations in hypothesized directions. The SOM's correlations with other optimism measures indicate preliminary construct validity. CFA statistics indicated acceptable fit of the SOM model.

CONCLUSIONS

We developed a psychometrically-sound measure of state optimism that can be used in various settings. Predictive and criterion validity will be tested in future studies.

A positive psychology intervention for patients with bipolar depression: a randomized pilot trial

Background: There are few effective treatments for bipolar depression, a common and debilitating illness.Aims: We aimed to examine the feasibility and preliminary efficacy of a four-week, telephone-delivered positive psychology (PP) intervention for patients with bipolar depression.Methods: Twenty-five patients hospitalized for bipolar depression were randomized to receive a PP (n = 14) or control condition (CC; n = 11) intervention. Following discharge, participants completed weekly exercises and phone calls with a study trainer. PP intervention feasibility was assessed by the number of exercises completed, and acceptability was examined on five-point Likert-type scales of ease and utility. Between-group differences on psychological constructs at 4 and 8 weeks post-enrollment were assessed using mixed effects regression models.Results: Participants in the PP group completed an average of three out of four PP exercises and found PP exercises to be subjectively helpful, though neither easy nor difficult. Compared to CC, the PP intervention led to trends towards greater improvements in positive affect and optimism at follow-up, with large effect sizes (modified Cohen's d = 0.95-1.24). PP had variable, non-significant effects on negative psychological constructs.Conclusions: Larger, randomized trials are needed to further evaluate the efficacy of this intervention in this high-risk population.

Magnitude and sources of distress in mid-life adults with chronic medical illness: an exploratory mixed-methods analysis

Most mid-life adults have at least one chronic medical condition (CMC) and are at risk for developing additional CMCs. Stressors specific to this life stage may contribute to CMC development by hindering healthy behaviors. The goal of this study was to compare sources and intensity of distress, as they relate to health behaviors, between mid-life and non-mid-life adults with CMCs. We utilized a mixed-methods approach by analyzing quantitative self-report measures of psychiatric symptoms and psychological well-being, with in-depth, semi-structured qualitative interviews to identify sources of stress in three cohorts of patients with CMCs (heart failure, type 2 diabetes, and coronary artery disease). Between-group differences on self-report measures were compared via independent samples t-tests and relevant themes from interview transcripts were compared via chi-square analysis. We found that mid-life participants (n = 30) reported greater psychological distress (depression/anxiety) than non-mid-life (n = 62) participants (Hospital Anxiety and Depression Scale scores 13.8 [SD 7.3] vs. 10.6 [SD 6.6]; t(90)=2.13; p = .035), and qualitative analysis revealed several specific sources of stress significantly more common (p < .001) in mid-life adults. Interventions targeting the needs of this population could reduce distress, improve health behaviors, and have a major impact on public health.

A longitudinal investigation of the Concise Health Risk Tracking Self-Report (CHRT-SR) in suicidal patients during and after hospitalization

The Concise Health Risk Tracking Self-Report (CHRT-SR) scale is a brief self-report instrument to assess suicide risk. Initial investigations have indicated good psychometric properties in psychiatric outpatients. The aims of this paper were to examine the construct validity and factor structure of the twelve- (CHRT-SR12) and seven-item (CHRT-SR7) versions and to test if clinically expected within-person changes in suicide risk over time were measurable using the CHRT-SR in two study cohorts hospitalized for suicidal ideation or behavior: (1) patients with major depressive disorder (MDD) who participated in a psychological intervention trial, n = 65, and (2) participants with bipolar disorder or MDD in an observational study, n = 44. The CHRT-SR12 and self-report measures of hopelessness, depression, and positive psychological states were administered during admission and several times post-discharge. Both versions showed good internal consistency in inpatients and confirmed the three-factor structure (i.e., hopelessness, perceived lack of social support and active suicidal ideation and plans) found in outpatients. CHRT-SR scores had strong correlations with negative and positive affective constructs in the expected directions, and indicated decreases in suicide risk following discharge, in line with clinical expectations. The CHRT-SR12 and CHRT-SR7 are promising self-report measures for assessing suicide risk in very high-risk patient populations.

The Positive Emotions after Acute Coronary Events behavioral health intervention: Design, rationale, and preliminary feasibility of a factorial design study

BACKGROUND

Positive psychological constructs, such as optimism, are associated with greater participation in cardiac health behaviors and improved cardiac outcomes. Positive psychology interventions, which target psychological well-being, may represent a promising approach to improving health behaviors in high-risk cardiac patients. However, no study has assessed whether a positive psychology intervention can promote physical activity following an acute coronary syndrome.

OBJECTIVE

In this article we will describe the methods of a novel factorial design study to aid the development of a positive psychology-based intervention for acute coronary syndrome patients and aim to provide preliminary feasibility data on study implementation.

METHODS

The Positive Emotions after Acute Coronary Events III study is an optimization study (planned N = 128), subsumed within a larger multiphase optimization strategy iterative treatment development project. The goal of Positive Emotions after Acute Coronary Events III is to identify the ideal components of a positive psychology-based intervention to improve post-acute coronary syndrome physical activity. Using a 2 × 2 × 2 factorial design, Positive Emotions after Acute Coronary Events III aims to: (1) evaluate the relative merits of using positive psychology exercises alone or combined with motivational interviewing, (2) assess whether weekly or daily positive psychology exercise completion is optimal, and (3) determine the utility of booster sessions. The study's primary outcome measure is moderate-to-vigorous physical activity at 16 weeks, measured via accelerometer. Secondary outcome measures include psychological, functional, and adherence-related behavioral outcomes, along with metrics of feasibility and acceptability. For the primary study outcome, we will use a mixed-effects model with a random intercept (to account for repeated measures) to assess the main effects of each component (inclusion of motivational interviewing in the exercises, duration of the intervention, and inclusion of booster sessions) from a full factorial model controlling for baseline activity. Similar analyses will be performed on self-report measures and objectively-measured medication adherence over 16 weeks. We hypothesize that the combined positive psychology and motivational interviewing intervention, weekly exercises, and booster sessions will be associated with superior physical activity.

RESULTS

Thus far, 78 participants have enrolled, with 72% of all possible exercises fully completed by participants.

CONCLUSION

The Positive Emotions after Acute Coronary Events III study will help to determine the optimal content, intensity, and duration of a positive psychology intervention in post-acute coronary syndrome patients prior to testing in a randomized trial. This study is novel in its use of a factorial design within the multiphase optimization strategy framework to optimize a behavioral intervention and the use of a positive psychology intervention to promote physical activity in high-risk cardiac patients.

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46-.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47-.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Understanding motivations to participate in an observational research study: Why do patients enroll?

By understanding common motivations for participating in observational research studies, clinicians may better understand the perceived benefits of research participation from their clients' perspective. We enrolled 164 cardiac patients in a study about the effects of gratitude and optimism. Two weeks post-enrollment, participants completed a four-item questionnaire regarding motivations for study enrollment. Altruistic motivation ranked highest, while intellectual, health-related, and financial motivations rated lower. Four subgroups of participants emerged, each with distinct characteristics and different priorities for participating. These findings may help front-line clinicians to understand which motivations for participation apply to their clients who enroll in non-treatment-based research projects.

Implementing collaborative care programs for psychiatric disorders in medical settings: a practical guide

OBJECTIVE

Collaborative care is a systematic, team-based approach to the management of depression and other psychiatric disorders in medical settings. Collaborative care has been found to be effective and cost-effective, but there is little information to guide its implementation in clinical care. The objective of this article is to provide a practical guide to the implementation of collaborative care programs in real-world settings.

METHODS

Based on our experience delivering collaborative care programs, we provide (a) specific, stepwise recommendations for the successful implementation of collaborative care in outpatient settings and (b) an examination of the additional benefits and challenges of collaborative care programs that begin during hospitalization.

RESULTS

The implementation of collaborative care requires senior buy-in, an effective team, clear treatment components, engaged clinicians, procedures to ensure quality and adequate infrastructure. Beginning these programs with hospitalized patients may offer additional advantages but also requires additional flexibility to adapt to the inpatient setting.

CONCLUSION

A systematic approach to the development and implementation of collaborative care programs may allow clinicians to effectively and efficiently treat psychiatric illness in medical populations in both inpatient and outpatient settings.

Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease

BACKGROUND

The risk of suicide is elevated in patients with cardiac disease in comparison with the general population.

OBJECTIVE

In distressed cardiac inpatients, we explored the use of Item 9 of the Patient Health Questionnaire-9, which inquires about thoughts of death or suicide, and a detailed suicide evaluation (DSE) triggered by positive responses to Item 9 as means of assessing suicide.

METHODS

Among cardiac inpatients endorsing current emotional distress, we recorded the prevalence of positive responses to Item 9, gathered information about outcomes and time spent completing the DSE, and examined the frequency of imminent suicidality identified by the DSE among Item 9-positive patients.

RESULTS

Among 366 patients, 77 (21%) answered affirmatively to Item 9. All DSEs were successfully completed but consumed 17 clinician hours. Among the 71 patients receiving the DSE, 2 (0.5% of total sample; 2.8% of Item 9-positive patients) were imminently suicidal (i.e., had intent or plan).

CONCLUSION

Nearly 1 in 4 patients had a positive response to Item 9, but very few had imminent suicidality; the DSE was easy to use and acceptable to patients but time consuming. A more narrowly focused alternative to Item 9 may more accurately predict imminent suicidality and reduce the burden of further detailed suicide screening.

An exploratory mixed methods analysis of adherence predictors following acute coronary syndrome

Adherence to cardiac health behaviors is a critical predictor of prognosis in the months following an acute coronary syndrome (ACS). However, there has been minimal concomitant study of multiple nonadherence risk factors, as assessed via record review, structured assessments, and qualitative interviews, among hospitalized ACS patients. Accordingly, we completed an exploratory mixed methods study with 22 individuals who were admitted for ACS and had suboptimal pre-ACS adherence to physical activity, heart-healthy diet, and/or medications, defined by a Medical Outcomes Study Specific Adherence Scale (MOS SAS) score <15/18. During hospitalization, participants underwent quantitative assessments of sociodemographic, medical, and psychological variables, followed by in-depth semi-structured interviews to explore intentions, plans, and perceived barriers related to post-discharge health behavior changes. The MOS SAS was readministered at 3 months and participants were designated as persistently nonadherent (MOS SAS <15; n = 9) or newly adherent (n = 13). Interviews were transcribed and coded by trained raters via content analysis, and quantitative variables were compared between groups using chi-square analysis and independent-samples t-tests. On our primary qualitative analysis, we found that participants with vaguely described intentions/plans regarding health behavior change, and those who focused on barriers to change that were perceived as static, were more likely to be persistently nonadherent. On exploratory quantitative analyses, greater medical burden, diabetes, depressive symptoms, and low optimism/positive affect at baseline were associated with subsequent post-ACS nonadherence (all p < .05). In conclusion, this appears to be the first study to prospectively examine all of these constructs in hospitalized ACS patients, and we found that specific factors were associated with nonadherence to key health behaviors 3 months later. Therefore it may be possible to predict future nonadherence in ACS patients, even during hospitalization, and specific interventions during admission may be indicated to prevent adverse outcomes among patients at highest risk for post-ACS nonadherence.

Positive psychological states and health behaviors in acute coronary syndrome patients: A qualitative study

Positive psychological states are linked to superior cardiac outcomes, possibly mediated through increased participation in health behaviors. Trained study staff conducted in-depth semi-structured interviews in the hospital and 3 months later for 34 patients diagnosed with an acute coronary syndrome. These interviews focused on positive psychological states, cardiac health behaviors, and their connection; the interviews were transcribed and independently coded using directed content analysis. Both optimism and positive affect were associated with completion of physical activity and healthy eating in a bidirectional manner. In contrast, gratitude, while common, was infrequently linked to completion of health behaviors.

Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial

IMPORTANCE

Depression and anxiety are associated with adverse cardiovascular outcomes in patients with recent acute cardiac events. There has been minimal study of collaborative care (CC) management models for mental health disorders in high-risk cardiac inpatients, and no prior CC intervention has simultaneously managed depression and anxiety disorders.

OBJECTIVE

To determine the impact of a low-intensity CC intervention for depression, generalized anxiety disorder, and panic disorder among patients hospitalized for an acute cardiac illness.

DESIGN, SETTING, AND PARTICIPANTS

Single-blind randomized clinical trial, with study assessors blind to group assignment, from September 2010 through July 2013 of 183 patients admitted to inpatient cardiac units in an urban academic general hospital for acute coronary syndrome, arrhythmia, or heart failure and found to have clinical depression, generalized anxiety disorder, or panic disorder on structured assessment.

INTERVENTIONS

Participants were randomized to 24 weeks of a low-intensity telephone-based multicomponent CC intervention targeting depression and anxiety disorders (n = 92) or to enhanced usual care (serial notification of primary medical providers; n = 91). The CC intervention used a social work care manager to coordinate assessment and stepped care of psychiatric conditions and to provide support and therapeutic interventions as appropriate.

MAIN OUTCOMES AND MEASURES

Improvement in mental health-related quality of life (Short Form-12 Mental Component Score [SF-12 MCS]) at 24 weeks, compared between groups using a random-effects model in an intent-to-treat analysis.

RESULTS

Patients randomized to CC had significantly greater estimated mean improvements in SF-12 MCS at 24 weeks (11.21 points [from 34.21 to 45.42] in the CC group vs 5.53 points [from 36.30 to 41.83] in the control group; estimated mean difference, 5.68 points [95% CI, 2.14-9.22]; P = .002; effect size, 0.61). Patients receiving CC also had significant improvements in depressive symptoms and general functioning, and higher rates of treatment of a mental health disorder; anxiety scores, rates of disorder response, and adherence did not differ between groups.

CONCLUSIONS AND RELEVANCE

A novel telephone-based, low-intensity model to concurrently manage cardiac patients with depression and/or anxiety disorders was effective for improving mental health-related quality of life in a 24-week trial.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01201967.

Design and baseline data from the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized controlled trial

BACKGROUND

Depression and anxiety in cardiac patients are independently associated with adverse cardiovascular outcomes, including mortality. Collaborative care (CC) programs, which use care managers to assess patients, coordinate care, and perform therapeutic interventions, have proven effective in managing depression in this population. However, no prior CC intervention has simultaneously managed depression and anxiety disorders, and there has been minimal study of CC in high-risk cardiac inpatients.

MATERIALS AND METHODS

The Management of Sadness and Anxiety in Cardiology (MOSAIC) study was a prospective randomized trial of a low-intensity CC intervention, compared to enhanced usual care, for patients hospitalized for acute coronary syndrome, heart failure, or arrhythmia, and diagnosed with depression, generalized anxiety disorder (GAD), or panic disorder (PD). The primary outcome measure for MOSAIC was mental health-related quality of life (HRQoL), measured using the Medical Outcomes Study Short Form-12. Additional outcomes included psychological, functional, and medical outcomes, including rehospitalizations.

RESULTS

A total of 183 eligible participants were enrolled (92 collaborative care, 91 enhanced usual care); 94% of depressed patients reported being depressed for >1month, and 53% of those with GAD reported clinically significant anxiety for >1year. One hundred thirty-three patients had depression, 118 had GAD, and 19 had PD; 74 participants (40%) had two or more of the disorders.

CONCLUSION

The MOSAIC trial will provide data regarding whether an intervention that concurrently manages these common psychiatric disorders results in meaningful improvements in HRQoL, psychiatric symptoms, and medical outcomes in cardiac patients at high risk for adverse outcomes.

Baseline physical health-related quality of life and subsequent depression outcomes in cardiac patients

Among 137 depressed cardiac patients, lower baseline physical health-related quality of life (HRQoL) was independently associated with greater depression persistence at 6 months among patients randomized to collaborative care, but not usual care. Low physical HRQoL may impact collaborative care effectiveness and indicate a need for alternate depression treatment.

Development of a positive psychology intervention for patients with acute cardiovascular disease

The management of depression and other negative psychological states in cardiac patients has been a focus of multiple treatment trials, though such trials have not led to substantial improvements in cardiac outcomes. In contrast, there has been minimal focus on interventions to increase positive psychological states in cardiac patients, despite the fact that optimism and other positive states have been associated with superior cardiovascular outcomes. Our objective was to develop an 8-week, phone-based positive psychology intervention for patients hospitalized with acute cardiac disease (acute coronary syndrome or decompensated heart failure). Such an intervention would consist of positive psychology exercises adapted for this specific population, and it would need to be feasible for practitioners and patients in real-world settings. By adapting exercises that were previously validated in healthy individuals, we were able to generate a positive psychology telemedicine intervention for cardiac patients that focused on optimism, kindness, and gratitude. In addition, we successfully created a companion treatment manual for subjects to enhance the educational aspects of the intervention and facilitate completion of exercises. Finally, we successfully performed a small pilot trial of this intervention, and found that the positive psychology intervention appeared to be feasible and well-accepted in a cohort of patients with acute cardiac illness. Future studies should further develop this promising intervention and examine its impact on psychological and medical outcomes in this vulnerable population of cardiac patients.

A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes

BACKGROUND

Depression in cardiac patients is common, under-recognized, and independently associated with mortality.

OBJECTIVES

Our objectives in this initial report from a 6-month longitudinal trial were to determine whether a collaborative care program improves rates of depression treatment by discharge among patients hospitalized with acute cardiovascular disease, and to assess key clinical characteristics of depression in this cohort.

METHOD

This was a prospective, randomized trial comparing collaborative care and usual care interventions for depressed cardiac patients who were admitted to cardiac units in an urban academic medical center. For collaborative care subjects, the care manager performed a multi-component depression intervention in the hospital that included patient education and treatment coordination; usual care subjects' inpatient providers were informed of the depression diagnosis.

RESULTS

The mean Patient Health Questionnaire-9 for subjects (N = 175) was 17.6 (SD 3.5; range 11-26), consistent with moderate-severe depression. The majority of subjects had depression for over one month (n = 134; 76.6%) and a prior depressive episode (n = 124; 70.8%); nearly one-half (n = 75; 42.9%) had thoughts that life was not worth living in the preceding 2 weeks. Collaborative care subjects were far more likely to receive adequate depression treatment by discharge (71.9% collaborative care vs. 9.5% usual care; p < 0.001).

CONCLUSION

Depression identified by systematic screening in hospitalized cardiac patients appears was prolonged, and of substantial severity. A collaborative care depression management model appears to vastly increase rates of appropriate treatment by discharge.

Impact of a depression care management program for hospitalized cardiac patients

BACKGROUND

Depression is independently associated with poor outcomes among patients with acute cardiac disease. Collaborative care depression management programs have been used in outpatients to improve depression outcomes, but such a program had never been initiated in the hospital or used for patients with a wide range of cardiac illnesses.

METHODS AND RESULTS

This was a prospective, randomized trial of a low-intensity, 12-week collaborative care program versus usual care for 175 depressed patients hospitalized for acute coronary syndrome, arrhythmia, or heart failure. Study outcomes, assessed using mixed regression models to compare groups at 6 weeks, 12 weeks, and 6 months, included mental health (depression, cognitive symptoms of depression, anxiety, and mental health-related quality of life) and medical (physical health-related quality of life, adherence to medical recommendations, and cardiac symptoms) outcomes. Collaborative care subjects (n=90) had significantly greater improvements on all mental health outcomes at 6 and 12 weeks, including rates of depression response (collaborative care, 59.7% versus usual care 33.7%; odds ratio, 2.91; P=0.003 at 6 weeks; 51.5% versus 34.4%; odds ratio, 2.02; P=0.04 at 12 weeks), though these effects decreased after intervention. At 6 months, intervention subjects had significantly greater self-reported adherence and significantly reduced number and intensity of cardiac symptoms.

CONCLUSIONS

Among patients with a broad range of cardiac diagnoses, a collaborative care depression management program initiated during hospitalization led to significant improvements in multiple clinically important mental health outcomes and had promising effects on relevant medical outcomes after intervention. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00847132.

Detection of depression in cardiac inpatients: feasibility and results of systematic screening

BACKGROUND

A recent American Heart Association (AHA) Prevention Committee report recommended depression screening of all coronary heart disease patients using 2- and 9-item instruments from the Patient Health Questionnaire (PHQ-2 and PHQ-9) to identify patients who may need further assessment and treatment. Our objective was to assess the feasibility and results of such screening on inpatient cardiac units.

METHODS

In September 2007, the PHQ-2 was added to the nursing interview dataset on 3 cardiac units in a general hospital; this screen was completed as part of routine clinical care. Rates and results of depression screening, reasons for patients not being screened, and results of a nursing satisfaction survey were tabulated, and differences in baseline characteristics between screened and unscreened patients were analyzed via chi(2) and independent-samples t tests.

RESULTS

For a 12-month period, 4,783 patients were admitted to the cardiac units; 3,504 (73.3%) received PHQ-2 depression screening. Approximately 9% of screened patients had a PHQ-2 score > or =3 and were approached for further depression evaluation (PHQ-9) by a social worker; 74.1% of the positive-screen patients had a PHQ-9 score of > or =10, suggestive of major depression. Nurses (n = 66) reported high satisfaction with the screening process, and mean reported PHQ-2 screening time was 1.4 (+/-1.1) minutes.

CONCLUSIONS

Systematic depression screening of cardiac patients using methods outlined by the AHA Prevention Committee is feasible, well-accepted, and does not appear markedly resource-intensive. Future studies should link these methods to an efficient and effective program of depression management in this vulnerable population.

Understanding the decision to take the predictive test for Huntington disease

The predictive test for Huntington disease (HD) has allowed those at risk to determine gene status prior to symptoms. The purpose of this research was to understand the motivation and the anticipated reactions of those requesting the test. Forty persons at 50% risk for HD and 31 companions participated in a structured personal interview as part of the predictive test protocol. Reasons for taking the test centered on the reduction of anxiety and uncertainty associated with being at risk and enhanced planning and decision making. Participants also believed that taking the test would produce more positive than negative outcomes. With a favorable result, most anticipated a reduction of anxiety, a more normal future, and relief knowing their children would be at a very low risk. Most also cited benefits as more likely than consequences with an unfavorable result. Making the most of life, easier planning, and reduced uncertainty were rated as more likely than any of the adverse impacts, including short-term depression and becoming frightened. Almost all participants (95%) said they would rather learn that they have the HD gene than remain at 50% risk. The uncertainty, anxiety, and chronic stress associated with being at risk appears to underlie the motivation of many seeking the predictive test for HD.

Homozygote for Huntington disease

Four offspring of three different Huntington disease (HD) affected x affected matings were assessed by genetic linkage analysis for possible homozygosity. One individual was found to have a 95% likelihood of being an HD homozygote. The homozygote individual had an age at onset and symptoms which were similar to those of affected HD heterozygote relatives, including some with younger onset. This confirms the observation of Wexler et al. that in HD the homozygote is not more severely afflicted than the heterozygote.

Estimation of fertility and fitness in Huntington disease in New England

The advent of presymptomatic and prenatal testing in Huntington disease (HD) may change the reproductive behavior of persons at risk for HD. In order to assess future change, an analysis of fertility and reproductive fitness was carried out on 999 affected and 2,253 unaffected offspring from 235 New England families. Ascertainment biases observed for persons born before 1910 and after 1929 reduced the sample to 250 HD cases and 201 unaffected sib controls born between 1910 and 1929. No increase in reproductive rate was found in HD-affected men compared to male control sibs. A small increase in fertility averaging 0.5 child was seen in HD-affected females compared to unaffected females, but this difference was not significant. The increase in mean number of children for HD females is accounted for in part by a small number of affected women who had very large families. No evidence was found to suggest that any increase in reproductive rate for affected persons was related to offspring being born after HD onset. The fitness of both HD-affected and unaffected females was not significantly different from that of the general population of Massachusetts.

Predictive testing for Huntington's disease with use of a linked DNA marker

The probability of carrying the gene for Huntington's disease can in many cases be estimated in the children of affected persons by identifying a specific DNA marker that is genetically linked to the gene. We studied 47 persons at 50 percent risk of inheriting Huntington's disease who requested a presymptomatic or prenatal genetic-linkage test between September 1986 and January 1988. The participants were given pre-test counseling and psychological and neurologic evaluations. Nineteen persons later voluntarily withdrew from the protocol, including one who would have been excluded anyway, and one person was from a family that was too small to allow testing. Three D4S10 restriction-fragment-length polymorphisms produced by the HindIII, EcoRI, and Bg/I enzymes were used for all tests, and the probability that a subject was a Huntington's disease carrier was calculated. The accuracy of the test was compromised by a 4 percent recombination frequency between D4S10 and the Huntington's disease gene. Fifteen presymptomatic tests and one prenatal test were completed. Four yielded positive results, seven yielded negative results, and five were uninformative; seven persons are awaiting test results. All participants with positive tests experienced intermittent depression, but none required hospitalization, and no suicide threats were reported. Five participants received a diagnosis of Huntington's disease on the basis of the neurologic assessment. We conclude that some persons in the early stages of Huntington's disease may seek presymptomatic testing rather than neurologic evaluations.