Above and Beyond Number of Illnesses: A Two-Sample Replication of Current Approaches to Depressive Symptoms in Multimorbidity

OBJECTIVES

To expand current models of depressive symptoms in older adults with multimorbidity (MM) beyond the number of illnesses as a predictor of worsened mental health.

METHODS

Two-sample replication study of adults ≥62 years old with ≥ two chronic illnesses, who completed validated questionnaires assessing depressive symptoms, and disease- and treatment-related stressors. Data were analyzed using hierarchical linear regression.

RESULTS

The model of cumulative number of illnesses was worse at explaining variance in depressive symptoms (Sample 1 R2 = .035; Sample 2 R2 = .029), compared to models including disease- and treatment-related stressors (Sample 1 R2 = .37; Sample 2 R2 = .47). Disease-related stressors were the strongest factor associated with depressive symptoms, specifically, poor subjective cognitive function (Sample 1: b = -.202, p = .013; Sample 2: b = -.288, p < .001) and greater somatic symptoms (b = .455, p < .001; Sample 2: b = .355, p < .001).

CONCLUSIONS

Using the number of illnesses to understand depressive symptoms in MM is a limited approach. Models that move beyond descriptive relationships between MM and depressive symptoms are needed.

CLINICAL IMPLICATIONS

Providers should consider the role of somatic symptom management in patients with MM and depressive symptoms.

"Your cancer is no longer considered cancer": Psychological reactions to reclassification information and communication preferences

Objective

In 2016, the encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This reclassification removed the word "carcinoma" and the definition of cancer from the diagnosis. While the nomenclature change was expected to psychologically impact patients, that question has not been systematically explored. Using qualitative methods, we aimed to explore the psychological impact of reclassification on thyroid cancer patients and their preferences for receiving reclassification information.

Methods

Semi-structured interviews with nine non-EFVPTC thyroid cancer survivors were conducted. Participants were presented with a hypothetical reclassification scenario, and interview transcripts were analyzed using a thematic content analytic approach.

Results

Participants expressed a range of psychological reactions to reclassification information, primarily negative, including anger, mistrust, and uncertainty, but also relief. All participants expressed difficulty understanding the concept of reclassification. Communication preferences favored conversation with an established medical provider over written materials, such as a letter.

Discussion and conclusion

Communication must align with patient preferences. Being mindful of potential negative psychological reactions when providing information on cancer reclassification is vital.

Innovation

This study examines reactions to cancer reclassification information and preferences for how this information should be communicated.

Multimorbidity and Depressive Symptoms in Older Adults: A Contextual Approach

BACKGROUND AND OBJECTIVES

Among older adults, depressive symptoms increase with each chronic illness; however, specific disease-related stressors (e.g., pain) and contextual moderators (interpersonal, sociocultural, temporal) of this relationship remain understudied. We explored disease-related stressors associated with depressive symptoms and moderating effects of contextual factors on this relationship, guided by a social ecological framework.

RESEARCH DESIGN AND METHODS

Adults ≥62 years with multimorbidity (n = 366) completed validated scales assessing diagnoses, disease-related stressors (pain intensity, subjective cognitive function, physical function, somatic symptoms), and depressive symptoms. Moderators included age, expectations regarding aging, perceived social support, and difficulty affording medications. Data were analyzed using structural equation modeling.

RESULTS

Participants were 62-88 years old, with several comorbidities (M = 3.5; range: 2-9). As hypothesized, disease-related stressors were associated with depressive symptoms (b = 0.64, SE = 0.04, p < .001). The effect of disease-related stressors on depressive symptoms was greater among those reporting low social support (B = 0.70, SE = 0.06, p < .001) than for those reporting high social support (B = 0.46, SE = 0.06, p < .001). The negative effect of disease-related stressors on depressive symptoms was stronger for those with poorer expectations of aging (B = 0.68, SE = 0.07, p < .001), compared to those with more positive expectations (B = 0.47, SE = 0.06, p < .001). Age and difficulties affording medications were not significant moderators.

DISCUSSION AND IMPLICATIONS

Garnering social support and addressing low expectations for aging may prevent the detrimental effect of multimorbidity on mental health.

DEPRESSIVE SYMPTOMS AND MULTIMORBIDITY IN CONTEXT: INTERPERSONAL, SOCIOCULTURAL, AND TEMPORAL EFFECTS

Among older adults with multimorbidity (MM), disease-related stressors (e.g., pain) are associated with greater depressive symptoms. However, the contextual factors influencing this relationship remain understudied. We explored the moderating effects of interpersonal, sociocultural, and temporal factors as buffers of this relationship. Adults ≥ 62 years with MM (n=366) recruited through a national health volunteer registry and an online panel platform completed validated scales assessing diagnoses, disease-related stressors (pain intensity, subjective cognitive function, physical function, somatic symptoms), depressive symptoms. Potential moderators: age, expectations regarding aging, perceived social support, and difficulty affording medications (proxy for SES). Data were analyzed with structural equation modeling. Participants were 62-88 years old and living with many illnesses (M = 3.5; range: 2-9); 15% reported moderate-to-severe depressive symptoms. Among those with low social support, the effect of disease-related factors on depressive symptoms was greater (B = .70, SE = .06, p <.001) than for those with high social support (B = .46, SE = .06, p < .001)]. The negative effect of disease-related factors on depressive symptoms was stronger for those with worse expectations of aging (B = .68, SE = .07, p <.001), compared to those with more positive expectations (B = .47, SE = .06, p < .001). Age and difficulties affording medications were not significant moderators. Among older adults with MM, garnering social support and addressing low expectations for old age may be key to preventing the detrimental effect of MM on mental health.

Comorbidities and depressive symptoms among older adults with asthma

OBJECTIVE

Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma.

METHODS

Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors.

RESULTS

Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms (F (8, 330) = 7.7, p < 0.0001, R2 = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses.

CONCLUSIONS

In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.

Racial/ethnic concordance between patients and researchers as a predictor of study attrition

RATIONALE

The differential attrition of racial/ethnic minority participants in clinical research is a major threat to advancing medical and behavioral science.

OBJECTIVE

Our aim was to examine the influence of racial/ethnic concordance between participants and research staff on study attrition.

METHOD

Data were pooled from participants and clinical research coordinators (CRCs) in six longitudinal studies of respiratory illness. Dyads were classified as concordant if the patient and CRC were of the same racial/ethnic group. Multilevel modeling examined the effect of racial/ethnic concordance on attrition at the first and one-year follow-ups.

RESULTS

Spanish language, lower education, and greater depressive symptoms predicted greater attrition, but these effects disappeared in adjusted models. Race/ethnicity, age, gender and health literacy did not predict attrition. Contrary to hypotheses, attrition was greater among concordant than discordant dyads: Attrition was almost five times greater at first follow-up for Black and Hispanic participants in concordant dyads, and almost four times greater at one year.

CONCLUSIONS

Racial/ethnic concordance between participant and CRCs was related to greater attrition in a highly diverse sample of adults with respiratory illness. Differential attrition of racial/ethnic minorities is a major threat to advancing public health. Interactions with research staff may be critical to bridging the disparities gap.

Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults: The SAMBA Study Randomized Clinical Trial

IMPORTANCE

Older adults with asthma have worse control and outcomes than younger adults. Interventions to address suboptimal self-management among older adults with asthma are typically not tailored to the specific needs of the patient.

OBJECTIVE

To test the effect of a comprehensive, patient-tailored asthma self-management support intervention for older adults on clinical and self-management outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm randomized clinical trial conducted between February 2014 and December 2017 at primary care practices and personal residences in New York City. Adults 60 years and older with persistent, uncontrolled asthma were identified from electronic medical records at an academic medical center and a federally qualified health center. Of 1349 patients assessed for eligibility, 406 met eligibility criteria, consented to participate, and were randomized to 1 of 3 groups: home-based intervention, clinic-based intervention, or control (usual care). A total of 391 patients received the allocated treatment.

INTERVENTIONS

Screening for psychosocial, physical, cognitive, and environmental barriers to asthma control and self-management with actions to address identified barriers. The intervention was delivered in the home or primary care practices by asthma care coaches.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and emergency department visits for asthma care. Primary analyses compared intervention (home or clinic based) with usual care.

RESULTS

Of the 391 patients who received treatment, 58 (15.1%) were men, and the mean (SD) age was 67.8 (7.4) years. After accounting for baseline scores, scores on the asthma control test were better in the intervention groups vs the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P = .02; 6 months, 1.0; 95% CI, 0.0-2.1; P = .049; 12 months, 0.6; 95% CI, -0.5 to 1.8; P = .28; and overall, χ2 = 13.4, with 4 degrees of freedom; P = .01). Emergency department visits were lower at 12 months for the intervention groups vs the control group (16 [6.2%] vs 17 [12.7%]; P = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P = .03). Statistically significant improvements were observed for the intervention vs control patients in quality of life (overall effect: χ2 = 10.5, with 4 degrees of freedom; P = .01), medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P = .049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]). No significant differences in outcomes were observed between patients receiving the intervention in home vs practice settings.

CONCLUSIONS AND RELEVANCE

An intervention directed by patients' needs and barriers improved asthma outcomes and self-management behaviors among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02316223.

Temporal trends in sperm count: a systematic review and meta-regression analysis

BACKGROUND

Reported declines in sperm counts remain controversial today and recent trends are unknown. A definitive meta-analysis is critical given the predictive value of sperm count for fertility, morbidity and mortality.

OBJECTIVE AND RATIONALE

To provide a systematic review and meta-regression analysis of recent trends in sperm counts as measured by sperm concentration (SC) and total sperm count (TSC), and their modification by fertility and geographic group.

SEARCH METHODS

PubMed/MEDLINE and EMBASE were searched for English language studies of human SC published in 1981-2013. Following a predefined protocol 7518 abstracts were screened and 2510 full articles reporting primary data on SC were reviewed. A total of 244 estimates of SC and TSC from 185 studies of 42 935 men who provided semen samples in 1973-2011 were extracted for meta-regression analysis, as well as information on years of sample collection and covariates [fertility group ('Unselected by fertility' versus 'Fertile'), geographic group ('Western', including North America, Europe Australia and New Zealand versus 'Other', including South America, Asia and Africa), age, ejaculation abstinence time, semen collection method, method of measuring SC and semen volume, exclusion criteria and indicators of completeness of covariate data]. The slopes of SC and TSC were estimated as functions of sample collection year using both simple linear regression and weighted meta-regression models and the latter were adjusted for pre-determined covariates and modification by fertility and geographic group. Assumptions were examined using multiple sensitivity analyses and nonlinear models.

OUTCOMES

SC declined significantly between 1973 and 2011 (slope in unadjusted simple regression models -0.70 million/ml/year; 95% CI: -0.72 to -0.69; P < 0.001; slope in adjusted meta-regression models = -0.64; -1.06 to -0.22; P = 0.003). The slopes in the meta-regression model were modified by fertility (P for interaction = 0.064) and geographic group (P for interaction = 0.027). There was a significant decline in SC between 1973 and 2011 among Unselected Western (-1.38; -2.02 to -0.74; P < 0.001) and among Fertile Western (-0.68; -1.31 to -0.05; P = 0.033), while no significant trends were seen among Unselected Other and Fertile Other. Among Unselected Western studies, the mean SC declined, on average, 1.4% per year with an overall decline of 52.4% between 1973 and 2011. Trends for TSC and SC were similar, with a steep decline among Unselected Western (-5.33 million/year, -7.56 to -3.11; P < 0.001), corresponding to an average decline in mean TSC of 1.6% per year and overall decline of 59.3%. Results changed minimally in multiple sensitivity analyses, and there was no statistical support for the use of a nonlinear model. In a model restricted to data post-1995, the slope both for SC and TSC among Unselected Western was similar to that for the entire period (-2.06 million/ml, -3.38 to -0.74; P = 0.004 and -8.12 million, -13.73 to -2.51, P = 0.006, respectively).

WIDER IMPLICATIONS

This comprehensive meta-regression analysis reports a significant decline in sperm counts (as measured by SC and TSC) between 1973 and 2011, driven by a 50-60% decline among men unselected by fertility from North America, Europe, Australia and New Zealand. Because of the significant public health implications of these results, research on the causes of this continuing decline is urgently needed.

Mood disorders in first- and second-generation immigrants: systematic review and meta-analysis

BackgroundAlthough there are consistent reports of higher psychosis rates among immigrants, the information on mood disorders is limited.AimsTo review and quantify the difference in incidence of mood disorders in first- and second-generation immigrant (FGI and SGI) groups v. non-immigrants.MethodPubMed, EMBASE and PsycINFO were searched for articles from cohort studies reporting incidence of mood disorders among FGIs and SGIs.ResultsEighteen studies met our inclusion criteria. The summary relative risk (RR) for FGIs was 1.25 (95% CI 1.11-1.41), based on 17 effect sizes and 6120 cases, and 1.16 (95% CI 0.96-1.40) for SGIs based on three effect sizes. Men seemed at higher risk (RR = 1.29, 95% CI 1.06-1.56).ConclusionsClinicians should view FGIs as a group at risk of mood disorders, especially men. Further research is needed to understand immigrants' risk, especially in SGI.

Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers

OBJECTIVE

Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity.

METHODS

Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures.

RESULTS

Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons).

CONCLUSIONS

There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.

Impact of Community Interventions on the Social Representation of Depression in Rural Gujarat

There is a pressing need to develop community interventions that will address stigma against mental illness in rural India. This cross-sectional study will compare social representations of depression in villages where educational programs have targeted mental illness and stigma versus control villages. Participants from the villages exposed to the educational interventions (n = 146) will be compared with a sample from six control villages (n = 187) in the same geographic region, using a structured questionnaire. The impact of the intervention as a predictor for questionnaire score will be assessed along with socio-demographic variables. The intervention villages showed higher levels of literacy regarding depression and lower levels of stigma, after adjusting for all other socio-demographic variables. While some demographic factors associated with the knowledge and attitudes towards depression are not modifiable, our research provides evidence in favor of the positive influence a community grassroots intervention can have on mental health literacy in rural settings.