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Greenberg RL, Guzick AG, Schneider SC, Weinzimmer SA, Kook M, Perozo Garcia AB, Storch EA. Depressive Symptoms in Autistic Youth with Anxiety Disorders. J Dev Behav Pediatr 2023; 44:e597-e603. [PMID: 38019467 PMCID: PMC10873531 DOI: 10.1097/dbp.0000000000001223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/07/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Anxiety and depression often coexist in youth and share overlapping symptomatology; however, little is known about the comorbidity of anxiety and depression in autistic youth. This study explores (1) the frequency of depressive symptoms among autistic children with clinically significant anxiety, (2) clinical variables that may be associated with elevated depressive symptoms, and (3) whether pretreatment depressive symptoms predict cognitive behavioral therapy (CBT) outcomes for anxiety. METHOD Children aged 7 to 13 years (N = 87) and their parents participated in a randomized controlled trial comparing 2 versions of a parent-led, telehealth-delivered CBT program. Parents and children completed a variety of clinical assessments and self-report questionnaires before and after treatment. RESULTS Fifty-seven percent of the child sample reported experiencing elevated depressive symptoms while roughly 20% of parents reported elevated depressive symptoms in their child. A strong association between anxiety and depression was found. Heightened feelings of loneliness, per child report, and functional impairment, per parent report, were found to be uniquely associated with elevated depressive symptoms. Finally, depressive symptoms were not a significant predictor of CBT outcomes for anxiety. CONCLUSION Findings suggest high degrees of comorbidity between anxiety and depression among autistic children and that feelings of loneliness, anxiety, and functional impairment may be early indicators of mood-related concerns. Further research is needed to determine the full extent of the association between anxiety and depression and additional options for treating depression in autistic children.
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Affiliation(s)
- Rebecca L Greenberg
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
| | - Andrew G Guzick
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Sophie C Schneider
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
| | - Saira A Weinzimmer
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
| | - Minjee Kook
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
| | - Amanda B Perozo Garcia
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and
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2
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Armstrong GM, Greenberg RL, Smárason O, Frederick RM, Guzick AG, Schneider SC, Spencer SD, Cervin M, Storch EA. Factors associated with internalizing and externalizing symptoms in a clinical sample of youth with misophonia. J Obsessive Compuls Relat Disord 2023; 39:100831. [PMID: 37692107 PMCID: PMC10485913 DOI: 10.1016/j.jocrd.2023.100831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Misophonia is an often chronic condition characterized by strong, unpleasant emotional reactions when exposed to specific auditory or visual triggers. While not currently defined within existing classification systems, and not clearly fitting within the framework of extant psychiatric conditions, misophonia has historically been studied most frequently within the context of obsessive-compulsive and related disorders. Internalizing and externalizing psychiatric symptoms are common in misophonia, but specific factors that confer risk for these symptoms remain unknown. The present cross-sectional study examined whether sensory sensitivity and cognitive emotion regulation facets are associated with co-occurring internalizing and externalizing symptoms in 102 youth with misophonia aged 8-17 years (Nfemales = 69). Participants completed self-report assessments of misophonia severity, sensory sensitivity, cognitive emotion regulation, and emotional-behavioral functioning. In the final model, controlling for all variables, multiple linear regression analyses revealed that sensory sensitivity and age were significant predictors of internalizing symptoms, while sensory sensitivity and the other-blame cognitive emotion regulation facet were significant predictors of externalizing symptoms. Further, findings demonstrated that the positive reappraisal cognitive emotion regulation facet moderated the effect of misophonia severity on internalizing symptoms. Results highlight a strong, consistent relation between sensory sensitivities (beyond sound sensitivity) and psychiatric symptoms in misophonic youth. Further research is necessary to determine mechanisms and clinical variables impacting internalizing and externalizing symptoms within youth with misophonia.
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Affiliation(s)
- Gabrielle M Armstrong
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Rebecca L Greenberg
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Orri Smárason
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
- Faculty of Psychology, University of Iceland
| | - Renee M Frederick
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Andrew G Guzick
- Department of Psychiatry and Behavioral Sciences, University of Pennsylvania
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Sophie C Schneider
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Samuel D Spencer
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Matti Cervin
- Department of Clinical Sciences Lund, Lund University
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
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Guzick AG, Schneider SC, Perozo Garcia AB, Kook M, Greenberg RL, Riddle D, McNeel M, Rodriguez-Barajas S, Yang M, Upshaw B, Storch EA. Development and pilot testing of internet-delivered, family-based cognitive behavioral therapy for anxiety and obsessive-compulsive disorders in autistic youth. J Obsessive Compuls Relat Disord 2023; 37:100789. [PMID: 36908861 PMCID: PMC9997671 DOI: 10.1016/j.jocrd.2023.100789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Cognitive behavioral therapy adapted for autistic youth with anxiety and/or OCD has a strong evidence base, but few have access. A 12-week family-based, Internet-delivered cognitive behavioral therapy (iCBT) program for 7-15 year-old autistic youth with anxiety and/or OCD was developed as a potential method to address this problem. Quantitative and qualitative feedback from stakeholders (parents, youth, clinicians) was gathered on an initial draft of content before conducting a pilot trial. This feedback suggested high quality, engagement, usability, and informativeness of the material. Suggestions were incorporated into the treatment program that was tested in a pilot trial. Eight families were randomized to the iCBT program with either 1) weekly email support or 2) weekly email support plus biweekly telehealth check-ins, and seven of these families completed pre- and post-treatment assessments. An average reduction of 39% in anxiety severity was found, with six of the seven being classified as responders. Preliminary evidence suggests that family-based iCBT is an acceptable and promising treatment for autistic youth with anxiety and/or obsessive-compulsive disorders that should be further modified and tested in future work.
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Affiliation(s)
- Andrew G Guzick
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sophie C Schneider
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Amanda B Perozo Garcia
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Minjee Kook
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Rebecca L Greenberg
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - David Riddle
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Morgan McNeel
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, Texas, USA
| | | | - Michelle Yang
- Department of Psychological Sciences, Rice University, Houston, TX, USA
| | - Blake Upshaw
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA
| | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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4
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Lohman MC, Scherer EA, Whiteman KL, Greenberg RL, Bruce ML. Factors Associated With Accelerated Hospitalization and Re-hospitalization Among Medicare Home Health Patients. J Gerontol A Biol Sci Med Sci 2019; 73:1280-1286. [PMID: 28329251 DOI: 10.1093/gerona/glw335] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/13/2016] [Indexed: 01/04/2023] Open
Abstract
Background Preventing hospitalizations and re-hospitalizations of older adults receiving Medicare home health (HH) services is a key goal for patients and care providers. This study aimed to identify factors related to greater risk of and earlier hospitalizations from HH, a key step in targeting preventive efforts. Methods Data come from Medicare mandated start-of-care assessments from 87,780 HH patients served by 132 agencies in 32 states, collected from January 2013 to March 2015. Using parametric accelerated failure time (AFT) survival models, we evaluated the association between key patient and environmental characteristics and the hazard of and time until hospitalization and re-hospitalization. Results In total, 15,030 hospitalizations, including 6,539 re-hospitalizations, occurred in the sample within 60 days of start of HH. Factors most strongly associated with substantially greater risk of and earlier hospitalization included male gender, history of hospitalization, polypharmacy, elevated depressive symptoms, greater functional disability, primary diagnoses of heart disease, chronic obstructive pulmonary disease, and urinary tract infection, and government-controlled agency care. In addition to these factors, black race and primary diagnosis of skin wounds were uniquely related to risk of earlier re-hospitalization. Conclusions Results suggest that factors collected during routine HH patient assessments can provide important information to predict risk of earlier hospitalization and re-hospitalization among Medicare HH patients. Identified factors can help identify patients at greatest risk of early hospitalization and may be important targets for agencies and care providers to prevent avoidable hospitalizations.
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Affiliation(s)
- Matthew C Lohman
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Community and Family Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire
| | - Emily A Scherer
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Karen L Whiteman
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Community and Family Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire
| | - Rebecca L Greenberg
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Martha L Bruce
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Community and Family Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire
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5
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Lohman MC, Cotton BP, Zagaria AB, Bao Y, Greenberg RL, Fortuna KL, Bruce ML. Hospitalization Risk and Potentially Inappropriate Medications among Medicare Home Health Nursing Patients. J Gen Intern Med 2017; 32:1301-1308. [PMID: 28849426 PMCID: PMC5698223 DOI: 10.1007/s11606-017-4157-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/27/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospitalizations and potentially inappropriate medication (PIM) use are significant and costly issues among older home health patients, yet little is known about the prevalence of PIM use in home health or the relationship between PIM use and hospitalization risk in this population. OBJECTIVE To describe the prevalence of PIM use and association with hospitalization among Medicare home health patients. DESIGN Cross-sectional analysis using data from 132 home health agencies in the US. SUBJECTS Medicare beneficiaries starting home health nursing services between 2013 and 2014 (n = 87,780). MAIN MEASURES Prevalence of individual and aggregate PIM use at start of care, measured using the 2012 Beers criteria. Relative risk (RR) of 30-day hospitalization or re-hospitalization associated with individual and aggregate PIM use, compared to no PIM use. KEY RESULTS In total, 30,168 (34.4%) patients were using at least one PIM, with 5969 (6.8%) taking at least two PIMs according to the Beers list. The most common types of PIMs were those affecting the brain or spinal cord, analgesics, and medications with anticholinergic properties. With the exception of nonsteroidal anti-inflammatory drugs (NSAIDs), PIM use across all classes was associated with elevated risk (10-33%) of hospitalization compared to non-use. Adjusting for demographic and clinical characteristics, patients using at least one PIM (excluding NSAIDs) had a 13% greater risk (RR = 1.13, 95% CI: 1.09, 1.17) of being hospitalized than patients using no PIMs, while patients using at least two PIMs had 21% greater risk (RR = 1.21, 95% CI: 1.12, 1.30). Similar associations were found between PIMs and re-hospitalization risk among patients referred to home health from a hospital. CONCLUSIONS Given the high prevalence of PIM use and the association between PIMs and hospitalization risk, home health episodes represent opportunities to substantially reduce PIM use among older adults and prevent adverse outcomes. Efforts to address medication use during home health episodes, hospitalizations, and care transitions are justified.
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Affiliation(s)
- Matthew C Lohman
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. .,Dartmouth Centers for Health and Aging, Lebanon, NH, USA.
| | - Brandi P Cotton
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth Centers for Health and Aging, Lebanon, NH, USA
| | - Alexandra B Zagaria
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Yuhua Bao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA.,Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Rebecca L Greenberg
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, NY, USA
| | - Karen L Fortuna
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth Centers for Health and Aging, Lebanon, NH, USA
| | - Martha L Bruce
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth Centers for Health and Aging, Lebanon, NH, USA
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Pickett YR, Greenberg RL, Bazelais KN, Ghesquiere A, Bruce ML. The Impact of Depression on Discharge to Hospitals and Other Outcomes in Medicare Home Health Care Patients. Home Health Care Management & Practice 2016. [DOI: 10.1177/1084822316645920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to determine the association of active depressive symptoms in older home health care (home care) patients and discharge to the hospital. This study was based on a cross-sectional secondary data analysis. The data were from the Montefiore Home Healthcare Agency, Bronx, New York. Patients 65 years and older who were admitted to home care in 2010 ( N = 3,761) with a valid depression screen in the medical record were included. Disposition at discharge and the Patient Health Questionnaire–2 depression screen were collected from the home care nursing assessment. Demographic and clinical factors were collected from the medical record. The adjusted odds ratio (AOR) was greater for discharge resulting in hospitalization (AOR = 1.70, 95% confidence interval = [1.29, 2.25]) among those with positive depression screens compared with those with a negative screen at the time of admission. Conclusion: Active depressive symptoms at the time of admission to home care were associated with increased odds of hospitalization at discharge. Interventions to reduce depression during the home care admission may have implications for readmission rates and overall health care utilization.
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Affiliation(s)
| | | | | | | | - Martha L. Bruce
- Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
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7
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Lohman MC, Whiteman KL, Greenberg RL, Bruce ML. Incorporating Persistent Pain in Phenotypic Frailty Measurement and Prediction of Adverse Health Outcomes. J Gerontol A Biol Sci Med Sci 2016; 72:216-222. [PMID: 28087677 DOI: 10.1093/gerona/glw212] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/01/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Frailty, a syndrome of physiological deficits, is prevalent among older adults and predicts elevated risk of adverse health outcomes. Although persistent pain predicts similar risk, it is seldom considered in frailty measurement. This article evaluated the construct and predictive validity of including persistent pain in phenotypic frailty measurement. METHODS Frailty and persistent pain were operationalized using data from the Health and Retirement Study (2006-2012 waves). Among a subset of adults aged 65 and older (n = 3,652), we used latent class analysis to categorize frailty status and to evaluate construct validity. Using Cox proportional hazards models, we compared time to incident adverse outcomes (death, fall, hospitalization, institutionalization, and functional disability) between frailty classes determined by either including or excluding persistent pain as a frailty component. RESULTS In latent class models, persistent pain occurred with other frailty components in patterns consistent with a medical syndrome. Frail and intermediately frail classes determined by including persistent pain were more strongly associated with all adverse outcomes compared with frail and intermediately frail classes determined excluding persistent pain. Frail respondents had significantly greater risk of death compared with nonfrail respondents when frailty models included rather than excluded persistent pain (respectively, hazard ratio [HR] = 3.87, 95% confidence interval [CI] = 2.99-5.00 (including pain); HR = 2.10, 95% CI = 1.71-2.59 (excluding pain). CONCLUSIONS Findings support consideration of persistent pain as a component of the frailty phenotype. Persistent pain assessment may provide an expedient method to enhance frailty measurement and improve prediction of adverse outcomes.
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Affiliation(s)
- Matthew C Lohman
- Department of Community and Family Medicine of the Dartmouth Geisel School of Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire. .,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Karen L Whiteman
- Department of Community and Family Medicine of the Dartmouth Geisel School of Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Rebecca L Greenberg
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Martha L Bruce
- Department of Community and Family Medicine of the Dartmouth Geisel School of Medicine, Dartmouth Centers for Health and Aging, Lebanon, New Hampshire.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Bruce ML, Lohman MC, Greenberg RL, Bao Y, Raue PJ. Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial. J Am Geriatr Soc 2016; 64:2196-2203. [PMID: 27739067 DOI: 10.1111/jgs.14440] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. DESIGN Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). SETTING Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. PARTICIPANTS Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). INTERVENTION The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. MEASUREMENTS Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. RESULTS The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. CONCLUSION Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.
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Affiliation(s)
- Martha L Bruce
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Psychiatry, Weill Cornell Medical College, New York City, New York
| | - Matthew C Lohman
- Department of Psychiatry, Weill Cornell Medical College, New York City, New York
| | - Rebecca L Greenberg
- Department of Psychiatry, Weill Cornell Medical College, New York City, New York
| | - Yuhua Bao
- Department of Psychiatry, Weill Cornell Medical College, New York City, New York.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York
| | - Patrick J Raue
- Department of Psychiatry, Weill Cornell Medical College, New York City, New York
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9
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Ghesquiere AR, Bazelais KN, Berman J, Greenberg RL, Kaplan D, Bruce ML. Associations Between Recent Bereavement and Psychological and Financial Burden in Homebound Older Adults. Omega (Westport) 2016. [DOI: 10.1177/0030222815590709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Bereavement is common in older adults, but it remains unknown whether bereavement contributes to poor outcomes in the vulnerable population of older adults receiving home-based services. We examine whether recent bereavement was associated with worse physical or mental health, presence of abuse or neglect, and financial strain. Research Design Cross-sectional analyses of an assessment of functional and social vulnerabilities collected by the New York City Department for the Aging (DFTA), the largest Area Agency on Aging in New York. Assessments were completed on 5,576 New York City Department for the Aging long-term care program, recipients aged ≥60 who received services in 2012. Assessment also collected data on partner or child death in the last year. Results Logistic regression indicated that the recently bereaved were more likely than the nonbereaved to report both depression symptoms and financial strain. Conclusion Enhanced efforts to identify and address mental health and financial concerns in bereaved homebound older adults may be warranted.
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Affiliation(s)
- Angela R. Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College of the City University of New York, NY, USA
| | - Kisha N. Bazelais
- University of Miami, Student Counseling Center, Coral Gables, FL, USA
| | | | | | - Daniel Kaplan
- Department of Psychiatry, Weill Cornell Medical College, NY, USA
| | - Martha L. Bruce
- Department of Psychiatry, Weill Cornell Medical College, NY, USA
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10
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Lohman PhD MC, Raue PhD PJ, Greenberg RL, Bruce ML. Reducing suicidal ideation in home health care: results from the CAREPATH depression care management trial. Int J Geriatr Psychiatry 2016; 31:708-15. [PMID: 26552852 PMCID: PMC4861681 DOI: 10.1002/gps.4381] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The study evaluated the effectiveness of a depression care management intervention in reducing suicidal ideation (SI) among home health patients. METHODS Data come from the cluster-randomized effectiveness trial of the Depression Care for Patients at Home (Depression CAREPATH), an intervention that integrates depression care management into the routine nursing visits of Medicare home health patients screening positive for depression. Patients were interviewed at baseline, 3, 6, and 12-month follow-up. SI was measured using the Hamilton Rating Scale for Depression item. We compared likelihood of any level of SI between intervention and usual care patients using longitudinal logistic mixed-effects models. RESULTS A total of 306 eligible patients enrolled in the trial. Among them, 70 patients (22.9%) reported SI at baseline. Among patients with SI, patients under the care of nurses randomized to CAREPATH were less likely to report SI over the study period (odds ratio = 0.51, 95% CI; 0.24-1.07), with 63.6% of usual care versus 31.3% of CAREPATH participants continuing to report SI after one year. Baseline major depression, greater perceived burdensomeness, and greater functional disability were associated with greater likelihood of SI. CONCLUSION SI is reported in more than 10% of Medicare home health patients. The Depression CAREPATH intervention was associated with a reduction in patients reporting SI at one year, compared to enhanced usual care. Given relative low burden on nursing staff, depression care management may be an important component of routine home health practices producing long-term reduction in SI among high-risk patients. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Matthew C. Lohman PhD
- Department of Psychiatry, Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Patrick J. Raue PhD
- Department of Psychiatry, Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Rebecca L. Greenberg
- Department of Psychiatry, Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Martha L. Bruce
- Department of Psychiatry, Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York
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11
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Bruce ML, Raue PJ, Reilly CF, Greenberg RL, Meyers BS, Banerjee S, Pickett YR, Sheeran TF, Ghesquiere A, Zukowski D, Rosas VH, McLaughlin J, Pledger L, Doyle J, Joachim P, Leon AC. Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial. JAMA Intern Med 2015; 175:55-64. [PMID: 25384017 PMCID: PMC4516039 DOI: 10.1001/jamainternmed.2014.5835] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression. OBJECTIVE To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study. INTERVENTIONS The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week. MAIN OUTCOMES AND MEASURES Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D). RESULTS The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005). CONCLUSION AND RELEVANCE Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01979302.
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Affiliation(s)
- Martha L. Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Patrick J. Raue
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Catherine F. Reilly
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | | | - Barnett S. Meyers
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- New York Presbyterian Hospital-Westchester Division, White Plains, New York
| | - Samprit Banerjee
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Department of Health Policy and Research, Weill Cornell Medical College, New York City, New York
| | - Yolonda R. Pickett
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- New York Presbyterian Hospital-Westchester Division, White Plains, New York
- Montefiore Home Health Agency, Bronx, New York
| | - Thomas F. Sheeran
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Rhode Island Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Angela Ghesquiere
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Brookdale Center for Healthy Aging, Hunter College, New York City, New York
| | | | | | | | - Lori Pledger
- Baptist Home Health Network, Little Rock, Arkansas
| | - Joan Doyle
- Penn Care at Home, Bala Cynwyd, Pennsylvania
| | | | - Andrew C. Leon
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
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Ghesquiere AR, Park M, Bogner HR, Greenberg RL, Bruce ML. The effect of recent bereavement on outcomes in a primary care depression intervention study. Am J Geriatr Psychiatry 2014; 22:1555-64. [PMID: 24418366 PMCID: PMC4057992 DOI: 10.1016/j.jagp.2013.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 12/06/2013] [Accepted: 12/11/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Although bereavement and depression are both common in older primary care patients, the effect of bereavement on depression intervention outcomes is unknown. We examined whether standard interventions for depression in primary care were as effective for bereaved as for non-bereaved depressed patients. DESIGN Randomized controlled trial. SETTING Twenty community-based primary care practices in New York City, greater Philadelphia, and Pittsburgh. Randomization to either intervention or usual care occurred by practice. PARTICIPANTS Patients aged 60 years or older who met criteria for major depression or clinically significant minor depression (N = 599). Patients who did not complete the bereavement measure or who were missing 4-month data were excluded (final N = 417). INTERVENTION Study-trained depression care managers offered guideline-concordant recommendations to primary care physicians at intervention sites and assisted patients with treatment adherence. Patients who did not wish to take antidepressants could receive interpersonal psychotherapy. MEASUREMENTS Bereavement was captured using the Louisville Older Persons Events Schedule. Depression severity was assessed using the 24-item Hamilton Depression Rating Scale (HDRS). Outcomes at 4 months were remission (HDRS ≤7) and response (HDRS reduction ≥50% from baseline). RESULTS Logistic regressions indicated that, for non-bereaved participants, response and remission were higher in intervention than usual care. However, recently bereaved older adults were less likely to achieve response or remission at 4 months if treated in the intervention condition. CONCLUSIONS Standard depression care management appears to be ineffective among recently bereaved older primary care patients. Greater attention should be paid in primary care to emotional distress in the context of bereavement.
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Affiliation(s)
- Angela R. Ghesquiere
- Corresponding Author: Angela Ghesquiere, PhD, Weill Cornell Medical College, 21 Bloomingdale Road, 7 South, Room 101-A, White Plains, NY 10605, Phone: (914) 997-8683, Fax: (914) 682-6979,
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13
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Pickett YR, Bazelais KN, Greenberg RL, Bruce ML. Racial and ethnic variation in home healthcare nurse depression assessment of older minority patients. Int J Geriatr Psychiatry 2014; 29:1140-4. [PMID: 24243823 PMCID: PMC4022696 DOI: 10.1002/gps.4001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/06/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study is to determine the racial/ethnic effect of depression symptom recognition by home healthcare nurses. METHODS This is a secondary analysis of administrative data from a large urban home healthcare agency. Patients' age were 65 years and older with a valid depression screen, identified as Caucasian, African American, or Hispanic and admitted to homecare in 2010 (N = 3711). All demographic and clinical information were obtained from the electronic medical record. RESULTS Subjects were 29.34% Caucasian, 37.81% African American, and 32.85% Hispanic. About 6.52% had a formal chart diagnosis of depression, and 13.39% received antidepressant therapy. The rates of positive depression screens by nurses were higher in Caucasians than that of in African Americans or Hispanics (13.41% vs. 9.27% vs. 10.99%; χ(2) = 10.70, df [degrees of freedom] = 2; p < 0.01). Depression screening rates were then stratified by the number of clinical indicators from the chart (depression diagnosis or antidepressant on medication list). The proportion of positive screen increased for minorities with an increase in the number of indicators. African Americans had significantly greater positive screens with two indicators compared with that of the Caucasians and Hispanics (50.00% vs. 23.81% vs. 35.59%; χ(2) = 6.65, df = 2; p = 0.04). CONCLUSIONS These findings show a wide range of variation in screening for depression among ethnic groups. The rates increase for minorities with the presence of increased clinical indicators, suggesting that nurses may screen higher in minorities when there is higher clinical suspicion. Future research in home healthcare should be aimed at training nurses to conduct culturally tailored depression screening to improve management of depression in older minorities.
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Affiliation(s)
- Yolonda R. Pickett
- Weill Cornell Medical College, Department of Psychiatry,Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences
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14
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Beyer JL, Greenberg RL, Marino P, Bruce ML, Al Jurdi RK, Sajatovic M, Gyulai L, Mulsant BH, Gildengers A, Young RC. Social support in late life mania: GERI-BD. Int J Geriatr Psychiatry 2014; 29:1028-32. [PMID: 24664811 PMCID: PMC4545672 DOI: 10.1002/gps.4093] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 01/23/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Using the database of the National Institute of Mental Health-sponsored acute treatment of late life mania study (GERI-BD), we assessed the role of social support in the presentation of late life bipolar mania. METHODS In the first 100 subjects randomized in geriatric BD, we explored the demographic, clinical, and social support characteristics (assessed using the Duke Social Support Index) and aspects of manic presentation. We selected two dependent variables: symptom severity, as determined by the Young Mania Rating Scale (YMRS) at baseline, and duration of episode. We selected nine potential independent variables on the basis of Pearson correlation coefficients. We derived two final models using multiple regression analysis employing an iterative process. RESULTS In our severity model, being married was associated with a higher YMRS score (p = 0.05), whereas higher social interaction scores with non-family members were associated with a lower YMRS score (p = 0.011). In the episode duration model, longer duration was associated with a higher Hamilton Depression Rating Scale score (p = 0.03) and higher social interaction scores with non-family members (p = 0.0003), younger age (p = 0.04), higher number of persons in one's family social network (p = 0.017), and higher instrumental support scores (p = 0.0062). CONCLUSIONS In late life mania, more social interaction with one's community appears to be associated with less severe symptoms at presentation for treatment, however, it can also be associated with slightly longer the duration of episode. Two aspects of the Duke Social Support Index are associated with a shorter episode duration prior to seeking treatment: being part of a larger family network and a having a higher level of instrumental support prior to treatment. The Instrumental Support Subscale measures the degree of assistance that is available for the respondent in performing daily tasks. These findings suggest that in older adults with BD, close social interactions and support are important in limiting the length of the illness episode prior to treatment. Social interactions involving non-family members may be less important in moderating the intensity of the symptoms at presentation.
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Affiliation(s)
| | | | | | | | | | | | | | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Toronto and University of Toronto, Ontario,University of Pittsburg School of Medicine
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Pickett YR, Greenberg RL, Bazelais KN, Bruce ML. Depression treatment disparities among older minority home healthcare patients. Am J Geriatr Psychiatry 2014; 22:519-22. [PMID: 23711738 PMCID: PMC3760983 DOI: 10.1016/j.jagp.2013.01.078] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 01/25/2013] [Accepted: 01/28/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Determine the racial/ethnic effect on depression treatment among home healthcare patients. DESIGN Cross-sectional analyses of administrative data. SETTING A large home healthcare agency in Bronx, NY. PARTICIPANTS Patients 65 years and older admitted to homecare in 2010 (N = 3,744). MEASUREMENTS Patient Health Questionnaire (PHQ)-2 depression screen. Other data, such as diagnosis, medications, and demographics, were collected from the patient electronic medical record. RESULTS 6.52% of the sample had a depression diagnosis, 11.11% screened positive for depression (+PHQ-2), and 13.39% were prescribed antidepressants. The odds of receiving an antidepressant among those who screened positive for depression were 0.42 (95% confidence interval [CI]: 0.22-0.79) for African Americans and 0.49 (95% CI: 0.26-0.93) for Hispanics compared with Caucasians. CONCLUSIONS These findings suggest that disparities continue to exist in depression treatment for older minority home healthcare patients compared with older Caucasians.
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Affiliation(s)
- Yolonda R Pickett
- Department of Psychiatry, Weill Cornell Medical College, New York, NY; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York, NY.
| | | | - Kisha N Bazelais
- Department of Psychiatry, Weill Cornell Medical College, New York, NY
| | - Martha L Bruce
- Department of Psychiatry, Weill Cornell Medical College, New York, NY
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Sheeran T, Greenberg RL, Davan LA, Dealy JA, Young RC, Bruce ML. A descriptive study of older bipolar disorder residents living in New York City's adult congregate facilities. Bipolar Disord 2012; 14:756-63. [PMID: 23107221 PMCID: PMC4098752 DOI: 10.1111/bdi.12008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Much of the research on geriatric bipolar disorder is from outpatient populations or epidemiological surveys with small samples. In contrast, in this study a descriptive analysis was conducted of geriatric and younger adult residents with bipolar disorder or mania in non-clinical adult congregate facilities (ACFs) in the greater New York City region. METHODS A total of 2602 ACF residents were evaluated in 19 facilities, across multiple demographic and health domains. Within this sample, 200 residents had chart diagnoses of bipolar disorder or mania. Among these, 50 geriatric residents (age ≥ 60) were compared to 50 younger adult residents (age < 50) on a number of demographic and health measures. RESULTS Based on chart diagnoses, the overall prevalence of bipolar disorder was 7.8%. Compared to other studies of outpatient, epidemiological, and census samples, both older and younger residents with bipolar disorder had higher rates of cognitive impairment, impairment in executive functioning, vision impairment, and proportion of residents who had never been married. The younger group also had higher rates of obesity and the elderly group had a greater proportion of residents without high-school education. Both age groups had rates of lithium or valproate use comparable to those found in outpatient studies. Comparing the two age groups, the elderly sample had lower overall cognitive and executive functioning, and was using a larger number of medication classes than the younger group. The elderly group also had a larger proportion of residents who were separated/divorced or widowed compared to the younger group, which had higher rates of never-married residents. CONCLUSIONS Overall, both age groups had relatively high rates of bipolar disorder, with significant cognitive impairment, medical burden, obesity, mental health service use, and lower education levels, as compared to outpatient, epidemiological, and census samples. Of note was the significant cognitive impairment across age groups.
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Affiliation(s)
- Thomas Sheeran
- Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA.
| | - Rebecca L Greenberg
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Laura A Davan
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Jennifer A Dealy
- Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI
| | - Robert C Young
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Martha L Bruce
- Institute of Geriatric Psychiatry, Weill Cornell Medical College, New York, NY, USA
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Al Jurdi RK, Schulberg HC, Greenberg RL, Kunik ME, Gildengers A, Sajatovic M, Mulsant BH, Young RC. Characteristics associated with inpatient versus outpatient status in older adults with bipolar disorder. J Geriatr Psychiatry Neurol 2012; 25:62-8. [PMID: 22467848 PMCID: PMC3623950 DOI: 10.1177/0891988712436684] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This is an exploratory analysis of ambulatory and inpatient services utilization by older persons with type I bipolar disorder experiencing elevated mood. The association between type of treatment setting and the person's characteristics is explored within a framework that focuses upon predisposing, enhancing, and need characteristics. METHOD Baseline assessments were conducted with the first 51 inpatients and 49 outpatients 60 years of age and older, meeting criteria for type I bipolar disorder, manic, hypomanic, or mixed episode enrolled in the geriatric bipolar disorder study (GERI-BD) study. We compared participants recruited from inpatient versus outpatient settings in regard to the patients' predisposing, enabling, and need characteristics. RESULTS Being treated in an inpatient rather than an outpatient setting was associated with the predisposing characteristic of being non-Hispanic caucasian (odds ratio [OR]: 0.1; P = .005) and past history of treatment with first-generation antipsychotics (OR: 6.5; P < .001), and the need characteristic reflected in having psychotic symptoms present in the current episode (OR: 126.08; P < .001). CONCLUSION Ethnicity, past pharmacologic treatment, and current symptom severity are closely associated with treatment in inpatient settings. Clinicians and researchers should investigate whether closer monitoring of persons with well-validated predisposing and need characteristics can lead to their being treated in less costly but equally effective ambulatory rather than inpatient settings.
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Affiliation(s)
- Rayan K. Al Jurdi
- The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Baylor College of Medicine, Houston, TX, USA,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA
| | | | | | - Mark E. Kunik
- The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA,Baylor College of Medicine, Houston, TX, USA,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA,Houston Center for Quality of Care & Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Ariel Gildengers
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Martha Sajatovic
- Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland OH, USA
| | - Benoit H. Mulsant
- Center for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto ON, Canada
| | - Robert C. Young
- Weill Cornell Medical College, White Plains, New York, NY, USA
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Sajatovic M, Al Jurdi R, Gildengers A, Greenberg RL, Tenhave T, Bruce ML, Mulsant B, Young RC. Depression symptom ratings in geriatric patients with bipolar mania. Int J Geriatr Psychiatry 2011; 26:1201-8. [PMID: 21360754 PMCID: PMC3651791 DOI: 10.1002/gps.2664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 10/26/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life. METHODS Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20. RESULTS Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample. CONCLUSIONS These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms.
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Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Rayan Al Jurdi
- Department of Psychiatry, The Menninger Department of Psychiatry at Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Ariel Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA
| | | | - Thomas Tenhave
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Martha L. Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY
| | - Benoit Mulsant
- Geriatric Mental Health Program, Center for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Robert C. Young
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY
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Bruce ML, Sheeran T, Raue PJ, Reilly CF, Greenberg RL, Pomerantz JC, Meyers BS, Weinberger MI, Johnston CL. Depression care for patients at home (Depression CAREPATH): intervention development and implementation, part 1. Home Healthc Nurse 2011; 29:416-26. [PMID: 21716043 PMCID: PMC3520069 DOI: 10.1097/nhh.0b013e31821fe9f7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
High levels of depressive symptoms are common and contribute to poorer clinical outcomes even in geriatric patients who are already taking antidepressant medication. The Depression CARE for PATients at Home (Depression CAREPATH) intervention was designed for managing depression as part of ongoing care for medical and surgical patients. The intervention provides Home Health Agencies the resources needed to implement depression care management as part of routine clinical practice.
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Affiliation(s)
- Martha L Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY, USA.
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Sajatovic M, Gildengers A, Jurdi RKA, Gyulai L, Cassidy KA, Greenberg RL, Bruce ML, Mulsant BH, Have TT, Young RC. Multisite, open-label, prospective trial of lamotrigine for geriatric bipolar depression: a preliminary report. Bipolar Disord 2011; 13:294-302. [PMID: 21676132 PMCID: PMC3610426 DOI: 10.1111/j.1399-5618.2011.00923.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression. METHODS Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects. RESULTS A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed. CONCLUSIONS In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression.
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Affiliation(s)
- Martha Sajatovic
- Department of Psychiatry, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Ariel Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA
| | - Rayan K Al Jurdi
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Laszlo Gyulai
- Deparment of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Kristin A Cassidy
- Department of Psychiatry, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, OH
| | | | - Martha L Bruce
- Department of Psychiatry, Weill Cornell Medical College, New, York, NY, USA
| | - Benoit H Mulsant
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA
,Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Ten Have
- Division of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert C Young
- Department of Psychiatry, Weill Cornell Medical College, New, York, NY, USA
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Gildengers AG, Mulsant BH, Al Jurdi RK, Beyer JL, Greenberg RL, Gyulai L, Moberg PJ, Sajatovic M, ten Have T, Young RC. The relationship of bipolar disorder lifetime duration and vascular burden to cognition in older adults. Bipolar Disord 2010; 12:851-8. [PMID: 21176032 PMCID: PMC3038329 DOI: 10.1111/j.1399-5618.2010.00877.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition. METHODS A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden. RESULTS Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale. CONCLUSIONS In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age.
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Affiliation(s)
- Ariel G Gildengers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Bruce ML, Brown EL, Raue PJ, Mlodzianowski AE, Meyers BS, Leon AC, Heo M, Byers AL, Greenberg RL, Rinder S, Katt W, Nassisi P. A randomized trial of depression assessment intervention in home health care. J Am Geriatr Soc 2007; 55:1793-800. [PMID: 17916119 DOI: 10.1111/j.1532-5415.2007.01419.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement. DESIGN Training in the Assessment of Depression (TRIAD) was a three-group, nurse-randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks. SETTING Three certified home healthcare agencies in Westchester County, New York. PARTICIPANTS Fifty-three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged >65; N=477) yielded 256 (53.7%) enrolled subjects, 84 (17.6%) ineligibles, and 120 (25.2%) refusals; 233 of the 256 (87.1%) enrolled patients completed follow-up interviews. INTERVENTION Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS). MEASUREMENTS Nurse-assessed mood or anhedonia (OASIS) versus research assessments using the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders (SCID); referrals for mental health evaluation (agency records), and depression severity (24-item Hamilton Depression Rating Scale; HDRS). RESULTS Referral rates for patients with (SCID) depressed mood or anhedonia (n=75) varied according to nurse group: 50.0% full intervention, 18.5% minimal, 21.4% control (P=.047). Rates for nondepressed patients (n=180) did not differ (4.9%, 2.0%, 5.8%, respectively; P=.60). In patients with major or minor depression (n=37), referral was associated with symptom improvement. Change in HDRS was 5 points greater in referred patients than others (P=.04). Concordance between OASIS and SCID did not differ between intervention groups. CONCLUSION TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.
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Affiliation(s)
- Martha L Bruce
- Department of Psychiatry, Weill Medical College of Cornell University, White Plains, New York, USA.
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Brown EL, Raue PJ, Mlodzianowski AE, Meyers BS, Greenberg RL, Bruce ML. Transition to home care: quality of mental health, pharmacy, and medical history information. Int J Psychiatry Med 2007; 36:339-49. [PMID: 17236701 DOI: 10.2190/6n5p-5cxh-l750-a8hv] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the completeness and accuracy of clinical information provided by referral sources to visiting nurses for patients admitted to receive home health care. METHODS Clinical referral information for a representative sample of 243 older adults admitted to receive skilled home-health nursing was compared to medical record information from home-health charts and in-home research interviews to determine their concordance. Measures used included referral information, home-care chart documentation, in-home nurse review of medications, medication allergies, caregiver contact information, cognitive status, depression status, and follow-up plan. RESULTS There were medication discrepancies between in-home nurse review and admission information in 215 cases (88.4%). Clinical information on medication allergies was lacking from referrers in 85 cases (34.9%). No information was provided by the referrers about cognitive status in 38 (73%) cases classified as cognitively impaired and in only 2 of 35 cases with major depression identified with the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), was depression related information provided by referrers. CONCLUSIONS The primary finding of this study is that during a transfer of an older adult to the home care service sector, essential clinical information is often missing, and there are significant discrepancies between medication regimens. These findings support the need for both educational initiatives and technology to address the complex care needs of older adults across settings to reduce the risk for medication errors and poor outcomes.
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Affiliation(s)
- Ellen L Brown
- Stein Gerontological Institute, Miami Jewish Home and Hospital, Miami, Florida 33137, USA.
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Abstract
BACKGROUND Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure. OBJECTIVES We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model. METHODS Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months. RESULTS 3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity. CONCLUSIONS Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.
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Affiliation(s)
- Thomas E Oxman
- Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Abstract
A naturalistic study with no predetermined duration of treatment was undertaken in order to examine the effectiveness of cognitive therapy in the treatment of panic disorder. Seventeen patients diagnosed as having panic disorder according to the Structured Clinical Interview for DSM-III Personality Disorders received a mean of 18 individual cognitive therapy sessions. Patients with personality disorder or depression required a longer duration of treatment to become symptom-free. As measured by a self-report weekly panic log, the mean number of panic attacks was reduced significantly to zero at the end of treatment. There was a concomitant reduction in self-report measures of depression and anxiety. Further, there was a significant reduction on a measure of cognitive dysfunction during panic attacks. Treatment results were maintained at 12-month follow-up.
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Affiliation(s)
- L Sokol
- Center for Cognitive Therapy, University of Pennsylvania School of Medicine, Philadelphia 19104
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Torzilli PA, Greenberg RL, Hood RW, Pavlov H, Insall JN. Measurement of anterior-posterior motion of the knee in injured patients using a biomechanical stress technique. J Bone Joint Surg Am 1984; 66:1438-42. [PMID: 6548754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We performed biomechanical stress tests preoperatively on the knees of fifty-one patients with an injury to the knee. We measured the amount of anterior and posterior tibial translation at 90 degrees of knee flexion using a roentgenographic technique and a fifty-newton joint load. Knees with an isolated meniscal tear exhibited no abnormal motion. There was no difference in motion of the knee between patients with a rupture of the anterior cruciate ligament and patients with this injury who had had a prior medial meniscectomy. We found that prior knee surgery that was not associated with stability did not adversely affect the test procedure. A significant finding, however, was that only nineteen of twenty-five patients with a ruptured anterior cruciate ligament had greater excursion on the injured side compared with the uninjured knee. Because of this inconsistent result, a biomechanical stress test at 90 degrees of knee flexion measuring anterior and posterior translation under a fifty-newton joint load appears insufficient in itself to be of clinical use.
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Torzilli PA, Greenberg RL, Insall J. An in vivo biomechanical evaluation of anterior-posterior motion of the knee. Roentgenographic measurement technique, stress machine, and stable population. J Bone Joint Surg Am 1981; 63:960-8. [PMID: 7240337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Greenberg RL. New advances in the topical treatment of burns. Calif Med 1970; 113:69. [PMID: 18730435 PMCID: PMC1501782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Cronin TD, Greenberg RL. Our experiences with the silastic gel breast prosthesis. Plast Reconstr Surg 1970; 46:1-7. [PMID: 5430975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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