Journal of the American Heart Association, Jan 7, 2020
Background-Research links blood pressure variability (BPV) with stroke; however, the association ... more Background-Research links blood pressure variability (BPV) with stroke; however, the association with cerebral small-vessel disease (CSVD) remains unclear. As BPV and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding cerebrovascular morphological characteristics. Methods and Results-A systematic review was performed from inception until March 3, 2019. Eligibility criteria included population, adults without stroke (<4 weeks); exposure, BPV quantified by any metric over any duration; comparison, (1) low versus high or mean BPV and (2) people with versus without CSVD; and outcomes, (1) CSVD as subcortical infarct, lacunae, white matter hyperintensities, cerebral microbleeds, or enlarged perivascular spaces; and (2) standardized mean difference in BPV. A total of 27 articles were meta-analyzed, comprising 12 309 unique brain scans. A total of 31 odds ratios (ORs) were pooled, indicating that higher systolic BPV was associated with higher odds for CSVD (OR, 1.27; 95% CI, 1.14-1.42; I 2 =85%) independent of mean systolic pressure. Likewise, higher diastolic BPV was associated with higher odds for CSVD (OR, 1.30; 95% CI, 1.14-1.48; I 2 =53%) independent of mean diastolic pressure. There was no evidence of a pairwise interaction between systolic/diastolic and BPV/mean ORs (P=0.47), nor a difference between BPV versus mean pressure ORs (P=0.58). Fifty-four standardized mean differences were pooled and provided similar results for pairwise interaction (P=0.38) and difference between standardized mean differences (P=0.70). Conclusions-On the basis of the available studies, BPV was associated with CSVD independent of mean blood pressure. However, more high-quality longitudinal data are required to elucidate whether BPV contributes unique variance to CSVD morphological characteristics.
ObjectiveThere remains a lack of consensus around nosology for compulsive exercise (CE). Although... more ObjectiveThere remains a lack of consensus around nosology for compulsive exercise (CE). Although widely observed in eating disorders (ED), CE shares theoretical overlap with obsessive‐compulsive disorder (OCD), where exercise compulsions occur in response to obsessions. Yet, there is limited and mixed evidence of a relationship between CE with OCD. This study aims to explore the appropriate diagnostic classification of CE through examination of CE in relation to OCD, obsessional thinking, and ED symptoms.MethodTwo hundred and eighty one adults with mental health symptoms, dieting, and exercise behaviour completed measures of OCD, CE, and disordered eating symptoms. Regression and Receiver Operating Characteristic analyses examined relationships between dimensions of CE with OCD and ED symptoms, and the predictive ability of CE assessment for detecting threshold OCD and ED symptoms.ResultsCE assessment was poor at predicting threshold OCD symptoms, probable Anorexia Nervosa, and Binge Eating Disorder and moderate at detecting probable disordered eating and Bulimia Nervosa. Associations between CE and OCD symptoms were not significant after adjustment for ED symptoms. Obsessional thinking was associated only with lack of exercise enjoyment.ConclusionsResults indicate that excessive exercise might represent a distinct disorder, with some shared traits across CE, OCD and ED symptoms. Findings question the utility of adaptation of OCD diagnostic criteria for CE. Assessment and treatment implications are considered.
Purpose Orthorexia Nervosa (ON) is characterised as obsessional healthy eating that results in ma... more Purpose Orthorexia Nervosa (ON) is characterised as obsessional healthy eating that results in malnutrition and/or psychosocial impairment. Yet, its diagnostic classi cation remains uncertain, with theoretical overlap with Anorexia Nervosa (AN) and Obsessive-Compulsive Disorder (OCD). This study aimed to further understand appropriate diagnostic classi cation by assessing the ability of ON for detecting the presence/absence of AN and OCD. Method An observational survey was completed by 362 participants recruited through eating-disorder, dieting and mental health support groups. Receiver Operating Characteristics (ROC) curve analyses determined the predictive ability of ON symptoms (assessed by ORTO-15 and ORTO-9) for detecting AN (determined by EAT-26 cut-scores and BMI >17.5), and OCD and Obsessional thinking (assessed by the OCI-R). Results Results showed both ON measures are able to adequately predict AN, however ON was poor to moderate at detecting OCD and Obsessional thinking. Speci city for detecting AN was poor and ability to discriminate between AN and ON was low. Conclusion These results suggest that ON, as it is currently measured, may be more closely related to EDs than OCD, and that ON may represent a subtype or subset of AN; although results are limited by the lack of de nitive ON diagnostic criteria and limitations of ON measures. Level of evidence-Level V, cross-sectional descriptive study What Is Already Known On This Subject? It is clear that ON has theoretical overlap with both AN and OCD. While theorised as related to eating behaviour and often considered within the diagnostic classi cation of EDs, ON also has core features, such as obsessional thinking, which suggest that ON might also t within the obsessive-compulsive spectrum of disorders. While evidence suggests ON might better be classi ed as an ED, ndings remain mixed and it is also unclear if ON might represent a distinct disorder, or subtype of AN. What This Study Adds? This study adds to the uncertain ndings regarding the diagnostic classi cation of ON. Our results suggest that ON is better at detecting AN than OCD and obsessional thinking, suggesting the ON has Page 3/19 more diagnostic overlap with AN and might better be classi ed as an eating disorder than an obsessivecompulsive disorder. The limited ability of ON to discriminate from AN suggest that ON might represent a subtype of AN and may also exist on the spectrum from healthy eating to AN. This study suggests that ED treatments might be more suitable for those presenting with ON.
The aim of the Cardiovascular Health in Anxiety and Mood Problems Study (CHAMPS) is to pilot the ... more The aim of the Cardiovascular Health in Anxiety and Mood Problems Study (CHAMPS) is to pilot the Unified Protocol (UP) for the transdiagnostic treatment of depression and anxiety disorders in patients recently hospitalized for cardiovascular diseases (CVDs) and evaluate the feasibility. Methods: The present study is a controlled, block randomized pragmatic pilot-feasibility trial incorporating qualitative interview data, comparing UP (n = 9) with enhanced usual care (EUC, n = 10). Eligible trial participants had a recent CVD-cause admission and were above the severity threshold for depression or anxiety denoted by Patient Health Questionnaire (PHQ-9) total scores ≥10 and/or Generalized Anxiety Disorder (GAD-7) total scores ≥7 respectively on two occasions, and met criteria for one or more depression or anxiety disorders determined by structured clinical interview. Study outcomes were analyzed as intention-to-treat using linear mixed models and qualitative interview data were analyzed with content analysis. Results: Quantitative and qualitative measured indicated acceptability of the transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders. Satisfaction with UP was comparable to antidepressant therapy and higher than general physician counseling. However, there were difficulties recruiting participants with current disorders and distress on two occasions. The UP was associated with a reduction in total number of disorders determined by blinded raters. Linear mixed models indicated that a significantly greater reduction in anxiety symptoms was evident in the UP group Discussion: In conclusion, this feasibility trial indicates acceptability of transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders that is tempered by difficulties with recruitment. Larger trials are required to clarify the efficacy of transdiagnostic depression and anxiety disorder CBT in populations with CVDs and depressive or anxiety disorders.
Background: Previous psychological and pharmacological interventions have primarily focused on de... more Background: Previous psychological and pharmacological interventions have primarily focused on depression disorders in populations with cardiovascular diseases (CVDs) and the efficacy of anxiety disorder interventions is only more recently being explored. Transdiagnostic interventions address common emotional processes and the full range of anxiety and depression disorders often observed in populations with CVDs. The aim of CHAMPS is to evaluate the feasibility of a unified protocol (UP) for the transdiagnostic treatment of emotional disorders intervention in patients recently hospitalized for CVDs. The current study reports the protocol of a feasibility randomized controlled trial to inform a future trial. Methods/Design: This is a feasibility randomized, controlled trial with a single-center design. A total of 50 participants will be block-randomized to either a UP intervention or enhanced usual care. Both groups will receive standard CVD care. The UP intervention consists of 1) enhancing motivation, readiness for change, and treatment engagement; (2) psychoeducation about emotions; (3) increasing present focused emotion awareness; (4) increasing cognitive flexibility; (5) identifying and preventing patterns of emotion avoidance and maladaptive emotion-driven behaviors (EDBs, including tobacco smoking, and alcohol use); (6) increasing tolerance of emotion-related physical sensations; (7) interoceptive and situation-based emotion-focused exposure; and (8) relapse prevention strategies. Treatment duration is 12 to 18 weeks. Relevant outcomes include the standard deviation of self-rated anxiety, depression and quality of life symptoms. Other outcomes include intervention acceptability, satisfaction with care, rates of EDBs, patient adherence, physical activity, cardiac and psychiatric readmissions. Parallel to the main trial, a nonrandomized comparator cohort will be recruited comprising 150 persons scoring below the predetermined depression and anxiety severity thresholds. Discussion: CHAMPS is designed to evaluate the UP for the transdiagnostic treatment of emotional disorders targeting emotional disorder processes in a CVD population. The design will provide preliminary evidence of feasibility, attrition, and satisfaction with treatment to design a definitive trial. If the trial is feasible, it opens up the possibility for interventions to target broader emotional processes in the precarious population with CVD and emotional distress. Trial registration: ACTRN12615000555550, registered on 29/05/2015
Unrecognized anxiety is a difficult clinical presentation in cardiology. Anxiety leads to recurri... more Unrecognized anxiety is a difficult clinical presentation in cardiology. Anxiety leads to recurring emergency department visits and the need for numerous diagnostic evaluations to rule out cardiovascular disease (CVD). This review focuses broadly on anxiety and its subtypes in relation to the onset and progression of CVD while describing helpful guidelines to better identify and treat anxiety. Potential mechanisms of cardiopathogenesis are also described. An emerging literature demonstrates that anxiety disorders increase the risk for incident CVD but a causal relationship has not been demonstrated. Anxiety portends adverse prognosis in persons with established CVD that is independent from depression. The level of clinical priority received by depression should be extended to research and clinical intervention efforts in anxiety. Anxiety holds direct relevance for uncovering mechanisms of cardiopathogenesis, developing novel therapeutic strategies, and initiating clinical interventions in the population at risk of developing heart disease, or those already diagnosed with CVD.
To describe the relationship between the personality changes and pathological cerebro-spinal flui... more To describe the relationship between the personality changes and pathological cerebro-spinal fluid (CSF) biomarkers. Method One hundred and ten subjects, of whom 57 patients with mild cognitive impairment (MCI), 9 subjects with mild dementia, and 44 healthy controls had an extensive medical and neuropsychological examination as well as lumbar puncture to evaluate concentrations of CSF biomarkers of AD pathology [amyloid- 1-42 (A 1-42), phosphorylated tau (ptau-181), and total-tau (tau)]. The proxies of the participants completed the Revised NEO Personality Inventory (NEO-PI-R) to assess subjects' personality at the time being and 5 years retrospectively. Results In a hierarchical multivariate regression analysis, including age, gender, education, Mini Mental State Examination (MMSE), and APOEe4 status, lower A 1-42 concentrations in CSF were associated with increasing neuroticism, and decreasing extraversion and conscientiousness. Decreasing extraversion, openness to experience and conscientiousness were associated with higher tau/A 1-42 ratio, and higher ptau-181/A 1-42 ratio was related to decreasing extraversion. Personality changes in the domain of agreeableness did not yield any significant effect as a predictor on any of CSF biomarkers. Conclusions Our findings suggest that early and specific changes in personality traits are associated with cerebral AD pathology, in particular with amyloid pathology, and may serve as clinical signs to consider when evaluating MCI and mild dementia. Disclosure of interest The authors have not supplied their declaration of competing interest.
Current psychiatry research and review, Jan 15, 2020
Post-traumatic stress disorder in heart failure patients: a test of the cardiac disease-induced P... more Post-traumatic stress disorder in heart failure patients: a test of the cardiac disease-induced PTSD hypothesis
Objective: Diuretic drugs have been a mainstay of hypertension treatment in the elderly however t... more Objective: Diuretic drugs have been a mainstay of hypertension treatment in the elderly however their dementia sparing effects are under-reported. The objective was to quantify dementia risk in relation to diuretic antihypertensive drugs. Methods: Electronic databases were searched until June 2015. Eligibility criteria: population, adults without dementia from primary care, community cohort, residential/institutionalized, or randomized controlled trial; exposure, diuretic antihypertensive drug; comparison, no diuretic drug, other or no antihypertensive drug, placebocontrol; outcome, incident dementia diagnosed by standardized criteria. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were pooled in fixed-effects models with RevMan 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark) and the findings rated according to The Grading of Recommendations Assessment, Development and Evaluation criteria. Results: A total of 15 articles were included (52 599 persons, 3444 dementia cases, median age 76.1 years) and median follow-up was 6.1 years. Diuretics were associated with reduced dementia risk (HR 0.83; 95% CI 0.76-0.91, P < 0.0001, I 2 ¼ 0) and Alzheimer's disease risk (HR 0.82; 95% CI 0.71-0.94, P ¼ 0.004, I 2 ¼ 0). Stratified analysis indicated a difference between potassium sparing, thiazide and loop diuretics (P ¼ 0.01). Risk estimates were generally consistent comparing monotherapy vs. combination therapy, study design and follow-up. Meta-regression showed that demographics, stroke, heart failure, diabetes, liver disease, attrition, mortality rate, cognitive function, and apolipoprotein E allele did not moderate the results. Conclusion: Diuretic antihypertensive drugs were associated with a consistent reduction in dementia risk without heterogeneity, pointing to generalizability of these findings.
Objectives: To systematically review the efficacy of collaborative care (CC) for depression in ad... more Objectives: To systematically review the efficacy of collaborative care (CC) for depression in adults with coronary heart disease (CHD) and depression. Design: Systematic review and meta-analysis. Data sources: Electronic databases (Cochrane Central Register of Controlled Trials MEDLINE, EMBASE, PsycINFO and CINAHL) were searched until April 2014. Inclusion criteria: Population, depression comorbid with CHD; intervention, randomised controlled trial (RCT) of CC; comparison, either usual care, wait-list control group or no further treatment; and outcome, (primary) major adverse cardiac events (MACE), (secondary) standardised measure of depression, anxiety, quality of life (QOL) and cost-effectiveness. Data extraction and analysis: RevMan V.5.3 was used to synthesise the data as risk ratios (RRs), ORs and standardised mean differences (SMD) with 95% CIs in random effect models. Results: Six RCTs met the inclusion criteria and comprised 655 participants randomised to CC and 629 participants randomised to the control group (total 1284). Collaborative depression care led to a significant reduction in MACE in the short term (three trials, RR 0.54; 95% CI 0.31 to 0.95, p=0.03) that was not sustained in the longer term. Small reductions in depressive symptoms were evident in the short term (6 trials, pooled SMD −0.31; 95% CI −0.43 to −0.19, p<0.00001) and depression remission was more likely to be achieved with CC (5 trials, OR 1.77; 95% CI 1.28 to 2.44, p=0.0005). Likewise, a significant effect was observed for anxiety symptoms (SMD −0.36) and mental QOL (SMD 0.24). The timing of the intervention was a source of between-group heterogeneity for depression symptoms (between groups p=0.04, I 2 =76.5%). Conclusions: Collaborative depression care did not lead to a sustained reduction in the primary MACE end point. Small effects were observed for depression, depression remission, anxiety and mental QOL.
Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulti... more Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulting in an increased risk of recurring major adverse cardiac events (MACE) and mortality. Despite the higher risk, patients with comorbid depression or anxiety disorders are twice as likely to be non-adherent to secondary prevention. Therefore, better understanding of the adherence experiences of this subgroup is needed to inform service delivery and enhance adherence for this higher risk group. This study aims to explore the perceptions, understandings, and experiences of adherence to secondary prevention amongst 33 cardiac patients with diagnosed depression and/or anxiety disorder. Participants were recruited as part of the Cardiovascular Health in Anxiety or Mood Problems Study. Semi-structured interviews were conducted and data were analysed via inductive thematic analysis. Patient understandings of adherence to secondary prevention were limited, with medication compliance considered the marker of adherence. Further, participants did not perceive unintentional non-adherence to constitute non-adherence, rather an intent to engage was viewed as defining adherence. Participants also reported that a lack of practitioner understanding and management around their mental health negatively impacted the practitioner-patient relationship and their engagement with secondary prevention. Results highlight that unique barriers, especially around management of comorbid mental health exist for this subgroup. Additionally, adherence to secondary prevention might be limited by patients' narrow understandings of adherence as the intent to engage and as medication compliance.
Hearing loss (HL) is highly common in older adulthood, constituting the third most prevalent chro... more Hearing loss (HL) is highly common in older adulthood, constituting the third most prevalent chronic health condition in this population. In addition to posing a substantial burden to disease and negatively impacting quality of life, an emerging literature highlights that HL is associated with unipolar depression including among older adults. This review outlines evidence examining the HL and depression relationship as well as clinical implications for assessment and treatment of comorbid depression and HL. Although prevalence estimates of comorbid depression in HL vary, as many as 1 in 5 experience clinically relevant depression symptoms. Both cross-sectional and longitudinal studies indicate that HL is related to increased unipolar depression symptoms, although the strength of the association varies between studies. A range of methodological variations, such as inclusion age, severity of HL and assessment of depression, likely underpin this heterogeneity. Overall, however, the evidence clearly points to an association of HL with clinically relevant depression symptoms. The association with the diagnosis of major depression disorder remains less clear and underresearched. HL is also associated with a range of other poor mental health outcomes in older adults, including anxiety and suicidal ideation, and predicts poorer cognitive functioning. Accordingly, assessment and treatment of comorbid depression in HL is pertinent to promote mental well-being among older adults. Currently, evidence regarding best practice for treating depression in HL remains scant. Preliminary evidence indicates that audiological rehabilitation, including use of hearing aids, as well as community-based hearing interventions can also improve mental health. Psychological intervention that enhances communication skills and addresses coping strategies might also be beneficial for this population. Additionally, evidence suggests that online interventions are feasible and may circumvent communication difficulties in therapy associated with HL. Due to poor help-seeking among this population, an enhanced focus on specific and targeted assessment and treatment is likely necessary to ensure reduced mental health burden among older adults with HL.
Hoarding disorder (HD) is characterized by an accumulation of possessions due to excessive acquis... more Hoarding disorder (HD) is characterized by an accumulation of possessions due to excessive acquisition of, or difficulty discarding possessions. Evidence demonstrates an increased cardiovascular response in patients with HD. Cognitive-behavioral therapy modifications are described for HD patients with heart failure to compensate for fatigability, syncope and falls risk. Key Clinical Message: To ensure heart failure patients are involved in sorting/discarding tasks during cognitive-behavioral therapy for hoarding disorder, modifications are necessary to compensate for high fatigability and reduce the risk for serious adverse events.
Background: Cardiovascular diseases (CVD) are commonly comorbid with mental health disorders, por... more Background: Cardiovascular diseases (CVD) are commonly comorbid with mental health disorders, portending poorer cardiac prognosis. Despite the high prevalence of depression and anxiety, and guidelines recommending routine depression screening and referral, uptake of mental healthcare in CVD populations remains low. Reasons for the underutilisation of mental health and psychological services for this population remain largely unknown. Methods: Thirteen CVD patients with clinically significant psychological symptoms (depression, anxiety and/or stress) participated in one-on-one in-depth semi-structured interviews. Data were analysed using inductive thematic analysis. Results: Barriers to uptake included the timing of referral and screening, with patients reporting a need for longer term follow-up. A lack of information provision and understanding around mental health and services, especially following cardiac-events were further barriers. A reluctance to report mental health or engage in services was also identified, with patients indicating a preference for informal peer support networks. A range of practical barriers such as mobility, transport and cost were also reported. Conclusions: Longer term follow-up and routine mental health assessment may be beneficial to facilitate use of mental health services. Upskilling of practitioners around mental health may be a further avenue to promote information provision and enhance service use. Further focus on enhancing informal peer support may be a valuable initial approach for the CVD population. The implications for improving services and enhancing service use are discussed.
Participation in elite-sport and education is stressful and can result in sacrificed educational ... more Participation in elite-sport and education is stressful and can result in sacrificed educational attainment. A dearth of research, however, has explored the specific stressors encountered by student athletes and coping strategies used, resulting in limited knowledge of how to best support student athletes. Interviews with 20 Australian university student athletes were conducted and data were analyzed via thematic analysis. Interviewees reported encountering numerous stressors, especially relating to schedule clashes, fatigue, financial pressure, and inflexibility of coaches. Athletes identified few coping strategies but reported that support from parents and coaches was paramount. Athletes would benefit from upskilling in several areas such as effective use of time, self-care, time management, enhanced self-efficacy, and specific strategies for coping with stress. Coaches have the opportunity to play a pivotal role in facilitating successful integration of sport and education.
Journal of the American Heart Association, Jan 7, 2020
Background-Research links blood pressure variability (BPV) with stroke; however, the association ... more Background-Research links blood pressure variability (BPV) with stroke; however, the association with cerebral small-vessel disease (CSVD) remains unclear. As BPV and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding cerebrovascular morphological characteristics. Methods and Results-A systematic review was performed from inception until March 3, 2019. Eligibility criteria included population, adults without stroke (<4 weeks); exposure, BPV quantified by any metric over any duration; comparison, (1) low versus high or mean BPV and (2) people with versus without CSVD; and outcomes, (1) CSVD as subcortical infarct, lacunae, white matter hyperintensities, cerebral microbleeds, or enlarged perivascular spaces; and (2) standardized mean difference in BPV. A total of 27 articles were meta-analyzed, comprising 12 309 unique brain scans. A total of 31 odds ratios (ORs) were pooled, indicating that higher systolic BPV was associated with higher odds for CSVD (OR, 1.27; 95% CI, 1.14-1.42; I 2 =85%) independent of mean systolic pressure. Likewise, higher diastolic BPV was associated with higher odds for CSVD (OR, 1.30; 95% CI, 1.14-1.48; I 2 =53%) independent of mean diastolic pressure. There was no evidence of a pairwise interaction between systolic/diastolic and BPV/mean ORs (P=0.47), nor a difference between BPV versus mean pressure ORs (P=0.58). Fifty-four standardized mean differences were pooled and provided similar results for pairwise interaction (P=0.38) and difference between standardized mean differences (P=0.70). Conclusions-On the basis of the available studies, BPV was associated with CSVD independent of mean blood pressure. However, more high-quality longitudinal data are required to elucidate whether BPV contributes unique variance to CSVD morphological characteristics.
ObjectiveThere remains a lack of consensus around nosology for compulsive exercise (CE). Although... more ObjectiveThere remains a lack of consensus around nosology for compulsive exercise (CE). Although widely observed in eating disorders (ED), CE shares theoretical overlap with obsessive‐compulsive disorder (OCD), where exercise compulsions occur in response to obsessions. Yet, there is limited and mixed evidence of a relationship between CE with OCD. This study aims to explore the appropriate diagnostic classification of CE through examination of CE in relation to OCD, obsessional thinking, and ED symptoms.MethodTwo hundred and eighty one adults with mental health symptoms, dieting, and exercise behaviour completed measures of OCD, CE, and disordered eating symptoms. Regression and Receiver Operating Characteristic analyses examined relationships between dimensions of CE with OCD and ED symptoms, and the predictive ability of CE assessment for detecting threshold OCD and ED symptoms.ResultsCE assessment was poor at predicting threshold OCD symptoms, probable Anorexia Nervosa, and Binge Eating Disorder and moderate at detecting probable disordered eating and Bulimia Nervosa. Associations between CE and OCD symptoms were not significant after adjustment for ED symptoms. Obsessional thinking was associated only with lack of exercise enjoyment.ConclusionsResults indicate that excessive exercise might represent a distinct disorder, with some shared traits across CE, OCD and ED symptoms. Findings question the utility of adaptation of OCD diagnostic criteria for CE. Assessment and treatment implications are considered.
Purpose Orthorexia Nervosa (ON) is characterised as obsessional healthy eating that results in ma... more Purpose Orthorexia Nervosa (ON) is characterised as obsessional healthy eating that results in malnutrition and/or psychosocial impairment. Yet, its diagnostic classi cation remains uncertain, with theoretical overlap with Anorexia Nervosa (AN) and Obsessive-Compulsive Disorder (OCD). This study aimed to further understand appropriate diagnostic classi cation by assessing the ability of ON for detecting the presence/absence of AN and OCD. Method An observational survey was completed by 362 participants recruited through eating-disorder, dieting and mental health support groups. Receiver Operating Characteristics (ROC) curve analyses determined the predictive ability of ON symptoms (assessed by ORTO-15 and ORTO-9) for detecting AN (determined by EAT-26 cut-scores and BMI >17.5), and OCD and Obsessional thinking (assessed by the OCI-R). Results Results showed both ON measures are able to adequately predict AN, however ON was poor to moderate at detecting OCD and Obsessional thinking. Speci city for detecting AN was poor and ability to discriminate between AN and ON was low. Conclusion These results suggest that ON, as it is currently measured, may be more closely related to EDs than OCD, and that ON may represent a subtype or subset of AN; although results are limited by the lack of de nitive ON diagnostic criteria and limitations of ON measures. Level of evidence-Level V, cross-sectional descriptive study What Is Already Known On This Subject? It is clear that ON has theoretical overlap with both AN and OCD. While theorised as related to eating behaviour and often considered within the diagnostic classi cation of EDs, ON also has core features, such as obsessional thinking, which suggest that ON might also t within the obsessive-compulsive spectrum of disorders. While evidence suggests ON might better be classi ed as an ED, ndings remain mixed and it is also unclear if ON might represent a distinct disorder, or subtype of AN. What This Study Adds? This study adds to the uncertain ndings regarding the diagnostic classi cation of ON. Our results suggest that ON is better at detecting AN than OCD and obsessional thinking, suggesting the ON has Page 3/19 more diagnostic overlap with AN and might better be classi ed as an eating disorder than an obsessivecompulsive disorder. The limited ability of ON to discriminate from AN suggest that ON might represent a subtype of AN and may also exist on the spectrum from healthy eating to AN. This study suggests that ED treatments might be more suitable for those presenting with ON.
The aim of the Cardiovascular Health in Anxiety and Mood Problems Study (CHAMPS) is to pilot the ... more The aim of the Cardiovascular Health in Anxiety and Mood Problems Study (CHAMPS) is to pilot the Unified Protocol (UP) for the transdiagnostic treatment of depression and anxiety disorders in patients recently hospitalized for cardiovascular diseases (CVDs) and evaluate the feasibility. Methods: The present study is a controlled, block randomized pragmatic pilot-feasibility trial incorporating qualitative interview data, comparing UP (n = 9) with enhanced usual care (EUC, n = 10). Eligible trial participants had a recent CVD-cause admission and were above the severity threshold for depression or anxiety denoted by Patient Health Questionnaire (PHQ-9) total scores ≥10 and/or Generalized Anxiety Disorder (GAD-7) total scores ≥7 respectively on two occasions, and met criteria for one or more depression or anxiety disorders determined by structured clinical interview. Study outcomes were analyzed as intention-to-treat using linear mixed models and qualitative interview data were analyzed with content analysis. Results: Quantitative and qualitative measured indicated acceptability of the transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders. Satisfaction with UP was comparable to antidepressant therapy and higher than general physician counseling. However, there were difficulties recruiting participants with current disorders and distress on two occasions. The UP was associated with a reduction in total number of disorders determined by blinded raters. Linear mixed models indicated that a significantly greater reduction in anxiety symptoms was evident in the UP group Discussion: In conclusion, this feasibility trial indicates acceptability of transdiagnostic CBT intervention for CVD patients with depression or anxiety disorders that is tempered by difficulties with recruitment. Larger trials are required to clarify the efficacy of transdiagnostic depression and anxiety disorder CBT in populations with CVDs and depressive or anxiety disorders.
Background: Previous psychological and pharmacological interventions have primarily focused on de... more Background: Previous psychological and pharmacological interventions have primarily focused on depression disorders in populations with cardiovascular diseases (CVDs) and the efficacy of anxiety disorder interventions is only more recently being explored. Transdiagnostic interventions address common emotional processes and the full range of anxiety and depression disorders often observed in populations with CVDs. The aim of CHAMPS is to evaluate the feasibility of a unified protocol (UP) for the transdiagnostic treatment of emotional disorders intervention in patients recently hospitalized for CVDs. The current study reports the protocol of a feasibility randomized controlled trial to inform a future trial. Methods/Design: This is a feasibility randomized, controlled trial with a single-center design. A total of 50 participants will be block-randomized to either a UP intervention or enhanced usual care. Both groups will receive standard CVD care. The UP intervention consists of 1) enhancing motivation, readiness for change, and treatment engagement; (2) psychoeducation about emotions; (3) increasing present focused emotion awareness; (4) increasing cognitive flexibility; (5) identifying and preventing patterns of emotion avoidance and maladaptive emotion-driven behaviors (EDBs, including tobacco smoking, and alcohol use); (6) increasing tolerance of emotion-related physical sensations; (7) interoceptive and situation-based emotion-focused exposure; and (8) relapse prevention strategies. Treatment duration is 12 to 18 weeks. Relevant outcomes include the standard deviation of self-rated anxiety, depression and quality of life symptoms. Other outcomes include intervention acceptability, satisfaction with care, rates of EDBs, patient adherence, physical activity, cardiac and psychiatric readmissions. Parallel to the main trial, a nonrandomized comparator cohort will be recruited comprising 150 persons scoring below the predetermined depression and anxiety severity thresholds. Discussion: CHAMPS is designed to evaluate the UP for the transdiagnostic treatment of emotional disorders targeting emotional disorder processes in a CVD population. The design will provide preliminary evidence of feasibility, attrition, and satisfaction with treatment to design a definitive trial. If the trial is feasible, it opens up the possibility for interventions to target broader emotional processes in the precarious population with CVD and emotional distress. Trial registration: ACTRN12615000555550, registered on 29/05/2015
Unrecognized anxiety is a difficult clinical presentation in cardiology. Anxiety leads to recurri... more Unrecognized anxiety is a difficult clinical presentation in cardiology. Anxiety leads to recurring emergency department visits and the need for numerous diagnostic evaluations to rule out cardiovascular disease (CVD). This review focuses broadly on anxiety and its subtypes in relation to the onset and progression of CVD while describing helpful guidelines to better identify and treat anxiety. Potential mechanisms of cardiopathogenesis are also described. An emerging literature demonstrates that anxiety disorders increase the risk for incident CVD but a causal relationship has not been demonstrated. Anxiety portends adverse prognosis in persons with established CVD that is independent from depression. The level of clinical priority received by depression should be extended to research and clinical intervention efforts in anxiety. Anxiety holds direct relevance for uncovering mechanisms of cardiopathogenesis, developing novel therapeutic strategies, and initiating clinical interventions in the population at risk of developing heart disease, or those already diagnosed with CVD.
To describe the relationship between the personality changes and pathological cerebro-spinal flui... more To describe the relationship between the personality changes and pathological cerebro-spinal fluid (CSF) biomarkers. Method One hundred and ten subjects, of whom 57 patients with mild cognitive impairment (MCI), 9 subjects with mild dementia, and 44 healthy controls had an extensive medical and neuropsychological examination as well as lumbar puncture to evaluate concentrations of CSF biomarkers of AD pathology [amyloid- 1-42 (A 1-42), phosphorylated tau (ptau-181), and total-tau (tau)]. The proxies of the participants completed the Revised NEO Personality Inventory (NEO-PI-R) to assess subjects' personality at the time being and 5 years retrospectively. Results In a hierarchical multivariate regression analysis, including age, gender, education, Mini Mental State Examination (MMSE), and APOEe4 status, lower A 1-42 concentrations in CSF were associated with increasing neuroticism, and decreasing extraversion and conscientiousness. Decreasing extraversion, openness to experience and conscientiousness were associated with higher tau/A 1-42 ratio, and higher ptau-181/A 1-42 ratio was related to decreasing extraversion. Personality changes in the domain of agreeableness did not yield any significant effect as a predictor on any of CSF biomarkers. Conclusions Our findings suggest that early and specific changes in personality traits are associated with cerebral AD pathology, in particular with amyloid pathology, and may serve as clinical signs to consider when evaluating MCI and mild dementia. Disclosure of interest The authors have not supplied their declaration of competing interest.
Current psychiatry research and review, Jan 15, 2020
Post-traumatic stress disorder in heart failure patients: a test of the cardiac disease-induced P... more Post-traumatic stress disorder in heart failure patients: a test of the cardiac disease-induced PTSD hypothesis
Objective: Diuretic drugs have been a mainstay of hypertension treatment in the elderly however t... more Objective: Diuretic drugs have been a mainstay of hypertension treatment in the elderly however their dementia sparing effects are under-reported. The objective was to quantify dementia risk in relation to diuretic antihypertensive drugs. Methods: Electronic databases were searched until June 2015. Eligibility criteria: population, adults without dementia from primary care, community cohort, residential/institutionalized, or randomized controlled trial; exposure, diuretic antihypertensive drug; comparison, no diuretic drug, other or no antihypertensive drug, placebocontrol; outcome, incident dementia diagnosed by standardized criteria. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were pooled in fixed-effects models with RevMan 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark) and the findings rated according to The Grading of Recommendations Assessment, Development and Evaluation criteria. Results: A total of 15 articles were included (52 599 persons, 3444 dementia cases, median age 76.1 years) and median follow-up was 6.1 years. Diuretics were associated with reduced dementia risk (HR 0.83; 95% CI 0.76-0.91, P < 0.0001, I 2 ¼ 0) and Alzheimer's disease risk (HR 0.82; 95% CI 0.71-0.94, P ¼ 0.004, I 2 ¼ 0). Stratified analysis indicated a difference between potassium sparing, thiazide and loop diuretics (P ¼ 0.01). Risk estimates were generally consistent comparing monotherapy vs. combination therapy, study design and follow-up. Meta-regression showed that demographics, stroke, heart failure, diabetes, liver disease, attrition, mortality rate, cognitive function, and apolipoprotein E allele did not moderate the results. Conclusion: Diuretic antihypertensive drugs were associated with a consistent reduction in dementia risk without heterogeneity, pointing to generalizability of these findings.
Objectives: To systematically review the efficacy of collaborative care (CC) for depression in ad... more Objectives: To systematically review the efficacy of collaborative care (CC) for depression in adults with coronary heart disease (CHD) and depression. Design: Systematic review and meta-analysis. Data sources: Electronic databases (Cochrane Central Register of Controlled Trials MEDLINE, EMBASE, PsycINFO and CINAHL) were searched until April 2014. Inclusion criteria: Population, depression comorbid with CHD; intervention, randomised controlled trial (RCT) of CC; comparison, either usual care, wait-list control group or no further treatment; and outcome, (primary) major adverse cardiac events (MACE), (secondary) standardised measure of depression, anxiety, quality of life (QOL) and cost-effectiveness. Data extraction and analysis: RevMan V.5.3 was used to synthesise the data as risk ratios (RRs), ORs and standardised mean differences (SMD) with 95% CIs in random effect models. Results: Six RCTs met the inclusion criteria and comprised 655 participants randomised to CC and 629 participants randomised to the control group (total 1284). Collaborative depression care led to a significant reduction in MACE in the short term (three trials, RR 0.54; 95% CI 0.31 to 0.95, p=0.03) that was not sustained in the longer term. Small reductions in depressive symptoms were evident in the short term (6 trials, pooled SMD −0.31; 95% CI −0.43 to −0.19, p<0.00001) and depression remission was more likely to be achieved with CC (5 trials, OR 1.77; 95% CI 1.28 to 2.44, p=0.0005). Likewise, a significant effect was observed for anxiety symptoms (SMD −0.36) and mental QOL (SMD 0.24). The timing of the intervention was a source of between-group heterogeneity for depression symptoms (between groups p=0.04, I 2 =76.5%). Conclusions: Collaborative depression care did not lead to a sustained reduction in the primary MACE end point. Small effects were observed for depression, depression remission, anxiety and mental QOL.
Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulti... more Over 20% of cardiovascular disease (CVD) patients have a comorbid mental health disorder, resulting in an increased risk of recurring major adverse cardiac events (MACE) and mortality. Despite the higher risk, patients with comorbid depression or anxiety disorders are twice as likely to be non-adherent to secondary prevention. Therefore, better understanding of the adherence experiences of this subgroup is needed to inform service delivery and enhance adherence for this higher risk group. This study aims to explore the perceptions, understandings, and experiences of adherence to secondary prevention amongst 33 cardiac patients with diagnosed depression and/or anxiety disorder. Participants were recruited as part of the Cardiovascular Health in Anxiety or Mood Problems Study. Semi-structured interviews were conducted and data were analysed via inductive thematic analysis. Patient understandings of adherence to secondary prevention were limited, with medication compliance considered the marker of adherence. Further, participants did not perceive unintentional non-adherence to constitute non-adherence, rather an intent to engage was viewed as defining adherence. Participants also reported that a lack of practitioner understanding and management around their mental health negatively impacted the practitioner-patient relationship and their engagement with secondary prevention. Results highlight that unique barriers, especially around management of comorbid mental health exist for this subgroup. Additionally, adherence to secondary prevention might be limited by patients' narrow understandings of adherence as the intent to engage and as medication compliance.
Hearing loss (HL) is highly common in older adulthood, constituting the third most prevalent chro... more Hearing loss (HL) is highly common in older adulthood, constituting the third most prevalent chronic health condition in this population. In addition to posing a substantial burden to disease and negatively impacting quality of life, an emerging literature highlights that HL is associated with unipolar depression including among older adults. This review outlines evidence examining the HL and depression relationship as well as clinical implications for assessment and treatment of comorbid depression and HL. Although prevalence estimates of comorbid depression in HL vary, as many as 1 in 5 experience clinically relevant depression symptoms. Both cross-sectional and longitudinal studies indicate that HL is related to increased unipolar depression symptoms, although the strength of the association varies between studies. A range of methodological variations, such as inclusion age, severity of HL and assessment of depression, likely underpin this heterogeneity. Overall, however, the evidence clearly points to an association of HL with clinically relevant depression symptoms. The association with the diagnosis of major depression disorder remains less clear and underresearched. HL is also associated with a range of other poor mental health outcomes in older adults, including anxiety and suicidal ideation, and predicts poorer cognitive functioning. Accordingly, assessment and treatment of comorbid depression in HL is pertinent to promote mental well-being among older adults. Currently, evidence regarding best practice for treating depression in HL remains scant. Preliminary evidence indicates that audiological rehabilitation, including use of hearing aids, as well as community-based hearing interventions can also improve mental health. Psychological intervention that enhances communication skills and addresses coping strategies might also be beneficial for this population. Additionally, evidence suggests that online interventions are feasible and may circumvent communication difficulties in therapy associated with HL. Due to poor help-seeking among this population, an enhanced focus on specific and targeted assessment and treatment is likely necessary to ensure reduced mental health burden among older adults with HL.
Hoarding disorder (HD) is characterized by an accumulation of possessions due to excessive acquis... more Hoarding disorder (HD) is characterized by an accumulation of possessions due to excessive acquisition of, or difficulty discarding possessions. Evidence demonstrates an increased cardiovascular response in patients with HD. Cognitive-behavioral therapy modifications are described for HD patients with heart failure to compensate for fatigability, syncope and falls risk. Key Clinical Message: To ensure heart failure patients are involved in sorting/discarding tasks during cognitive-behavioral therapy for hoarding disorder, modifications are necessary to compensate for high fatigability and reduce the risk for serious adverse events.
Background: Cardiovascular diseases (CVD) are commonly comorbid with mental health disorders, por... more Background: Cardiovascular diseases (CVD) are commonly comorbid with mental health disorders, portending poorer cardiac prognosis. Despite the high prevalence of depression and anxiety, and guidelines recommending routine depression screening and referral, uptake of mental healthcare in CVD populations remains low. Reasons for the underutilisation of mental health and psychological services for this population remain largely unknown. Methods: Thirteen CVD patients with clinically significant psychological symptoms (depression, anxiety and/or stress) participated in one-on-one in-depth semi-structured interviews. Data were analysed using inductive thematic analysis. Results: Barriers to uptake included the timing of referral and screening, with patients reporting a need for longer term follow-up. A lack of information provision and understanding around mental health and services, especially following cardiac-events were further barriers. A reluctance to report mental health or engage in services was also identified, with patients indicating a preference for informal peer support networks. A range of practical barriers such as mobility, transport and cost were also reported. Conclusions: Longer term follow-up and routine mental health assessment may be beneficial to facilitate use of mental health services. Upskilling of practitioners around mental health may be a further avenue to promote information provision and enhance service use. Further focus on enhancing informal peer support may be a valuable initial approach for the CVD population. The implications for improving services and enhancing service use are discussed.
Participation in elite-sport and education is stressful and can result in sacrificed educational ... more Participation in elite-sport and education is stressful and can result in sacrificed educational attainment. A dearth of research, however, has explored the specific stressors encountered by student athletes and coping strategies used, resulting in limited knowledge of how to best support student athletes. Interviews with 20 Australian university student athletes were conducted and data were analyzed via thematic analysis. Interviewees reported encountering numerous stressors, especially relating to schedule clashes, fatigue, financial pressure, and inflexibility of coaches. Athletes identified few coping strategies but reported that support from parents and coaches was paramount. Athletes would benefit from upskilling in several areas such as effective use of time, self-care, time management, enhanced self-efficacy, and specific strategies for coping with stress. Coaches have the opportunity to play a pivotal role in facilitating successful integration of sport and education.
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Papers by Phillip Tully