Ranak Trivedi

All Publications

• Can We Improve Patient Adherence by Harnessing Social Forces? Journal of general internal medicine Trivedi, R., Asch, S. M. 2019

  View details for DOI 10.1007/s11606-019-04856-4

  View details for PubMedID 30887442

• Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter. Journal of geriatric psychiatry and neurology Schwartz, R., Trivedi, R., Gray, C., Lorenz, K. A., Zulman, D. 2019: 891988719845509

  Abstract

  For patients with Parkinson's disease (PD), effective communication during neurology encounters is critical to ensuring the treatment plan maximizes quality of life. However, few research studies have engaged neurologists as key experts in identifying opportunities to optimize the clinical encounter. In this study, 16 neurologists from 4 clinic sites participated in hour-long semistructured interviews targeting opportunities to better address patients' quality of life needs.Neurologists identified opportunities to meet needs across 4 domains: (1) PD patient education materials and self-management tools to facilitate clinical communication; (2) techniques for improving clinical communication, including strategies for eliciting nonmotor symptoms and contextualizing symptoms to better meet patient quality of life needs; (3) addressing system-level barriers, including time constraints and the lack of an identified specialist referral network; and (4) training in how to lead difficult conversations.Neurologists identified specific barriers, and proposed solutions, to improving care delivery for patients with PD. Integrating practice tools to address quality of life needs, training neurologists in communication around end-of-life care, and strengthening referral networks for rehabilitation and psychosocial support hold promise for improving quality of life for patients with PD.

  View details for PubMedID 31046525

• Disability Rating, Age at Death, and Cause of Death in US Veterans with Service-Connected Conditions MILITARY MEDICINE Maynard, C., Trivedi, R., Nelson, K., Fihn, S. D. 2018; 183 (11-12): E371–E376

  Abstract

  The association between disability and cause of death in Veterans with service-connected disabilities has not been studied. The objective of this study was to compare age at death, military service and disability characteristics, including disability rating, and cause of death by year of birth. We also examined cause of death for specific service-connected conditions.This study used information from the VETSNET file, which is a snapshot of selected items from the Veterans Benefits Administration corporate database. We also used the National Death Index (NDI) for Veterans which is part of the VA Suicide Data Repository. In VETSNET, there were 758,324 Veterans who had a service-connected condition and died between the years 2004 and 2014. Using the scrambled social security number to link the two files resulted in 605,493 (80%) deceased Veterans. Age at death, sex, and underlying cause of death were obtained from the NDI for Veterans and military service characteristics and types of disability were acquired from VETSNET. We constructed age categories corresponding to period of service; birth years 1938 and earlier corresponded to Korea and World War II ("oldest"), birth years 1939-1957 to the Vietnam era ("middle"), and birth years 1958 and later to post Vietnam, Gulf War, and the more recent conflicts in Iraq and Afghanistan ("youngest").Sixty-two percent were in the oldest age category, 34% in the middle group, and 4% in the youngest one. The overall age at death was 75 ± 13 yr. Only 1.6% of decedents were women; among women 25% were in the youngest age group, while among men only 4% were in the youngest group. Most decedents were enlisted personnel, and 60% served in the U.S. Army. Nearly 61% had a disability rating of >50% and for the middle age group 54% had a disability rating of 100%. The most common service-connected conditions were tinnitus, hearing loss, and post-traumatic stress disorder (PTSD). In the oldest group, nearly half of deaths were due to cancer or cardiovascular conditions and <2% were due to external causes. In the youngest group, cardiovascular disease and cancer accounted for about 1/3 of deaths, whereas external causes or deaths due to accidents, suicide, or assault accounted for nearly 33% of deaths. For Veterans with service-connected PTSD or major depression; 6.5% of deaths were due to external causes whereas for Veterans without these conditions, only 3.1% were due to external causes.The finding of premature death due to external causes in the youngest age group as well as the finding of higher proportions of external causes in those with PTSD or major depression should be of great concern to those who care for Veterans.

  View details for DOI 10.1093/milmed/usy040

  View details for Web of Science ID 000451813600007

  View details for PubMedID 29590473

• Comparing Preventable Hospitalizations Among Veterans With and Without Mental Illnesses Before and After Implementation of PACT. Psychiatric services (Washington, D.C.) Trivedi, R., Sylling, P., Post, E. P., Wong, E. S., Mori, A. M., Fihn, S. D., Nelson, K. 2018: appips201700316

  Abstract

  OBJECTIVES:: The authors examined whether the rate of preventable hospitalizations among veterans with mental illness changed after implementation of the Department of Veterans Affairs (VA) primary care medical home-Patient Aligned Care Teams (PACT).METHODS:: A 12-year retrospective cohort analysis was conducted of data from 9,206,017 veterans seen in 942 VA primary care clinics between October 2003 and March 2015. Preventable hospitalizations were those related to ambulatory care-sensitive conditions (ACSCs), identified with ICD-9 codes. Changes in rates of ACSC-related hospitalizations were compared between patients with and without mental illness in two age groups (<65, ≥65). Patients with mental illness diagnoses were grouped as follows: depression, posttraumatic stress disorder, anxiety, substance use disorder, and serious mental illness. Interrupted time-series analysis was used to model long-term trends and detect deviations after PACT implementation.RESULTS:: There was an overall increase in mental illness diagnoses across both age groups. Among older veterans (≥65) with any mental illness, the rate (per 1,000 patients) of ACSC-related hospitalizations was five fewer in the post-PACT period, compared with the pre-PACT period. Among younger veterans (<65), there was a slight increase in ACSC-related hospitalizations in years 3-5 post-PACT if they had any mental illness (.6 per 1,000 patients), depression (.3), anxiety (1.4), or a substance use disorder (.6).CONCLUSIONS:: In this retrospective, observational study examining large systemwide changes in clinical practice, mental illness was more likely to be diagnosed after PACT implementation, compared with before, and results suggested a benefit of PACT implementation among older veterans in terms of a reduction in ACSC-related hospitalizations.

  View details for DOI 10.1176/appi.ps.201700316

  View details for PubMedID 30301446

• Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial TRIALS Rosland, A., Piette, J. D., Trivedi, R., Kerr, E. A., Stoll, S., Tremblay, A., Heisler, M. 2018; 19: 394

  Abstract

  Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care ("family supporters"). These family supporters are an important resource who could be leveraged to improve patients' engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications.We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients' primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients' diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient's diabetes care.If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients' available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities.ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.

  View details for DOI 10.1186/s13063-018-2785-2

  View details for Web of Science ID 000439668100001

  View details for PubMedID 30041685

  View details for PubMedCentralID PMC6057090

• Emotional Impact of Illness and Care on Patients with Advanced Kidney Disease CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY O'Hare, A. M., Richards, C., Szarka, J., McFarland, L. V., Showalter, W., Vig, E. K., Sudore, R. L., Crowley, S. T., Trivedi, R., Taylor, J. S. 2018; 13 (7): 1022–29

  Abstract

  The highly specialized and technologically focused approach to care inherent to many health systems can adversely affect patients' emotional experiences of illness, while also obscuring these effects from the clinician's view. We describe what we learned from patients with advanced kidney disease about the emotional impact of illness and care.As part of an ongoing study on advance care planning, we conducted semistructured interviews at the VA Puget Sound Healthcare System in Seattle, Washington, with 27 patients with advanced kidney disease between April of 2014 and May of 2016. Of these, ten (37%) were receiving center hemodialysis, five (19%) were receiving peritoneal dialysis, and 12 (44%) had an eGFR≤20 ml/min per 1.73 m2 and had not started dialysis. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory methods.We here describe three emergent themes related to patients' emotional experiences of care and illness: (1) emotional impact of interactions with individual providers: when providers seemed to lack insight into the patient's experience of illness and treatment, this could engender a sense of mistrust, abandonment, isolation, and/or alienation; (2) emotional impact of encounters with the health care system: just as they could be affected emotionally by interactions with individual providers, patients could also be affected by how care was organized, which could similarly lead to feelings of mistrust, abandonment, isolation, and/or alienation; and (3) emotional impact of meaning-making: patients struggled to make sense of their illness experience, worked to apportion blame, and were often quick to blame themselves and to assume that their illness could have been prevented.Interactions with individual providers and with the wider health system coupled with patients' own struggles to make meaning of their illness can take a large emotional toll. A deeper appreciation of patients' emotional experiences may offer important opportunities to improve care.

  View details for DOI 10.2215/CJN.14261217

  View details for Web of Science ID 000438886000011

  View details for PubMedID 29954826

  View details for PubMedCentralID PMC6032592

• Mutuality and heart failure self-care in patients and their informal caregivers EUROPEAN JOURNAL OF CARDIOVASCULAR NURSING Hooker, S. A., Schmiege, S. J., Trivedi, R. B., Amoyal, N. R., Bekelman, D. B. 2018; 17 (2): 102–13

  Abstract

  Heart failure is a progressive condition characterized by frequent hospitalizations for exacerbated symptoms. Informal family caregivers may help patients improve self-care, which may in turn reduce hospitalizations. However, little is known about how mutuality, defined as the quality of the patient-caregiver relationship, and caregiver burden affect self-care.This study examines the associations among mutuality, patient self-care confidence (beliefs in abilities to engage in self-care behaviors) and maintenance (behaviors such as medication adherence, activity, and low salt intake), caregiver confidence in and maintenance of patient care, and caregiver perceived burden.This study used cross-sectional baseline data from a multi-site randomized clinical trial of a symptom and psychosocial care intervention. Patient-caregiver dyads ( N=99) completed self-report surveys of mutuality and self-care confidence and maintenance, and caregivers completed a measure of caregiver burden. Path analysis, with actor (effects within a person) partner (effects across the dyad) interdependence model paths and regression models were used to examine the associations among mutuality, caregiver burden, and self-care.The majority of patients ( M age=66, 21% female) and caregivers ( M age=57, 81% female) were spouses (60%). The path model demonstrated significant actor effects; patients and caregivers with better mutuality were more confident in patient self-care ( p<.05). Partner effects were not significant. Regression models indicated that caregivers with greater mutuality reported less perceived burden ( p<.01).Mutuality in patient-caregiver dyads is associated with patient self-care and caregiver burden and may be an important intervention target to improve self-care and reduce hospitalizations.

  View details for DOI 10.1177/1474515117730184

  View details for Web of Science ID 000424050500002

  View details for PubMedID 28868917

• "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients. Chronic illness Schwartz, R., Zulman, D., Gray, C., Goldstein, M. K., Trivedi, R. 2018: 1742395318799852

  Abstract

  Objectives Parkinson's disease presents an evolving challenge for patients and families due to an unpredictable disease trajectory and symptoms that complicate social interactions. In this study, we explore neurologists' perspectives on the challenges Parkinson's disease presents for families and the strategies they use to improve communication and quality of life. Methods We conducted hour-long semi-structured interviews with 16 neurologists at 4 care delivery institutions in the San Francisco Bay Area, focusing on techniques neurologists use to support families through the Parkinson's disease journey. Results Neurologists identified strategies for addressing caregiver-patient disagreements around symptom accuracy and negotiating driving safety. Family education is needed to contextualize patient symptoms and to identify psychosocial support resources. Unmet caregiver needs remain, particularly in the form of psychosocial support, respite care and support for unequal gender dynamics in the Parkinson's disease caregiving experience. Discussion Family members of Parkinson's disease patients face unique caregiving and interpersonal challenges due to the nature of the disease. Targeted education and structural support are needed to alleviate current burdens and allow for improved patient- and family-centered care.

  View details for PubMedID 30208725

• Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes CHRONIC ILLNESS Bouldin, E. D., Trivedi, R. B., Reiber, G. E., Rosland, A., Silverman, J. B., Krieger, J., Nelson, K. M. 2017; 13 (4): 239–50

  Abstract

  Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

  View details for DOI 10.1177/1742395317690032

  View details for Web of Science ID 000433669300001

  View details for PubMedID 29119864

• "Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease. Clinical journal of the American Society of Nephrology O'Hare, A. M., Szarka, J., McFarland, L. V., Vig, E. K., Sudore, R. L., Crowley, S., Reinke, L. F., Trivedi, R., Taylor, J. S. 2017; 12 (6): 930-938

  Abstract

  Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease.As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes.The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient.Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.

  View details for DOI 10.2215/CJN.12721216

  View details for PubMedID 28356337

• Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities. Administration and policy in mental health Cooper, D. C., Helfrich, C. D., Thielke, S. M., Trivedi, R. B., Nelson, K. M., Reiber, G. E., Eugenio, E. C., Beaver, K., Nugent-Carney, J., Fan, V. S. 2016: -?

  Abstract

  We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

  View details for PubMedID 27909877

• Provider Perspectives on Advance Care Planning for Patients with Kidney Disease: Whose Job Is It Anyway? CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY O'Hare, A. M., Szarka, J., McFarland, L. V., Taylor, J. S., Sudore, R. L., Trivedi, R., Reinke, L. F., Vig, E. K. 2016; 11 (5): 855-866

  Abstract

  There is growing interest in efforts to enhance advance care planning for patients with kidney disease. Our goal was to elicit the perspectives on advance care planning of multidisciplinary providers who care for patients with advanced kidney disease.Between April and December of 2014, we conducted semistructured interviews at the Department of Veterans Affairs Puget Sound Health Care System with 26 providers from a range of disciplines and specialties who care for patients with advanced kidney disease. Participants were asked about their perspectives and experiences related to advance care planning in this population. Interviews were audiotaped, transcribed, and analyzed inductively using grounded theory.The comments of providers interviewed for this study spoke to significant system-level barriers to supporting the process of advance care planning for patients with advanced kidney disease. We identified four overlapping themes: (1) medical care for this population is complex and fragmented across settings and providers and over time; (2) lack of a shared understanding and vision of advance care planning and its relationship with other aspects of care, such as dialysis decision making; (3) unclear locus of responsibility and authority for advance care planning; and (4) lack of active collaboration and communication around advance care planning among different providers caring for the same patients.The comments of providers who care for patients with advanced kidney disease spotlight both the need for and the challenges to interdisciplinary collaboration around advance care planning for this population. Systematic efforts at a variety of organizational levels will likely be needed to support teamwork around advance care planning among the different providers who care for patients with advanced kidney disease.

  View details for DOI 10.2215/CJN.11351015

  View details for Web of Science ID 000375460200017

  View details for PubMedID 27084877

  View details for PubMedCentralID PMC4858488

• A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Frontiers in public health Trivedi, R., Slightam, C., Fan, V. S., Rosland, A., Nelson, K., Timko, C., Asch, S. M., Zeliadt, S. B., Heidenreich, P., Hebert, P. L., Piette, J. D. 2016; 4: 171-?

  Abstract

  Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

  View details for DOI 10.3389/fpubh.2016.00171

  View details for PubMedID 27626029

• Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans. American journal of public health Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., Maynard, C., Arnow, B., Curtis, I., Fihn, S. D., Nelson, K. 2015; 105 (12): 2564-2569

  Abstract

  We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI).A total of 4 461 208 veterans were seen in the Veterans Health Administration's patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement.A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes.Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.

  View details for DOI 10.2105/AJPH.2015.302836

  View details for PubMedID 26474009

• Participant exclusion criteria in treatment research on neurological disorders: Are unrepresentative study samples problematic? CONTEMPORARY CLINICAL TRIALS Trivedi, R. B., Humphreys, K. 2015; 44: 20-25

  View details for DOI 10.1016/j.cct.2015.07.009

  View details for Web of Science ID 000362616300003

• Potential Impact of Incorporating a Patient-Selected Support Person into mHealth for Depression JOURNAL OF GENERAL INTERNAL MEDICINE Aikens, J. E., Trivedi, R., Heapy, A., Pfeiffer, P. N., Piette, J. D. 2015; 30 (6): 797-803

  Abstract

  Although telephone care management improves depression outcomes, its implementation as a standalone strategy is often not feasible in resource-constrained settings. Moreover, little research has examined the potential role of self-management support from patients' trusted confidants.To investigate the potential benefits of integrating a patient-selected support person into automated mobile health (mHealth) for depression.Patient preference trial.Depressed primary care patients who were at risk for antidepressant nonadherence (i.e., Morisky Medication Adherence Scale total score > 1).Patients received weekly interactive voice response (IVR) telephone calls for depression that included self-management guidance. They could opt to designate a lay support person from outside their home to receive guidance on supporting their self-management. Patients' clinicians were automatically notified of urgent patient issues.Each week over a period of 6 months, we used IVR calls to monitor depression with the Patient Health Questionnaire-9 (PHQ-9; with total < 5 classified as remission), adherence (single item reflecting perfect adherence over the past week), and functional impairment (any bed days due to mental health).Of 221 at-risk patients, 61% participated with a support person. Analyses were adjusted for race, medical comorbidity, and baseline levels of symptom severity and adherence. Significant interaction effects indicated that during the initial phase of the program, only patients who participated with a support person improved significantly in their likelihood of either adhering to antidepressant medication (AOR = 1.31, 95% CI: 1.16-1.47, p < 0.001) or achieving remission of depression symptoms (AOR = 1.24, 95% CI: 1.14-1.34, p < 0.001). These benefits were maintained throughout the 6-month observation period.Incorporating the "human factor" of a patient-selected support person into automated mHealth for depression self-management may yield sustained improvements in antidepressant adherence and depression symptom remission. However, this needs to be confirmed in a subsequent randomized controlled trial.

  View details for DOI 10.1007/s11606-015-3208-7

  View details for Web of Science ID 000354961100019

  View details for PubMedID 25666218

• A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial JOURNAL OF MEDICAL INTERNET RESEARCH Piette, J. D., Striplin, D., Marinec, N., Chen, J., Trivedi, R. B., Aron, D. C., Fisher, L., Aikens, J. E. 2015; 17 (6)

  Abstract

  Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers' needs for information about the patient's status or how the caregiver can help.We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a "CarePartner" outside their household. Patients randomized to "standard mHealth" (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients' responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to "mHealth+CP" (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient's status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients' medication adherence and caregiver communication. mHealth+CP may also decrease patients' risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).

  View details for DOI 10.2196/jmir.4550

  View details for Web of Science ID 000356819800009

  View details for PubMedID 26063161

• Integrating Support Persons into Diabetes Telemonitoring to Improve Self-Management and Medication Adherence JOURNAL OF GENERAL INTERNAL MEDICINE Aikens, J. E., Trivedi, R., Aron, D. C., Piette, J. D. 2015; 30 (3): 319-326

  Abstract

  The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients' baseline level of psychological distress.The study was a quasi-experimental patient preference trial.The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient's health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0-4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.Of 98 initially nonadherent patients, 42% opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: -1.17 vs. -0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25% per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.

  View details for DOI 10.1007/s11606-014-3101-9

  View details for Web of Science ID 000350886500012

  View details for PubMedID 25421436

• Angina Symptom Burden Associated with Depression Status Among Veterans with Ischemic Heart Disease ANNALS OF BEHAVIORAL MEDICINE Trivedi, R., Gerrity, M., Rumsfeld, J. S., Spertus, J. A., Sun, H., McDonell, M., Doak, M., Lucas, L., Fihn, S. D. 2015; 49 (1): 58-65

  Abstract

  Angina and depression are common in ischemic heart disease (IHD), but their association remains understudied.This study was conducted in order to evaluate the association of 1 year change in depression with change in patient-reported outcomes of stable angina.Five hundred sixty-nine stable angina patients completed the Seattle Angina Questionnaire and Patient Health Questionnaire (PHQ) at baseline and 1 year. Participants were divided into four groups: not depressed, new onset of depression at 1 year, remitted at 1 year, and persistently depressed. Associations between depression and angina symptoms were evaluated using regression models.Compared to those not depressed, newly depressed participants reported more angina (β = -11.7, p < 0.001) and physical limitations (β = -11.8, p < 0.001) and lower treatment satisfaction (β = -15.03, p < 0.001) and quality of life (β = -15.4, p < 0.001). Persistently depressed participants reported physical limitations (β = -7.4, p < 0.05), lower treatment satisfaction (β = -10.1, p < 0.001), and poorer quality of life (β = -10.03, p < 0.001).Changes in depression scores and angina outcomes were significantly associated.

  View details for DOI 10.1007/s12160-014-9629-4

  View details for Web of Science ID 000350050800009

  View details for PubMedID 25008432

• Participant exclusion criteria in treatment research on neurological disorders: Are unrepresentative study samples problematic? Contemporary clinical trials Trivedi, R. B., Humphreys, K. 2015; 44: 20–25

  Abstract

  Exclusion criteria are an important determinant of the external validity of treatment research findings, yet the prevalence and impact of exclusion criteria have not been studied systematically. Our objective was to describe prevalent exclusion criteria in treatment research on neurological disorders and to analyze their impact on sample representativeness and generalizability of findings.Narrative literature review of studies focusing on treatment for neurological disorders. Studies were identified from PubMed and bibliographies.Eight studies were included in the narrative review: 3 studies focused on Alzheimer's disease/dementia, 2 each focused on traumatic brain injury (TBI) and epilepsy, and 1 focused on amyotrophic lateral sclerosis (ALS). The total number of patients screened across all studies was 20,018, of which 14,721 (73.5%) were excluded. An average of 6 exclusion criteria was applied. The criteria that contributed most to exclusion were the presence of comorbid psychiatric conditions, a history of alcohol or other substance misuse, and cognitive impairments. Women and the elderly were underrepresented among included samples. Race/ethnicity proportions were seldom reported.Exclusion criteria are used extensively in neurological treatment research and prevent about 3 in 4 patients from participating in research. This limits the generalizability of current findings. Further, because excluded individuals are disproportionately from vulnerable populations, extensive exclusion also raises ethical concerns. Exclusion criteria should be used only in cases where there is a strong rationale so that neurological treatment research can make a greater impact on clinical care.

  View details for PubMedID 26188162

• Antidepressant Adherence and Risk of Coronary Artery Disease Hospitalizations in Older and Younger Adults with Depression JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Cooper, D. C., Trivedi, R. B., Nelson, K. M., Reiber, G. E., Eugenio, E. C., Beaver, K. A., Fan, V. S. 2014; 62 (7): 1238-1245

  Abstract

  To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression.Retrospective cohort study.Department of Veterans Affairs outpatient clinics nationwide.Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups.After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models.Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults.Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.

  View details for DOI 10.1111/jgs.12849

  View details for Web of Science ID 000340482000004

  View details for PubMedID 24890000

• Diabetes self-management support using mHealth and enhanced informal caregiving. Journal of diabetes and its complications Aikens, J. E., Zivin, K., Trivedi, R., Piette, J. D. 2014; 28 (2): 171-176

  Abstract

  To characterize diabetes patient engagement and clinician notifications for an mHealth interactive voice response (IVR) service.Observational study.For three to six months, VA patients with diabetes received weekly IVR calls assessing health status and self-care along with tailored education. Patients could enroll with an informal caregiver who received suggestions on self-management support. Notifications were issued to clinicians when patients reported significant problems.Patients (n=303) participated for a total of 5684 patient-weeks, during which 84% of calls were completed. The odds of call completion decreased over time (AOR=0.96, p<0.001), and were lower among unmarried patients (AOR=0.67, p=0.038) and those who had difficulties with health literacy (AOR=0.67, p=0.039), diabetes-related distress (AOR=0.30, p=0.018), or medication nonadherence (AOR=0.57, p=0.002). Twenty-one clinician notifications were triggered per 100 patient-weeks. The odds of notification were higher during the early weeks of the program (AOR=0.95, p<0.001) and among patients who were older (AOR=1.03, p=0.004) or more physically impaired (AOR=0.97, p<0.001).By providing information that is reliable, valid, and actionable, IVR-based mHealth services may increase access to between-visit monitoring and diabetes self-management support. The system detects abnormal glycemia and blood pressure levels that might otherwise go unreported, although thresholds for clinician notifications might require adjustment to avoid overloading clinicians. Patient engagement might be enhanced by addressing health literacy and psychological distress.

  View details for DOI 10.1016/j.jdiacomp.2013.11.008

  View details for PubMedID 24374137

• Recruitment and retention rates in behavioral trials involving patients and a support person: A systematic review. Contemporary clinical trials Trivedi, R. B., Szarka, J. G., Beaver, K., Brousseau, K., Nevins, E., Yancy, W. S., Slade, A., Voils, C. I. 2013; 36 (1): 307-318

  Abstract

  Recruitment and retention challenges impede the study of behavioral interventions among patient-support person dyads.The aim of the study was to characterize recruitment and retention rates of behavioral interventions involving dyads.Using PRISMA guidelines and with the guidance of a medical librarian, we searched Medline, EMBASE, Cochrane Controlled Trials, PsycInfo, and CINAHL from inception until July 2011. Eligible articles involved RCTs of behavioral interventions targeting adult patients with a non-psychiatric illness and a support person. Sample and study characteristics, recruitment and retention strategies, and recruitment and retention rates were abstracted in duplicate. Quality of reporting was determined on a 5-point scale. Due to the heterogeneity in data reporting and missing data, a narrative synthesis was undertaken.53 unique studies involving 8081 dyads were included. 9 studies were ascertained to have a "high quality" of reporting. A majority of the studies did not report target sample size, time to complete recruitment, and sample sizes at each follow-up time point. Strategies employed to recruit support persons were rarely reported. 16 studies did not report the number of dyads screened. The mean recruitment rate was 51.2% (range: 4.3%-95.4%), and mean retention rate was 77.5% (range: 36%-100%).Details regarding recruitment and retention methodology were sparse in these interventions. Where available, data suggests that resources need to be devoted towards recruitment of sample but that retention rates are generally adequate.

  View details for DOI 10.1016/j.cct.2013.07.009

  View details for PubMedID 23916918

• A preliminary exploration of the feasibility of offering men information about potential prostate cancer treatment options before they know their biopsy results BMC MEDICAL INFORMATICS AND DECISION MAKING Zeliadt, S. B., Hannon, P. A., Trivedi, R. B., Bonner, L. M., Vu, T. T., Simons, C., Kimmie, C. A., Hu, E. Y., Zipperer, C., Lin, D. W. 2013; 13

  Abstract

  A small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making.Men with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic's usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18).A total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results.In this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.

  View details for DOI 10.1186/1472-6947-13-19

  View details for Web of Science ID 000316224400001

  View details for PubMedID 23388205

• Factors associated with presenting > 12 hours after symptom onset of acute myocardial infarction among Veteran men BMC CARDIOVASCULAR DISORDERS McDermott, K., Maynard, C., Trivedi, R., Lowy, E., Fihn, S. 2012; 12

  Abstract

  Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) ("late presenters"). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation.In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation.Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]).A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.

  View details for DOI 10.1186/1471-2261-12-82

  View details for Web of Science ID 000311604500001

  View details for PubMedID 23020779

• The Influence of Informal Caregivers on Adherence in COPD Patients ANNALS OF BEHAVIORAL MEDICINE Trivedi, R. B., Bryson, C. L., Udris, E., Au, D. H. 2012; 44 (1): 66-72

  Abstract

  Contributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.This study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.Three hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.Compared with the "no caregiver" group, antihypertensive medications adherence was higher in the "spousal caregiver" (0.68 vs. 0.81; 95% CI=0.04 and 0.22) and "non-spousal caregiver" (0.68 vs. 0.80; 95% CI=0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the "spousal caregiver" group (0.60 vs.0.80; 95% CI=0.05 and 0.43). Patients in the "spousal caregiver" group had fewer current smokers compared with the "no caregiver" (χ(2)=16.08; p<0.001) and "non-spousal caregiver" (χ(2)=5.07; p<0.05) groups; those in the "non-spousal caregiver" group reported fewer smokers than the "no caregiver" group (χ(2)=4.54; p<0.05).Caregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

  View details for DOI 10.1007/s12160-012-9355-8

  View details for Web of Science ID 000308822700010

  View details for PubMedID 22422104

• BRIEF PSYCHOTHERAPY FOR DEPRESSION: A SYSTEMATIC REVIEW AND META-ANALYSIS INTERNATIONAL JOURNAL OF PSYCHIATRY IN MEDICINE Nieuwsma, J. A., Trivedi, R. B., McDuffie, J., Kronish, I., Benjamin, D., Williams, J. W. 2012; 43 (2): 129-151

  Abstract

  Because evidence-based psychotherapies of 12 to 20 sessions can be perceived as too lengthy and time intensive for the treatment of depression in primary care, a number of studies have examined abbreviated psychotherapy protocols. The purpose of this study was to conduct a systematic review and meta-analysis to determine the efficacy of brief psychotherapy (i.e., < or =8 sessions) for depression.We used combined literature searches in PubMed, EMBASE, PsycINFO, and an Internet-accessible database of clinical trials of psychotherapy to conduct two systematic searches: one for existing systematic reviews and another for randomized controlled trials (RCTs). Included studies examined evidence-based psychotherapy(s) of eight or fewer sessions, focused on adults with depression, contained an acceptable control condition, were published in English, and used validated measures of depressive symptoms. Results: We retained 2 systematic reviews and 15 RCTs evaluating cognitive behavioral therapy, problem-solving therapy, and mindfulness-based cognitive therapy. The systematic reviews found brief psychotherapies to be more efficacious than control, with effect sizes ranging from -0.33 to -0.25. Our meta-analysis found six to eight sessions of cognitive behavioral therapy to be more efficacious than control (ES -0.42, 95% CI -0.74 to -0.10, 12 = 56%). A sensitivity analysis controlled for statistical heterogeneity but showed smaller treatment effects (ES -0.24, 95% CI -0.42 to -0.06, 12 = 0%).Depression can be efficaciously treated with six to eight sessions of psychotherapy, particularly cognitive behavioral therapy and problem-solving therapy. Access to non-pharmacologic treatments for depression could be improved by training healthcare providers to deliver brief psychotherapies.

  View details for DOI 10.2190/PM.43.2.c

  View details for Web of Science ID 000305727700003

  View details for PubMedID 22849036

• Examining the Interrelatedness of Patient and Spousal Stress in Heart Failure Conceptual Model and Pilot Data JOURNAL OF CARDIOVASCULAR NURSING Trivedi, R. B., Piette, J., Fihn, S. D., Edelman, D. 2012; 27 (1): 24-32

  Abstract

  Recent research has highlighted the positive influence that spouses can have on patient outcomes. It is not clear whether patients and spouses influence each other's well-being reciprocally or whether spousal well-being affects the success of patients' disease management. Our goals were 2-fold: (a) to propose a conceptual framework to examine the reciprocity between patient and spouses' well-being, especially as it relates to disease management, and (b) to begin to assess the validity of this model using pilot data.Twenty-three veterans with heart failure (HF) and their spouses were recruited into a pilot cross-sectional observational study. Participants completed psychosocial surveys to assess depressive symptoms, caregiver burden, relationship satisfaction, and disease management. Descriptive analyses and bivariate correlations between these measures were calculated.Using standard cutoffs, analyses suggested clinically significant depressive symptoms in patients (Center for Epidemiological Studies-Depression score >16; mean, 21.8 [SD, 13]) and a high level of caregiver burden among spouses (Zarit Burden Interview score >15; mean, 22.4 [SD, 15.4]). Both patients and spouses reported high relationship satisfaction levels (Dyadic Adjustment Scale score >100; mean, 112.6 [SD, 26.5] and 115.9 [SD, 14.4], respectively). On average, patients reported poor disease management (Self-care of Heart Failure Index subscale <70 across all subscales: confidence = 53.3 [SD, 28.2]; maintenance = 59.7 [SD, 17.3]; management = 54.0 [SD, 19.4]). Patient depressive symptoms were positively correlated with spouse depressive symptoms (r = 0.53) and caregiver burden (r = 0.64; all P's < .05). Spouses' depressive symptoms were additionally correlated with lower levels of perceived social support among patients (r = -0.47), poor patient relationship satisfaction (r = -0.51), and worse patient confidence in HF management (r = -0.48). Greater caregiver burden was associated with more patient disease complaints (r = 0.49), poorer patients' relationship satisfaction (r = -0.72), and poorer patients' perceived social support (r = -0.73).These results provide preliminary support to the proposed conceptual model. Further research is necessary to determine which spousal factors appear to be most relevant to disease management. Disease management interventions may benefit from engaging spouses in a way that enhances their role without adding to their burden.

  View details for DOI 10.1097/JCN.0b013e3182129ce7

  View details for Web of Science ID 000298376900004

  View details for PubMedID 21743348

• Examination of the Utility of Psychotherapy for Patients with Treatment Resistant Depression: A Systematic Review JOURNAL OF GENERAL INTERNAL MEDICINE Trivedi, R. B., Nieuwsma, J. A., Williams, J. W. 2011; 26 (6): 643-650

  Abstract

  To examine the utility of psychotherapy in managing treatment resistant depression.PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies.Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted.Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy.Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

  View details for DOI 10.1007/s11606-010-1608-2

  View details for Web of Science ID 000290576600016

  View details for PubMedID 21184287

  View details for PubMedCentralID PMC3101965

• Worsening Depressive Symptoms Are Associated With Adverse Clinical Outcomes in Patients With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Sherwood, A., Blumenthal, J. A., Hinderliter, A. L., Koch, G. G., Adams, K. F., Dupree, C. S., Bensimhon, D. R., Johnson, K. S., Trivedi, R., Bowers, M., Christenson, R. H., O'Connor, C. M. 2011; 57 (4): 418-423

  Abstract

  The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients.Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes.One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up).The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro-B-type natriuretic peptide level, and prior hospitalizations.Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

  View details for DOI 10.1016/j.jacc.2010.09.031

  View details for Web of Science ID 000286376500006

  View details for PubMedID 21251581

• Cardiovascular hemodynamics during stress in premenopausal versus postmenopausal women MENOPAUSE-THE JOURNAL OF THE NORTH AMERICAN MENOPAUSE SOCIETY Sherwood, A., Park, S. B., Hughes, J. W., Blumenthal, J. A., Hinderliter, A., Trivedi, R., McFetridge-Durdle, J. 2010; 17 (2): 403-409

  Abstract

  After menopause, women are at an increased risk of cardiovascular disease. The present study assessed cardiovascular hemodynamics in premenopausal versus postmenopausal women, with a focus on systemic vascular resistance (SVR) at rest and during stress. Sympathetic nervous system activity and cardiovascular adrenergic receptor (AR) function were also examined.A total of 90 women (45 premenopausal and 45 postmenopausal) completed a laboratory protocol composed of a resting baseline and four mental stress tasks. Measurements included blood pressure, cardiac output, SVR, and plasma catecholamine level. In addition, alpha- and beta-AR responsiveness to the infusion of selective pharmacological agonists was assessed.Compared with premenopausal women, postmenopausal women were characterized by similar blood pressure but lower cardiac output and higher SVR, both at rest and during stress (Ps < 0.05). Postmenopausal women also had higher baseline plasma norepinephrine levels (P = 0.007) and reduced beta-AR responsiveness (P = 0.02), although differences in beta-AR responsiveness may have been confounded by aging effects.After menopause, women exhibit altered sympathetic nervous system activity and a sustained increase in hemodynamic load that may contribute to pathological structural and functional changes in the heart and blood vessels.

  View details for DOI 10.1097/gme.0b013e3181b9b061

  View details for Web of Science ID 000275485200031

  View details for PubMedID 19770780

• Is there a nonadherent subtype of hypertensive patient? A latent class analysis approach PATIENT PREFERENCE AND ADHERENCE Trivedi, R. B., Ayotte, B. J., Thorpe, C. T., Edelman, D., Bosworth, H. B. 2010; 4: 255-262

  Abstract

  To determine subtypes of adherence, 636 hypertensive patients (48% White, 34% male) reported adherence to medications, diet, exercise, smoking, and home blood pressure monitoring. A latent class analysis approach was used to identify subgroups that adhere to these five self-management behaviors. Fit statistics suggested two latent classes. The first class (labeled "more adherent") included patients with greater probability of adhering to recommendations compared with the second class (labeled "less adherent") with regard to nonsmoking (97.7% versus 76.3%), medications (75.5% versus 49.5%), diet (70.7% versus 46.9%), exercise (63.4% versus 27.2%), and blood pressure monitoring (32% versus 3.4%). Logistic regression analyses used to characterize the two classes showed that "more adherent" participants were more likely to report full-time employment, adequate income, and better emotional and physical well-being. Results suggest the presence of a less adherent subtype of hypertensive patients. Behavioral interventions designed to improve adherence might best target these at-risk patients for greater treatment efficiency.

  View details for Web of Science ID 000208215200031

  View details for PubMedID 20694185

• Coping styles in heart failure patients with depressive symptoms JOURNAL OF PSYCHOSOMATIC RESEARCH Trivedi, R. B., Blumenthal, J. A., O'Connor, C., Adams, K., Hinderliter, A., Dupree, C., Johnson, K., Sherwood, A. 2009; 67 (4): 339-346

  Abstract

  Elevated depressive symptoms have been linked to poorer prognosis in heart failure (HF) patients. Our objective was to identify coping styles associated with depressive symptoms in HF patients.A total of 222 stable HF patients (32.75% female, 45.4% non-Hispanic black) completed multiple questionnaires. Beck Depression Inventory (BDI) assessed depressive symptoms, Life Orientation Test (LOT-R) assessed optimism, ENRICHD Social Support Inventory (ESSI) and Perceived Social Support Scale (PSSS) assessed social support, and COPE assessed coping styles. Linear regression analyses were employed to assess the association of coping styles with continuous BDI scores. Logistic regression analyses were performed using BDI scores dichotomized into BDI<10 vs. BDI> or =10, to identify coping styles accompanying clinically significant depressive symptoms.In linear regression models, higher BDI scores were associated with lower scores on the acceptance (beta=-.14), humor (beta=-.15), planning (beta=-.15), and emotional support (beta=-.14) subscales of the COPE, and higher scores on the behavioral disengagement (beta=.41), denial (beta=.33), venting (beta=.25), and mental disengagement (beta=.22) subscales. Higher PSSS and ESSI scores were associated with lower BDI scores (beta=-.32 and -.25, respectively). Higher LOT-R scores were associated with higher BDI scores (beta=.39, P<.001). In logistical regression models, BDI> or =10 was associated with greater likelihood of behavioral disengagement (OR=1.3), denial (OR=1.2), mental disengagement (OR=1.3), venting (OR=1.2), and pessimism (OR=1.2), and lower perceived social support measured by PSSS (OR=.92) and ESSI (OR=.92).Depressive symptoms in HF patients are associated with avoidant coping, lower perceived social support, and pessimism. Results raise the possibility that interventions designed to improve coping may reduce depressive symptoms.

  View details for DOI 10.1016/j.jpsychores.2009.05.014

  View details for Web of Science ID 000270567700009

  View details for PubMedID 19773027

• RACIAL DIFFERENCES IN HYPERTENSION KNOWLEDGE: EFFECTS OF DIFFERENTIAL ITEM FUNCTIONING ETHNICITY & DISEASE Ayotte, B. J., Trivedi, R., Bosworth, H. B. 2009; 19 (1): 23-27

  Abstract

  Health-related knowledge is an important component in the self-management of chronic illnesses. The objective of this study was to more accurately assess racial differences in hypertension knowledge by using a latent variable modeling approach that controlled for sociodemographic factors and accounted for measurement issues in the assessment of hypertension knowledge. Cross-sectional data from 1,177 participants (45% African American; 35% female) were analyzed using a multiple indicator multiple causes (MIMIC) modeling approach. Available sociodemographic data included race, education, sex, financial status, and age. All participants completed six items on a hypertension knowledge questionnaire. Overall, the final model suggested that females, Whites, and patients with at least a high school diploma had higher latent knowledge scores than males, African Americans, and patients with less than a high school diploma, respectively. The model also detected differential item functioning (DIF) based on race for two of the items. Specifically, the error rate for African Americans was lower than would be expected given the lower level of latent knowledge on the items, on the questions related to: (a) the association between high blood pressure and kidney disease, and (b) the increased risk African Americans have for developing hypertension. Not accounting for DIF resulted in the difference between Whites and African Americans to be underestimated. These results are discussed in the context of the need for careful measurement of health-related constructs, and how measurement-related issues can result in an inaccurate estimation of racial differences in hypertension knowledge.

  View details for Web of Science ID 000264494100006

  View details for PubMedID 19341159

• Evidence synthesis for determining the responsiveness of depression questionnaires and optimal treatment duration for antidepressant medications. Williams, J. W., Slubicki, M. N., Tweedy, D. S., Bradford, D. W., Trivedi, R. B., Baker, D. Department of Veterans Affairs. 2009 ; VA Evidence-based Synthesis Reports

  Abstract

  According to projections from the World Health Organization, depression will be the second leading cause of disability in the developed world by 2020. Primary care clinicians care for approximately two thirds of depressed individuals. In 2000, the U.S. economic burden of depressive disorders was estimated to be 83.1 billion dollars. This included 31% direct medical costs, 7% suicide-related mortality costs, and 62% workplace costs. A variety of strategies have been tested to improve patient outcomes. Among these, integrated care models have emerged as both effective and cost effective. A recent systematic review identifies symptom monitoring as a key element of these integrated care models. However, the review did not identify the standardized depression scales that are responsive to clinically important change. A separate but important issue raised by Veterans Administration (VA) Stakeholders is how long to continue antidepressant medication for patients who respond to acute phase treatment. Clinical guidelines recommend continuation treatment for 4-6 months for uncomplicated major depression and some national performance measures are linked to these guidelines. However, clinical guidelines for longer-term maintenance phase treatment are more variable and performance indicators (e.g., Healthcare Effectiveness Data and Information Set, HEDIS) do not address maintenance phase treatment. A better understanding of the evidence for long-term treatment efficacy with antidepressants would inform guidelines and performance measurement.

• The association of emotional well-being and marital status with treatment adherence among patients with hypertension JOURNAL OF BEHAVIORAL MEDICINE Trivedi, R. B., Ayotte, B., Edelman, D., Bosworth, H. B. 2008; 31 (6): 489-497

  Abstract

  We were interested in examining the relationship between psychosocial factors and hypertension-related behaviors. We hypothesized that lower emotional well-being and unmarried status would be related to higher BP, poorer medication adherence, greater difficulty adhering to diet and exercise, and current smoking. In a cross-sectional design, 636 hypertensive patients completed the Mental Component Summary (MCS) Scale of the SF-12 and rated their difficulty with adherence to diet, exercise, and medication-taking. In logistic regression analyses, lower MCS scores were associated with difficulty adhering to diet (OR = 0.97, p < .05) and exercise (OR = 0.97, p < .01), and current smoking status (OR = 0.98, p < .05). Being married was associated with higher probability of medication adherence (OR = 1.66, p < .01) and a lower probability of being a current smoker (OR = 0.34, p < .0001). Neither MCS scores nor being married were related to BP levels in adjusted analyses. Results emphasize the importance of assessing psychosocial factors to optimize hypertension treatment.

  View details for DOI 10.1007/s10865-008-9173-4

  View details for Web of Science ID 000260663000004

  View details for PubMedID 18780175

• Relationship of depression to mortality and hospitalization in patients with heart failure Archives of Internal Medicine Sherwood, A., Blumenthal, J. A., Trivedi, R., Johnson, K. S., O'Connor, C., Adams, K. A., Sueta-Dupree, C., Waugh, R. A., Bensimhon, D. R., Gaulden, L., Koch, G. G., Hinderliter, A. L. 2007; 167: 367-373
• Donepezil for Cognitive Decline Following Coronary Artery Bypass Surgery: A Pilot Randomized Controlled Trial PSYCHOPHARMACOLOGY BULLETIN Doraiswamy, P. M., Babyak, M. A., Hennig, T., Trivedi, R., White, W. D., Mathew, J. P., Newman, M. F., Blumenthal, J. A. 2007; 40 (2): 54-62

  Abstract

  To study the effect of donepezil in treating patients with cognitive decline following coronary artery bypass graft (CABG) surgery.Forty-four patients, with at least a 0.5 SD decline at 1 year post-CABG on at least one cognitive domain compared to their pre-CABG baseline score, were randomized to treatment with donepezil (titrated to 10 mg daily) or placebo in a 12-week double-blind, single center, randomized study. A composite cognitive change score served as the primary outcome. Secondary outcome measures included tests of memory, attention, psychomotor speed, and executive function.The composite cognitive outcome did not show significant treatment effects. Secondary measures varied in their sensitivity to donepezil effects with the largest effects seen on the Wechsler Visual Memory Scale-Delayed and Immediate recall tests. More than twice (52% vs. 22%) as many donepezil-treated patients showed a significant improvement compared with placebo patients on Delayed recall. Tests with weak effect sizes and minimal trends favoring donepezil were the Boston Naming and Digit Symbol. However, most of the other instruments (e.g., Digit Span, Trails B, and Controlled Word Association) showed no treatment benefits. More donepezil-treated than placebo-treated patients experienced diarrhea, but other adverse effects and safety measures did not differ between groups.In the post-CABG mild cognitive decline setting, donepezil did not improve composite cognitive performance but improved some aspects of memory. Donepezil was well tolerated and had no significant effects on EKG parameters. Because of limitations such as small sample size and multiplicity of tests, these findings are preliminary but add to our knowledge of cholinergic effects in vascular mild cognitive decline.

  View details for Web of Science ID 000207792600004

  View details for PubMedID 17514186

• Genetic and environmental influences on anger expression, John Henryism, and stressful life events: The Georgia cardiovascular twin study PSYCHOSOMATIC MEDICINE Wang, X. L., Trivedi, R., Treiber, F., Snieder, H. 2005; 67 (1): 16-23

  Abstract

  To examine the genetic and/or environmental origin of variation and covariation of perceived stressful life events and two stress-related coping styles, anger expression and John Henryism.Data were available from 306 European American (EA) and 213 African American (AA) twin pairs, including monozygotic and dizygotic of same as well as opposite sex (mean age, 14.8 +/- 3.1 years; range, 10.0-25.9 years). Anger expression, John Henryism, and life events were measured with the Anger Expression Scale (subscales: Anger-in, Anger-out, and Anger-control), the John Henryism Active Coping Scale, and the Adolescent Resources Challenges Scale, respectively.Model fitting showed no ethnic or sex differences for any of the scales. All traits showed at least some degree of familial resemblance, best explained by shared environment for Anger-in (18%), heritability for Anger-control (34%), John Henryism (34%), and life events (47%), and a combination of heritability (14% and 15%) and shared environment (10% and 20%) for Anger-out and overall anger expression, respectively. The remaining part of the variation for all traits was explained by environmental influences that are unique to the individual. Anger expression and life events were correlated (r = 0.28), and bivariate genetic modeling showed that 61% of this correlation was mediated by common genetic factors.Individual differences in coping styles and life events in youth can be explained by moderate genetic and substantial environmental influences, of which most are idiosyncratic to the individual. The association between anger expression and life events is largely the result of common genes.

  View details for DOI 10.1097/01.psy.0000146331.10104.d4

  View details for Web of Science ID 000226673700003

  View details for PubMedID 15673619