Publications by authors named "Waguih William Ishak"

66 Publications

Personalized treatments for depressive symptoms in patients with advanced heart failure: A pragmatic randomized controlled trial.

PLoS One 2021 7;16(1):e0244453. Epub 2021 Jan 7.

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.

Objectives: Heart Failure is a chronic syndrome affecting over 5.7 million in the US and 26 million adults worldwide with nearly 50% experiencing depressive symptoms. The objective of the study is to compare the effects of two evidence-based treatment options for adult patients with depression and advanced heart failure, on depressive symptom severity, physical and mental health related quality of life (HRQoL), heart-failure specific quality of life, caregiver burden, morbidity, and mortality at 3, 6 and 12-months.

Methods: Trial design. Pragmatic, randomized, comparative effectiveness trial. Interventions. The treatment interventions are: (1) Behavioral Activation (BA), a patient-centered psychotherapy which emphasizes engagement in enjoyable and valued personalized activities as selected by the patient; or (2) Antidepressant Medication Management administered using the collaborative care model (MEDS). Participants. Adults aged 18 and over with advanced heart failure (defined as New York Heart Association (NYHA) Class II, III, and IV) and depression (defined as a score of 10 or above on the PHQ-9 and confirmed by the MINI International Neuropsychiatric Interview for the DSM-5) selected from all patients at Cedars-Sinai Medical Center who are admitted with heart failure and all patients presenting to the outpatient programs of the Smidt Heart Institute at Cedars-Sinai Medical Center. We plan to randomize 416 patients to BA or MEDS, with an estimated 28% loss to follow-up/inability to collect follow-up data. Thus, we plan to include 150 in each group for a total of 300 participants from which data after randomization will be collected and analyzed.

Conclusions: The current trial is the first to compare the impact of BA and MEDS on depressive symptoms, quality of life, caregiver burden, morbidity, and mortality in patients with depression and advanced heart failure. The trial will provide novel results that will be disseminated and implemented into a wide range of current practice settings.

Registration: ClinicalTrials.Gov Identifier: NCT03688100.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244453PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790529PMC
January 2021

The impact of depression on heart transplant outcomes: A retrospective single-center cohort study.

Clin Transplant 2021 Mar 5;35(3):e14204. Epub 2021 Jan 5.

Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA.

Background: Depression is prevalent in patients with heart failure and after heart transplant. We identified the prevalence of pre- and post-transplant depression and its association with clinical characteristics and post-transplant outcomes.

Methods: We reviewed 114 adults transplanted 1/1/2015 to 12/31/2015 and identified patients with pre- and post-transplant depression. Clinical characteristics and outcomes were compared.

Results: Of 114 patients, 35.1% had pre-transplant depression and 26.3% had post-transplant depression. Patients with post-transplant depression within the first year were significantly more likely to have acute rejection (10% vs 0%), longer intensive care unit (11.7 days vs 7.8 days) and hospital stay (31.7 days vs 16.3 days), and discharge to inpatient rehabilitation (26.7% vs 8.3%). Patients with post-transplant depression within the first year had significantly higher 5-year mortality (30% vs 9.5%, p = .009). However, after adjustment for total artificial heart/biventricular assist device, acute rejection, intensive care unit, and hospital length of stay, this relationship was no longer significant (HR 2.11; 95% CI 0.18-25.27; p = .556).

Conclusions: Depression is common among heart transplant candidates and recipients. While pre-transplant depression did not impact outcomes, patients with post-transplant depression were more likely to have had a complicated course, suggesting the need for increased vigilance regarding depression in such patients.
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http://dx.doi.org/10.1111/ctr.14204DOI Listing
March 2021

Depression in Heart Failure: A Systematic Review.

Innov Clin Neurosci 2020 Apr;17(4-6):27-38

Drs. IsHak, Edwards, Herrera, Lin, Spiegel, Hedrick, Chernoff, Diniz, Danovitch; Mr. Mirocha and Mr. Peterson; and Ms. Hren, Ms. Nigor, Ms. Liu, and Ms. Manoukian and are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California.

: This paper sought to identify the instruments used to measure depression in heart failure (HF) and elucidate the impact of treatment interventions on depression in HF. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Studies published from 1988 to 2018 covering depression and HF were identified through the review of the PubMed and PsycINFO databases using the keywords: "depres*" AND "heart failure." Two authors independently conducted a focused analysis, identifying 27 studies that met the specific selection criteria and passed the study quality checks. Patient-reported questionnaires were more commonly adopted than clinician-rated questionnaires, including the Beck Depression Inventory, the Patient Health Questionnaire (PHQ-9), and the Hospital Anxiety and Depression Scale. Six common interventions were observed: antidepressant medications, collaborative care, psychotherapy, exercise, education, and other nonpharmacological interventions. Except for paroxetine, selective serotonin reuptake inhibitors failed to show a significant difference from placebo. However, the collaborative care model including the use of antidepressants showed a significant decrease in PHQ-9 score after one year. All of the psychotherapy studies included a variation of cognitive behavioral therapy and patients showed significant improvements. The evidence was mixed for exercise, education, and other nonpharmacological interventions. This study suggests which types of interventions are more effective in addressing depression in heart failure patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413333PMC
April 2020

The impact of antidepressants on depressive symptom severity, quality of life, morbidity, and mortality in heart failure: a systematic review.

Drugs Context 2020 29;9. Epub 2020 Jul 29.

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Objective: The purpose of this paper is to review the literature on the impact of antidepressants on depressive symptom severity, quality of life (QoL), morbidity, and mortality in patients with heart failure (HF).

Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies published from December 1969 to December 2019 that pertain to depression and HF were identified through the use of the PubMed and PsycINFO databases, using the keywords: 'antidepressant*' and 'heart failure.' Two authors independently conducted a focused analysis and reached a final consensus on 17 studies that met the specific selection criteria and passed the study quality checks.

Results: Studies varied in types of antidepressants used as well as in study designs. Ten studies were analyzed for the impact of antidepressant medications on depressive symptom severity. Five of these were randomized controlled trials (RCTs), out of which sertraline and paroxetine showed a significant reduction in depressive symptoms despite the small samples utilized. Four of the 17 studies addressed QoL as part of their outcomes showing no difference for escitalopram (RCT), significantly greater improvements for paroxetine controlled release (RCT), statistical significance for sertraline compared to control (pilot study), and showing significant improvement before and after treatment (open-label trial) for nefazodone. Thirteen of the 17 studies included measures of morbidity and mortality. Although early analyses have pointed to an association of antidepressant use and mortality particularly with fluoxetine, the reviewed studies showed no increase in mortality for antidepressants, and secondary analyses showed improved mortality in patients who achieved remission of depressive symptoms.

Conclusion: Out of the various antidepressants studied, which included sertraline, paroxetine, escitalopram, citalopram, bupropion, nefazodone, and nortriptyline, selective serotonin reuptake inhibitors seem to be a safe treatment option for patients with depression and HF. However, due to the variety of study designs as well as the mixed results for each antidepressant, more information for reducing depression severity, morbidity, and mortality and improving quality of life in patients with HF should be examined using robust large sample RCTs.
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http://dx.doi.org/10.7573/dic.2020-5-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398616PMC
July 2020

Psychiatric Symptoms in Cushing's Syndrome: A Systematic Review.

Innov Clin Neurosci 2020 Jan;17(1-3):30-35

Drs. Lin and Ishak are with the David Geffen School of Medicine at UCLA in Los Angeles, California.

Psychiatric symptoms are frequently comorbid with Cushing's syndrome (CS), a relatively rare condition that results from chronic hypercortisolism. Psychiatric manifestations might be present in the prodromal phase, during the course of the illness, and even after the resolution of CS. Our goals are to review the prevalence of psychiatric symptoms in CS; to determine the impact of psychiatric symptoms on morbidity, functioning, and quality of life; and to analyze the impact of treatment of CS on psychiatric symptoms. A systematic search of the literature database was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 17 articles to be included in this review. Overall, studies suggested that psychiatric symptoms-including, most prominently, depression-were present in a significant proportion of patients with CS. They reported lower health-related quality of life, which persisted even following the resolution of hypercortisolism. Though treatment and cure of CS significantly improved psychiatric symptoms, some patients did not achieve complete resolution of psychiatric symptoms and required continued psychiatric treatment. The majority of the literature indicates that psychiatric manifestations are an important part of CS and overall lower health-related quality of life and psychiatric symptoms can persist even after the cure of CS. This emphasizes the significance of early diagnosis for psychiatric management and stresses the importance of monitoring the long-term effects of neurocognitive and psychiatric symptoms and its impact on the quality of life, even after hypercortisolism resolution.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239565PMC
January 2020

Investigation of cortisol dynamics in human sweat using a graphene-based wireless mHealth system.

Matter 2020 Apr 26;2(4):921-937. Epub 2020 Feb 26.

Department of Medical Engineering, Division of Engineering and Applied Science, California Institute of Technology, Pasadena, California, 91125, USA.

Understanding and assessing endocrine response to stress is crucial to human performance analysis, stress-related disorder diagnosis, and mental health monitoring. Current approaches for stress monitoring are largely based on questionnaires, which could be very subjective. To avoid stress-inducing blood sampling and to realize continuous, non-invasive, and real-time stress analysis at the molecular levels, we investigate the dynamics of a stress hormone, cortisol, in human sweat using an integrated wireless sensing device. Highly sensitive, selective, and efficient cortisol sensing is enabled by a flexible sensor array that exploits the exceptional performance of laser-induced graphene for electrochemical sensing. Herein, we report the first cortisol diurnal cycle and the dynamic stress response profile constructed from human sweat. Our pilot study demonstrates a strong empirical correlation between serum and sweat cortisol, revealing exciting opportunities offered by sweat analysis toward non-invasive dynamic stress monitoring via wearable and portable sensing platforms.
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http://dx.doi.org/10.1016/j.matt.2020.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138219PMC
April 2020

Improving Depression Management in Patients with Medical Illness Using Collaborative Care: Linking Treatment from the Inpatient to the Outpatient Setting.

Innov Clin Neurosci 2019 Nov;16(11-12):19-24

Drs. Edwards, Herrera, Danovitch, and IsHak are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center in Los Angeles, California.

: This paper sought to review the impact of depression in patients with comorbid medical problems, the importance of bridging the gap between inpatient and outpatient care for medical inpatients with depression (especially for organizations that treat patients in both settings), and the elements necessary to implement a pilot for an outpatient Collaborative Care Management program for patients with depression following medical admissions. Taken into account is the presence of new billing mechanisms and potential cost offsets. The literature referenced in this paper was identified through a search of online databases, including PubMed and Google Scholar. The data used to analyze cost were drawn from national, publicly available sources, such as the Kaiser Family Foundation, Bureau of Labor Statistics, and the Organisation for Economic Cooperation and Development. Collaborative care is an evidence-based intervention for depression that can aid with successful transition of care as patients move from the inpatient to the outpatient setting. It can be considered cost-effective when treating a panel of patients that falls below the recommended caseload for a single case manager (i.e., 19-46 billed encounters, depending on the payer mix), particularly when considering the savings from a reduced length of stay associated with well-controlled depressive symptoms. Organizations should consider implementing collaborative care management for patients with depression to improve depression outcomes, reduce costs, and prepare themselves for a health financing environment that rewards value.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006865PMC
November 2019

Panic Attacks in HYPERALDOSTERONISM.

Innov Clin Neurosci 2019 Mar;16(3-4):19-21

Drs. Lin and IsHak are with the David Geffen School of Medicine at University of California-Los Angeles in Los Angeles, California.

Panic attacks and panic disorders are common in the general population. However, the presence of panic attacks associated with primary hyperaldosteronism has been rarely documented. We describe a patient with new-onset hyperaldosteronism secondary to adrenal adenoma who presented with recurrent panic attacks. The patient underwent adenoma resection, which was the definitive cure for the patient's hyperaldosteronism and panic attacks. Clinicians should include hyperaldosteronism on the differential for medical etiologies of panic attacks. Further research is needed to elucidate the mechanistic relationship between primary hyperaldosteronism and panic attacks.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538398PMC
March 2019

Association of Emotional Intelligence With Malpractice Claims: A Review.

JAMA Surg 2019 Mar;154(3):250-256

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.

Importance: Approximately 8% of physicians experience a malpractice claim annually. Most malpractice claims are a result of adverse events, which may or may not be a result of medical errors. However, not all medicolegal cases are the result of medical errors or negligence, but rather, may be associated with the individual nature of the patient-physician relationship. The strength of this relationship may be partially determined by a physician's emotional intelligence (EI), or his or her ability to monitor and regulate his or her emotions as well as the emotions of others. This review evaluates the role of EI in developing the patient-physician relationship and how EI may influence patient decisions to pursue medicolegal action.

Observations: Several physician characteristics are associated with increased medicolegal risk. Some of these traits, such as sex, age, level of experience, and specialty, are inherent. Other characteristics, such as patient interaction, patient satisfaction, and prior legal history, appear to be related to physicians themselves, yet they are modifiable if such physicians can be identified. Numerous tools exist that provide general measures of different aspects of EI. Furthermore, identification of those with lower EI and intervention with specific training has been shown to improve both EI and patient satisfaction.

Conclusions And Relevance: The study and effect of EI within medicine offers great opportunity to investigate how physician characteristics may influence one's EI, as well as medicolegal risk. This review suggests an indirect negative correlation between a physician's level of EI and his or her risk of litigation. Studies directly linking physicians with low EI to a higher risk of litigation are lacking and may provide valuable insight. Demonstrating such a correlation should prompt the development of interventions that may enhance a physician's level of EI early in his or her career and may limit future legal action.
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http://dx.doi.org/10.1001/jamasurg.2018.5065DOI Listing
March 2019

The Assessment and Measurement of Wellness in the Clinical Medical Setting: A Systematic Review.

Innov Clin Neurosci 2018 Oct;15(9-10):14-23

Dr. Bart is with Western University of Health Sciences and Cedars-Sinai Medical Center, in Los Angeles, California.

We conducted a systematic review of the published literature relating to the assessment and measurement of wellness in order to answer the following questions: 1) What is the working definition of wellness? 2) What wellness assessment instruments have been evaluated or applied in medical settings? 3) How valid, reliable, and accessible are these wellness assessment tools? The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this systematic review. Studies published from1990 to 2016 on wellness assessment were identified through Medline and PsycINFO using the following keywords: "assessment" OR "evaluation" OR "measurement" AND "wellness" OR "wellbeing." Two authors independently conducted a focused analysis then reached a consensus on 23 studies that met the specific selection criteria. This review revealed that there is a lack of uniform definition of wellness. The studies utilizing wellness assessment tools demonstrate strongest reliability values for the following instruments: Wellness Evaluation of Lifestyle, Five-factor Wellness Evaluation of Lifestyle, Perceived Wellness Survey, the Optimal Living Profile, and the Body-Mind-Spirit Wellness Behavior and Characteristic Inventory. However, there is insufficient evidence to support the clinical utility of a single particular wellness instrument. Properly defining wellness might help drive the development and validation of more precise assessment and measurement methods. This could reinforce interventions that promote wellness.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292717PMC
October 2018

Pain and Depression: A Systematic Review.

Harv Rev Psychiatry 2018 Nov/Dec;26(6):352-363

From the David Geffen School of Medicine at University of California Los Angeles (Drs. IsHak and Sadek; Mr. Marcia); Cedars-Sinai Medical Center, Los Angeles, CA (Drs. IsHak, Naghdechi, Vanle, Dang, Eskander, Sadek, Danovitch, and Louy; Messrs. Wen, Marcia, Yadegar; Mss. Dascal, Gohar, Aguilar-Hernandez); University of California, Riverside (Mr. Wen and Ms. Gohar); Western University of Health Sciences (Dr. Naghdechi); Harnett Health Systems, Dunn, NC (Dr. Knosp); California State University Long Beach (Ms. Hanna).

Background: Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options.

Aim: To review studies addressing pain comorbid with depression, and to report the impact of current treatments.

Method: A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review.

Results: Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression.

Conclusion: The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.
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http://dx.doi.org/10.1097/HRP.0000000000000198DOI Listing
June 2019

A Multidisciplinary Approach to Biopsychosocial Care for Adults With Inflammatory Bowel Disease: A Pilot Study.

Inflamm Bowel Dis 2018 11;24(12):2550-2554

F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Los Angeles, California.

Background: This study reports on the logistics and feasibility of a novel multidisciplinary approach to biopsychosocial care at a tertiary adult inflammatory bowel disease (IBD) center.

Methods: Consecutive patients referred for a new IBD consultation completed the following self-assessments: the Short Form-12, the Patient Reported Outcome Measurement Information System (PROMIS) Global Health Scale, the World Health Organization Disability Assessment Schedule 2.0, and the PROMIS-29. These measures were scored at the time of appointment check-in by a trained licensed clinical social worker (SW), and those scoring 1.5 standard deviations below the population mean were targeted for SW assessment and intervention at the point of care; patients or providers could also request a SW evaluation even if cutoffs were not met. In this stepped-care model, the SW could refer to same-day on-site psychiatry services or outside interventions and services. In addition, we implemented a 12-month curriculum with a monthly didactic and case-based education seminar for health care providers who interact with patients with IBD.

Results: Between February 2014 and May 2015, 110 patients (53% male; mean age, 42 years) completed a self-assessment. All patients completed their self-assessment within 10 minutes. Of these, 36.4% (40/110) were targeted for SW assessment and intervention. The SW interventions were grouped into 4 categories: psychological education and coping tools for symptom management and emotional wellness (n = 30); psychotherapy referrals (n = 30); financial/governmental programs (n = 11); and psychiatry referrals for consultation and/or medication prescription (n = 21). The educational seminars were highly rated by participating providers.

Conclusions: A multidisciplinary biopsychosocial approach to adult IBD care is feasible. Education for providers and close coordination across specialties are critical to the success of a multidisciplinary biopsychosocial program.
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http://dx.doi.org/10.1093/ibd/izy215DOI Listing
November 2018

NMDA antagonists for treating the non-motor symptoms in Parkinson's disease.

Transl Psychiatry 2018 06 15;8(1):117. Epub 2018 Jun 15.

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Among patients with Parkinson's disease (PD), depression is prevalent and disabling, impacting both health outcomes and quality of life. There is a critical need for alternative pharmacological methods to treat PD depression, as mainstream antidepressant drugs are largely ineffective in this population. Currently, there are no recommendations for the optimal treatment of PD neuropsychiatric symptoms. Given the dual antidepressant and anti-dyskinetic effects of ketamine and other N-methyl-D-aspartate (NMDA) antagonists for PD, this review aims to examine the current evidence of NMDA antagonists for treating neuropsychiatric symptoms, including memantine, amantadine, ketamine, dizoclopine, and d-cycloserine. A comprehensive literature search was conducted using the PubMed database. We also searched the following databases up to March 1, 2018: Ovid MEDLINE, PsycINFO, CINAHL, Google Scholar, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. The following keywords were used: NMDA antagonist and Parkinson's disease. Two authors independently reviewed the articles identified from the search using specific selection criteria, focusing on studies of mood, psychiatric condition, depression, cognition, and quality of life, and the consensus was reached on the 20 studies included. There is a preliminary evidence that NMDA antagonists may modulate psychiatric symptoms in PD. However, current evidence of psychiatric symptom-modifying effects is inconclusive and requires that further trials be conducted in PD. The repurposing of old NMDA antagonists, such as ketamine for depression and newer therapies, such as rapastinel, suggests that there is an emerging place for modulating the glutamatergic system for treating non-motor symptoms in PD.
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http://dx.doi.org/10.1038/s41398-018-0162-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003962PMC
June 2018

Trazodone for Insomnia: A Systematic Review.

Innov Clin Neurosci 2017 Jul-Aug;14(7-8):24-34. Epub 2017 Aug 1.

Mr. Jaffer is with the Faculty of Medicine, Cairo University, Egypt. Ms. Chang is with the University of California Los Angeles, Los Angeles, California. Dr. Vanle, Dr. Dang, Ms. Loera, Dr. Abdelmesseh, and Dr. Danovitch are with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Steiner is with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California. Dr. IsHak is with the Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, California, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.

While trazodone is approved for the treatment of depression, the off-label use of this medication for insomnia has surpassed its usage as an antidepressant. In this systematic review, we examined the evidence for the efficacy and safety of trazodone for insomnia. A literature search was conducted using MEDLINE/PubMed databases from the past 33 years (1983-2016) and the keywords insomnia, trazodone, sedative, treatment, and hypnotics. The results were restricted to English language and human subjects. All randomized clinical trials, meta-analyses, observational studies, and placebo-controlled trials regarding trazodone for the treatment of primary or secondary insomnia were reported, per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The study selection process yielded a total of 45 studies. Evidence for the efficacy of trazodone has been repeatedly demonstrated for primary insomnia, as well as secondary insomnia, including for symptoms that are a result of depression, dementia, and being a healthy man. Earlier studies (1980-2000) focused on utilizing trazodone at high doses (≥100mg/d) for the treatment of insomnia among the depressed population; however, since the 2000s, the utility of trazodone has been expanded to treat secondary insomnia among the non-depressed population as well. The side effects are dose-dependent, and the most common is drowsiness. A review of the literature suggests that there are adequate data supporting the efficacy and general safety of the low-dose use of trazodone for the treatment of insomnia.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888PMC
August 2017

Major Depression Comorbid with Medical Conditions: Analysis of Quality of Life, Functioning, and Depressive Symptom Severity.

Psychopharmacol Bull 2018 01;48(1):8-25

Drs. IsHak, Dang, Vanle, Elzahaby, Reid, Sumner, Danovitch, and Ms. Klimowicz, Kauzor, Cedars-Sinai Medical Center, Los Angeles, California, USA. Dr. Steiner, University of California, Los Angeles, California, USA. Ms. Klimowicz, Western University of Health Sciences, California, USA. Ms. Kauzor, California State University, Northridge, California, USA.

Background: The presence of Major Depressive Disorder (MDD) is often comorbid in patients with a variety of general medical conditions (GMCs) which could lead to less favorable outcomes.

Objective: The goal of this analysis is to examine functional outcomes of QOL and functioning before and after antidepressant treatment among patients with MDD with and without GMCs.

Methods: We performed a secondary analysis based on the STAR*D database. The analysis included two patient groups from the STAR*D trial: 1,198 patients comorbid with MDD and GMCs (MDD + GMC) and 1,082 patients with MDD and no GMCs (MDDnoGMC), as defined by the Cumulative Illness Rating Scale. We analyzed depressive symptom severity, functioning and quality of life (QOL) before and after level 1 treatment with citalopram.

Results: At baseline, the MDD + GMC group had significantly lower QOL (p < 0.001) and functioning (p = 0.001) than the MDDnoGMC group, although depressive symptom severity was not significantly different. Following antidepressant treatment, QOL, functioning and depressive symptom severity significantly improved for both MDD + GMC and MDDnoGMC groups. However, patients with MDD + GMC were more likely to experience severe impairments in QOL in (56.8% vs. 43.5% for MDDnoGMC, p < 0.001) and functioning (42.5% vs. 29.3% for MDDnoGMC, p < 0.001) following treatment. The remission rate was significantly lower for MDD + GMC (30.6% vs. 41.1% for MDDnoGMC, p < 0.001).

Conclusions: Our findings suggest that antidepressant treatment had a positive impact on patients with and without GMCs. However, those with GMCs experienced not only a lower remission rate, but also continued to experience more significantly severe impairments in QOL and functioning.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765436PMC
January 2018

Cryptococcal meningitis in a daily cannabis smoker without evidence of immunodeficiency.

BMJ Case Rep 2018 Jan 26;2018. Epub 2018 Jan 26.

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Cryptococcal meningitis is a life-threatening condition most commonly observed in immunocompromised individuals. We describe a daily cannabis smoker without evidence of immunodeficiency presenting with confirmed meningitis. An investigation of cannabis samples from the patient's preferred dispensary demonstrated contamination with several varieties of , including , and other opportunistic fungi. These findings raise concern regarding the safety of dispensary-grade cannabis, even in immunocompetent users.
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http://dx.doi.org/10.1136/bcr-2017-221435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787011PMC
January 2018

The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder.

Ther Adv Psychopharmacol 2018 Jan 1;8(1):49-58. Epub 2017 Nov 1.

Cedars-Sinai Medical Center Department of Psychiatry and UCLA, 8730 Alden Drive, Thalians E-132, Los Angeles, CA 90048-0750, USA.

The objective of this review was to evaluate the efficacy of selective serotonin reuptake inhibitors (SSRIs) and SSRIs compared with other treatment modalities in preventing relapse after an episode of major depressive disorder (MDD). An Ovid MEDLINE and PsycINFO search (from 1987 to August 2017) was conducted using the following terms: selective serotonin reuptake inhibitors, antidepressants, depression, prevention, prophylaxis, relapse and MDD. Using predefined criteria, two authors independently selected and reached consensus on the included studies. Sixteen articles met the criteria: 10 compared the relapse rate of selective SSRIs with placebo or other SSRIs; one discussed the effectiveness of SSRIs plus psychotherapy, two compared SSRI tricyclic antidepressants (TCAs), two were mainly composed of TCAs plus psychotherapy, and one compared SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs). According to the included studies, the relapse risk in adults was lower when SSRIs were combined with psychotherapy. Results comparing SSRIs and SNRIs were inconclusive. TCAs may be equally as effective as SSRIs. Atypical antidepressants (mirtazapine and St John's Wort) had no significant difference in efficacy and remission rates compared with SSRIs. Escitalopram appeared to fare better in efficacy than other SSRIs, owing to a higher prophylactic efficacy and lower side effects; however, according to the current data, this difference was not significant. To conclude, this review provides evidence that continuing SSRIs for 1 year reduces risk of MDD and relapse. Furthermore, the combination of SSRIs and cognitive behavioural therapy may effectively reduce relapse. Escitalopram appeared to yield better results and fewer side effects than did other SSRIs or SNRIs. The effectiveness in reducing relapse of SSRIs was similar to that of TCAs and atypical antidepressants.
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http://dx.doi.org/10.1177/2045125317737264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761909PMC
January 2018

Quality of Life, Functioning, and Depressive Symptom Severity in Older Adults With Major Depressive Disorder Treated With Citalopram in the STAR*D Study.

J Clin Psychiatry 2017 Jul;78(7):897-903

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, 8730 Alden Dr, Thalians E-132, Los Angeles, CA 90048.

Objective: Major depressive disorder (MDD) can substantially worsen patient-reported quality of life (QOL) and functioning. Prior studies have examined the role of age in MDD by comparing depressive symptom severity or remission rates between younger and older adults. This study examines these outcomes before and after SSRI treatment. On the basis of prior research, we hypothesized that older adults would have worse treatment outcomes in QOL, functioning, and depressive symptom severity and that nonremitters would have worse outcomes.

Methods: A retrospective secondary data analysis was conducted from the National Institute of Mental Health-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (July 2001-September 2006). We analyzed data for 2,280 nonpsychotic adults with DSM-IV-TR-defined MDD who received citalopram monotherapy. Older adults were classified as adults aged 65 years and above. All subjects completed patient-reported QOL, functioning, and depressive symptom severity measures at entry and exit. Subjects included 106 older adults and 2,174 adults < 65. MDD remission status posttreatment was also determined.

Results: Both older adults and adults < 65 experienced significant improvements and medium to large treatment responses across QOL, functioning, and depressive symptom severity (P < .001). Older adults had smaller treatment effect sizes for all outcomes, particularly functioning. Conversely, mean change scores from entry to exit were equivalent across all outcomes. Remitters at exit had significantly better responses to treatment than nonremitters for the majority of outcomes.

Conclusion: Findings suggest that older adults and younger adults have comparable treatment responses to citalopram monotherapy, with significant improvements in patient-reported depressive symptom severity, functioning, and QOL.

Trial Registration: ClinicalTrials.gov identifier: NCT00021528.
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http://dx.doi.org/10.4088/JCP.16m11335DOI Listing
July 2017

Quality of life and functioning of Hispanic patients with Major Depressive Disorder before and after treatment.

J Affect Disord 2018 01 14;225:117-122. Epub 2017 Aug 14.

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States. Electronic address:

Background: Similar rates of remission from Major Depressive Disorder (MDD) have been documented between ethnic groups in response to antidepressant treatment. However, ethnic differences in functional outcomes, including patient-reported quality of life (QOL) and functioning, have not been well-characterized. We compared symptomatic and functional outcomes of antidepressant treatment in Hispanic and non-Hispanic patients with MDD.

Methods: We analyzed 2280 nonpsychotic treatment-seeking adults with MDD who received citalopram monotherapy in Level 1 of the Sequenced Treatment Alternatives to Relieve Depression study. All subjects (239 Hispanic, 2041 non-Hispanic) completed QOL, functioning, and depressive symptom severity measures at entry and exit.

Results: Hispanic participants had significantly worse QOL scores at entry and exit (p < 0.01). However, after controlling for baseline QOL, there was no difference between Hispanic and non-Hispanic patients' QOL at exit (p = 0.21). There were no significant between-group differences at entry or at exit for depressive symptom severity or functioning. Both groups had significant improvements in depressive symptom severity, QOL, and functioning from entry to exit (all p values < 0.01). Patients with private insurance had lower depressive symptom severity, greater QOL, and better functioning at exit compared to patients without private insurance.

Limitations: This study was a retrospective data analysis, and the Hispanic group was relatively small compared to the non-Hispanic group.

Conclusions: Hispanic and non-Hispanic participants with MDD had similar responses to antidepressant treatment as measured by depressive symptom severity scores, quality of life, and functioning. Nevertheless, Hispanic patients reported significantly worse quality of life at entry.
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http://dx.doi.org/10.1016/j.jad.2017.08.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626642PMC
January 2018

Virtual Reality and Medical Inpatients: A Systematic Review of Randomized, Controlled Trials.

Innov Clin Neurosci 2017 Jan-Feb;14(1-2):14-21. Epub 2017 Feb 1.

All authors are from Cedars-Sinai Medical Center, Department of Psychiatry and Behavioral Neurosciences in Los Angeles, California.

We evaluated the evidence supporting the use of virtual reality among patients in acute inpatient medical settings. We conducted a systematic review of randomized controlled trials conducted that examined virtual reality applications in inpatient medical settings between 2005 and 2015. We used PsycINFO, PubMed, and Medline databases to identify studies using the keywords , , , and We identified 2,024 citations, among which 11 met criteria for inclusion. Studies addressed three general areas: pain management, eating disorders, and cognitive and motor rehabilitation. Studies were small and heterogeneous and utilized different designs and measures. Virtual reality was generally well tolerated by patients, and a majority of studies demonstrated clinical efficacy. Studies varied in quality, as measured by an evaluation metric developed by Reisch, Tyson, and Mize (average quality score=0.87; range=0.78-0.96). Virtual reality is a promising intervention with several potential applications in the inpatient medical setting. Studies to date demonstrate some efficacy, but there is a need for larger, well-controlled studies to show clinical and cost-effectiveness.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373791PMC
February 2017

The impact of cannabis and cannabinoids for medical conditions on health-related quality of life: A systematic review and meta-analysis.

Drug Alcohol Depend 2017 05 1;174:80-90. Epub 2017 Mar 1.

Cedars-Sinai Medical Center, Los Angeles, CA, United States.

Introduction: The use of cannabis or cannabinoids to treat medical conditions and/or alleviate symptoms is increasingly common. However, the impact of this use on patient reported outcomes, such as health-related quality of life (HRQoL), remains unclear.

Methods: We conducted a systematic review and meta-analysis, employing guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We categorized studies based on design, targeted disease condition, and type of cannabis or cannabinoid used. We scored studies based on quality and risk of bias. After eliminating some studies because of poor quality or insufficient data, we conducted meta-analyses of remaining studies based on design.

Results: Twenty studies met our pre-defined selection criteria. Eleven studies were randomized controlled trials (RCTs; 2322 participants); the remaining studies were of cohort and cross-sectional design. Studies of cannabinoids were mostly RCTs of higher design quality than studies of cannabis, which utilized smaller self-selected samples in observational studies. Although we did not uncover a significant association between cannabis and cannabinoids for medical conditions and HRQoL, some patients who used them to treat pain, multiple sclerosis, and inflammatory bower disorders have reported small improvements in HRQoL, whereas some HIV patients have reported reduced HRQoL.

Conclusion: The relationship between HRQoL and the use of cannabis or cannabinoids for medical conditions is inconclusive. Some patient populations report improvements whereas others report reductions in HRQoL. In order to inform users, practitioners, and policymakers more clearly, future studies should adhere to stricter research quality guidelines and more clearly report patient outcomes.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.12.030DOI Listing
May 2017

Screening for depression in hospitalized medical patients.

J Hosp Med 2017 02;12(2):118-125

Cedars-Sinai Medical Center, Division of General Internal Medicine, Los Angeles, CA, USA.

Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer-reviewed articles in English (1990-2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full-text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self-administered by patients or when abbreviated versions were administered by individuals without formal training. With regard to outcomes, studies from several individual hospitals found depression to be associated with poorer functional outcomes, worse physical health, and returns to the hospital after discharge. These findings suggest that depression screening may be feasible in the inpatient setting, and that more research is warranted to determine whether screening for and treating depression during hospitalization can improve patient outcomes. Journal of Hospital Medicine 2017;12:118-125.
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http://dx.doi.org/10.12788/jhm.2693DOI Listing
February 2017

Quality of life and recreational cannabis use.

Am J Addict 2017 Jan 21;26(1):8-25. Epub 2016 Dec 21.

Cedars-Sinai Medical Center, Los Angeles, California.

Introduction: Cannabis is now the most commonly used illicit drug in the United States and use is increasing. Frequent cannabis use has been associated with adverse social and health effects. We sought to evaluate the relationship between recreational cannabis use and Quality of Life (QoL), a person-centered measure that characterizes the overall sense of health and wellbeing. We hypothesized that QoL would be unchanged or increased among recreational cannabis users, who did not meet criteria for a Cannabis Use Disorder (CUD) and that QoL would be lower among those who met criteria for a CUD.

Methods: We conducted a systematic review, employing guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The results were categorized into tables and identified trends.

Results: Fourteen studies met our pre-defined selection criteria. The studies were heterogeneous and their quality was low. With one exception, we did not identify any population for whom cannabis use was associated with improved QoL. QoL was lower in persons who used cannabis heavily, or who met criteria for CUD. However, this association was inconsistent and the magnitude was weaker than the relationship between QoL and use of other addictive substances (including tobacco and illicit drugs).

Conclusion: In this systematic review, heavy cannabis use or CUD was associated with reduced QoL. It is unknown whether reduced QoL drives cannabis use, or whether cannabis use can lead to reduced QoL. Prospective studies are needed to evaluate the causal relationship between cannabis and QoL.

Scientific Significance: Furthering the understanding of the relationship between cannabis and QoL can inform public policy, prevention efforts, outcomes, and an objective understanding of the effects of cannabis users. (Am J Addict 2017;26:8-25).
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http://dx.doi.org/10.1111/ajad.12486DOI Listing
January 2017

The recovery index: A novel approach to measuring recovery and predicting remission in major depressive disorder.

J Affect Disord 2017 Jan 15;208:369-374. Epub 2016 Oct 15.

UCLA Graduate School of Education and Information Studies, United States.

Background: Clinicians view "recovery" as the reduction in severity of symptoms over time, whereas patients view it as the restoration of premorbid functioning level and quality of life (QOL). The main purpose of this study is to incorporate patient-reported measures of functioning and QOL into the assessment of patient outcomes in MDD and to use this data to define recovery.

Method: Using the STAR*D study of patients diagnosed with MDD, this present analysis grades patients' MDD severity, functioning level, and QOL at exit from each level of the study, as well as at follow-up. Using Item Response Theory, we combined patient data from functioning and QOL measures (WSAS, Q-LES-Q) in order to form a single latent dimension named the Recovery Index.

Results: Recovery Index - a latent measure assessing impact of illness on functioning and QOL - is able to predict remission of MDD in patients who participated in the STAR*D study.

Conclusions: By incorporating functioning and quality of life, the Recovery index creates a new dimension towards measuring restoration of health, in order to move beyond basic symptom measurement.
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http://dx.doi.org/10.1016/j.jad.2016.08.081DOI Listing
January 2017

Analysis of Patient-reported Outcomes of Quality of Life and Functioning Before and After Treatment of Major Depressive Disorder Comorbid With Alcohol Use Disorders.

J Addict Med 2017 Jan/Feb;11(1):47-54

Department of Psychiatry and Behavioral Neurosciences (ID, AJS, AK, MG, MH, BV, JD, WWI), Cedars-Sinai Medical Center; Department of Psychiatry and Biobehavioral Sciences (WWI), David Geffen School of Medicine, University of California; Department of Psychology (AJS), California School of Professional Psychology at Alliant International University; Biostatistics Core (JM), Research Institute and Clinical & Translational Science Institute (CTSI), Cedars-Sinai Medical Center, Los Angeles, CA; and Department of Psychological Sciences (KC), Purdue University, West Lafayette, IN.

Objective: Alcohol use disorders (AUDs) are common among persons with major depressive disorder (MDD) and have an adverse impact on course of illness and patient outcomes. The aim of this study was to examine whether AUD adversely impacted patient-centered outcomes in a sample of research subjects evaluated as part of a large clinical trial for depression. The outcomes of interest to this post hoc analysis are quality of life (QOL), functioning, and depressive symptom severity.

Methods: We analyzed 2280 adult MDD outpatient research subjects using data from the Sequenced Treatment Alternatives to Relieve Depression trial. We compared entry and post-selective serotonin reuptake inhibitors (SSRI) treatment QOL, functioning, and depressive symptom severity scores between 121comorbid MDD with AUD (MDD + AUD) subjects and 2159 MDD-no-AUD subjects, and also differences between subjects categorized as remitters versus nonremitters within each group at exit.

Results: At entry, MDD + AUD subjects reported similar QOL, functioning, and depressive symptom severity compared with the MDD-no-AUD subjects. After treatment with citalopram, both groups showed significant improvements throughout treatment; however, 36% to 55% of subjects still suffered from severely impaired QOL and functioning at exit.

Conclusions: The overall study population demonstrated a significant response to treatment with large effect sizes in depressive symptom reduction, but to a lesser extent in QOL and functioning. Findings suggest that subjects with MDD + AUD benefited equally as MDD-no-AUD from treatment with selective serotonin reuptake inhibitors (SSRI) medication, yet both groups continue to experience reduced QOL and functioning after treatment. Monitoring QOL and functioning is critical to determine whether interventions that improve clinical outcomes also impact patient-centered outcomes, and our analysis suggests that there is a pressing need for innovative interventions that effectively improve these outcomes.
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http://dx.doi.org/10.1097/ADM.0000000000000268DOI Listing
October 2017

Are sertraline, paroxetine and duloxetine the most effective antidepressants for use in depressed adults over 60 years?

Evid Based Ment Health 2016 11 7;19(4):e26. Epub 2016 Jul 7.

Western University of Health Sciences-College of Osteopathic Medicine of the Pacific, Pomona, California, USA.

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http://dx.doi.org/10.1136/eb-2016-102392DOI Listing
November 2016

Patient-reported functioning in major depressive disorder.

Ther Adv Chronic Dis 2016 May 31;7(3):160-9. Epub 2016 Mar 31.

Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA.

Objectives: Compared with the general population, patients with major depressive disorder (MDD) report substantial deficits in their functioning that often go beyond the clinical resolution of depressive symptoms. This study examines the impact of MDD and its treatment on functioning.

Methods: From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, we analyzed complete data of 2280 adult outpatients with MDD at entry and exit points of each level of antidepressant treatment and again 12 months post treatment. Functioning was measured using the Work and Social Adjustment Scale (WSAS).

Results: The results show that only 7% of patients with MDD reported within-normal functioning before treatment. The proportion of patients achieving within-normal functioning (WSAS) scores significantly increased after treatment. However, the majority of patients (>60%) were still in the abnormal range on functioning at exit. Although remitted patients had greater improvements compared with nonremitters, a moderate proportion of remitted patients continued to experience ongoing deficits in functioning after treatment (20-40%). Follow-up data show that the proportions of patients experiencing normal scores for functioning after 12 months significantly decreased from the end of treatment to the follow-up phase, from 60.1% to 49% (p < 0.0001), a finding that was particularly significant in nonremitters. Limitations of this study include the reliance on self-report of functioning and the lack of information on patients who dropped out.

Conclusion: This study points to the importance of functional outcomes of MDD treatment as well as the need to develop personalized interventions to improve functioning in MDD.
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http://dx.doi.org/10.1177/2040622316639769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907070PMC
May 2016

Examining the Impact of Patient-Reported Hope for Improvement and Patient Satisfaction with Clinician/Treatment on the Outcome of Major Depressive Disorder Treatment.

Int Neuropsychiatr Dis J 2016;7(2). Epub 2016 May 9.

School of Public Health, University of California Los Angeles, Los Angeles, California, USA.

Aims: This analysis aims at examining if patient-reported variables such as hope for improvement and patient satisfaction with clinician/treatment could influence the outcome major depressive disorder (MDD) treatment, namely depression remission, in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

Study Design: Retrospective cohort study.

Place And Duration Of Study: The STAR*D study was conducted at 18 primary care and 23 psychiatric care settings in the United States from 2001-2007 and was funded by the National Institute of Mental health (NIMH). The analysis contained in this manuscript was conceptualized at the Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences and performed at the UCLA School of Public Health.

Methodology: Using data from STAR*D, the current study used logistic regression and survival analyses to examine the relationship between depressive symptoms remission and two sets of self-reported factors: Hope for improvement and, Patient satisfaction with treatment/clinician.

Results: First, more than 90% of STAR*D patients reported having high hope for improvement (agree or strongly agree) and more than 66% endorsed high satisfaction with clinicians and more than 50% expressed high satisfaction with treatments (very or mostly satisfied). Second, hope for improvement was predictive of depression remission (p<0.05). Third, satisfaction with clinician/treatment, did not predict remission.

Conclusion: This study shows the impact that patients' subjective hope for improvement can have on predicting depression remission in contrast to satisfaction with clinician/treatment. Future studies should prospectively incorporate patients' subjective attitudes regarding hope for improvement and satisfaction with clinicians and treatments as mediators and moderators of MDD treatment success.
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http://dx.doi.org/10.9734/INDJ/2016/26203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902012PMC
May 2016

Polypharmacy in Maintenance of Bipolar Disorder.

Clin Neuropharmacol 2016 May-Jun;39(3):132-4

*Richmond University Medical Center and Freedom From Fear, Staten Island, NY; †Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona; and ‡Cedars-Sinai Medical Center, and §David Geffen School of Medicine at UCLA, Los Angeles, CA.

Objectives: To track the outcomes of bipolar patients who had remitted from an acute manic episode on single- and multiple-drug regimens including lithium (LI), valproate (VPA), and carbamazepine (CBZ), in order to compare relapse rates on 1, 2, or 3 medications.

Methods: Following treatment of an acute manic episode and a 1-month period of no signs of mood episodes, patients were evaluated at 1- to 2-month intervals as to the kind of regimen required to maintain their stability while continuing on this regimen for 2 years. Medication regimens included 1, 2, or 3 of the following drugs: LI, VPA, and/or CBZ. The 3 medication groups were followed from entry into the study through 3 possible end points based on the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition checklist: "NO-Relapse," "Relapse," or "Dropped out."

Results: Of the 1312 patients included in the study and followed up for 2 years, 281 patients (21.4%) were maintained on a single drug (LI, VPA, or CBZ), 852 (65%) on 2 drugs, and 179 (13.6%) on 3 or more drugs. A smaller percentage of patients on 1 medication had NO-Relapse for 2 years (22.8%), compared with patients on 2 medications (43.9%) and patients on 3 or more medications (41.9%): χ2 = 40.3, P < 0.001.

Conclusions: This study showed that overall, of the bipolar patients who were asymptomatic at 1 month, a smaller percentage of patients on 1 medication continued to be stable for 2 years, compared with patients on 2 medications and patients on 3 or more medications.
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http://dx.doi.org/10.1097/WNF.0000000000000147DOI Listing
January 2017