Category: Depression

Clinical depression can exacerbate the symptoms of knee arthritis beyond what is evident on X-rays, according to a new study from the Journal of Bone and Joint Surgery (JBJS). Patients with mild to moderate knee arthritis are especially affected by depression, the study notes.

"Knee osteoarthritis is a common cause of pain and impairment in older adults," said Tae Kyun Kim, MD, study author and director of the Division of Knee Surgery and Sports Medicine at Seoul National University Bundang Hospital's Joint Reconstruction Center. "Often, the level of arthritic symptoms reported by patients is much more severe than what is represented by X-rays, which can make it difficult for the doctor to treat.

"The results of this study indicate that depression can play a major role in the way patients experience the symptoms of knee arthritis, and that even when X-rays show the arthritis is not severe, patients with depression may report significant pain," Dr. Kim said. "The relationship between pain and depression suggests that both should be considered by physicians when treating patients with knee osteoarthritis, particularly in those with X-rays not indicating severe damage to the joint."

The study included 660 men and women aged 65 years or older who were evaluated for the severity of their knee arthritis on X-rays, as well as symptom severity. Patient interviews and questionnaires were used to assess coincident depressive disorders. The study was conducted as a part of the Korean Longitudinal Study on Health and Aging (KLoSHA).

As expected, the researchers found the levels of pain attributed to knee arthritis were higher in patients whose X-rays indicated greater joint damage; however, they also found depressive disorders were associated with an increase in pain in patients with mild to moderate knee arthritis, even when X-rays did not show significant joint damage.

"When evaluating the results of this study, the contribution of depression to knee osteoarthritis symptoms was almost as important as the damage indicated on X-rays," Dr. Kim noted.

Knee arthritis typically affects men and women over 50 years of age, and occurs most frequently in people who are overweight. Common symptoms include:

• pain or stiffness in or around the knee;
• swelling of the knee;
• limited range of motion when walking or moving the knee; or
• knee weakness or a feeling of instability.

In more severe cases, the knee joint may appear deformed, such as bowlegged or knock-kneed appearance, either bulging outward or toward the side of the leg. Knee replacement surgery is often performed in patients with severe symptoms.

Although studies have indicated depression is not uncommon among older adults, it remains largely underdiagnosed. According to the National Institute of Mental Health (NIMH):

• The risk of depression increases with other illnesses and when ability to function becomes limited.
• Estimates of major depression in older people range from 1 percent to 5 percent among those living in the community, to as high as 11.5 percent in hospital patients and 13.5 percent in those who require home healthcare.
• An estimated 5 million older adults have mild depression, which is often undiagnosed. Symptoms of depression may include:
• feelings of sadness or hopelessness;
• loss of interest in activities that were once enjoyed;
• change in appetite or sleep patterns;
• difficulty thinking and remembering; or
• frequent thoughts of death or dying.

"Despite the reported satisfactory outcomes of knee replacement surgery a percentage of patients still experience knee pain and impaired movement," said Dr. Kim said. "Sometimes pain and disability after surgery is medically unexplained, so in these patients screening for depression might be a very good option."

The numbers are, well, depressing: More than 2 million people age 65 and older suffer from depression, including 50 percent of those living in nursing homes. The suicide rate among white men over 85 is the highest in the country — six times the national rate.

And we're not getting any younger. In the next 35 years, the number of Americans over 65 will double and the number of those over 85 will triple.

So the question becomes, how to help elderly depressed individuals?

Researchers at UCLA turned to a gentle, Westernized version of tai chi chih, a 2,000-year-old Chinese martial art. When they combined a weekly tai chi exercise class with a standard depression treatment for a group of depressed elderly adults, they found greater improvement in the level of depression — along with improved quality of life, better memory and cognition, and more overall energy — than among a different group in which the standard treatment was paired with a weekly health education class.

The results of the study appear in the current online edition of the American Journal of Geriatric Psychiatry.

"This is the first study to demonstrate the benefits of tai chi in the management of late-life depression, and we were encouraged by the results," said first author Dr. Helen Lavretsky, a UCLA professor-in-residence of psychiatry. "We know that nearly two-thirds of elderly patients who seek treatment for their depression fail to achieve relief with a prescribed medication."

In the study, 112 adults age 60 or older with major depression were treated with the drug escitalopram, a standard antidepressant, for approximately four weeks. From among those participants, 73 who showed only partial improvement continued to receive the medication daily but were also randomly assigned to 10 weeks of either a tai chi class for two hours per week or a health education class for two hours per week.

All the participants were evaluated for their levels of depression, anxiety, resilience, health-related quality of life, cognition and immune system inflammation at the beginning of the study and again four months later.

The level of depression among each participant was assessed using a common diagnostic tool known as the Hamilton Rating Scale for Depression, which involves interviewing the individual. The questions are designed to gauge the severity of depression. A cut-off score of 10/11 is generally regarded as appropriate for the diagnosis of depression.

The researchers found that among the tai chi participants, 94 percent achieved a score of less than 10, with 65 percent achieving remission (a score of 6 or less). By comparison, among participants who received health education, 77 percent achieved scores of 10 or less, with 51 percent achieving remission.

While both groups showed improvement in the severity of depression, said Lavretsky, who directs UCLA's Late-Life Depression, Stress and Wellness Research Program, greater reductions were seen among those taking escitalopram and participating in tai chi, a form of exercise that is gentle enough for the elderly.

"Depression can lead to serious consequences, including greater morbidity, disability, mortality and increased cost of care," Lavretsky said. "This study shows that adding a mind-body exercise like tai chi that is widely available in the community can improve the outcomes of treating depression in older adults, who may also have other, co-existing medical conditions, or cognitive impairment.

"With tai chi," she said, "we may be able to treat these conditions without exposing them to additional medications."

Other authors on the study included Lily L. Alstein, Richard E. Olmstead, Linda M. Ercoli, Marquertie Riparetti-Brown, Natalie St. Cyr and Michael R. Irwin, all of UCLA.

Funding for the study was provided by the National Institutes of Health, the General Clinical Research Centers Program, the UCLA Cousins Center at the Semel Institute for Neuroscience and Human Behavior, and the UCLA Older Americans Independence Center.

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Journal Reference:

1. Helen Lavretsky, Lily L. Alstein, Richard E. Olmstead, Linda M. Ercoli, Marquertie Riparetti-Brown, Natalie St. Cyr, Michael R. Irwin. Complementary Use of Tai Chi Chih Augments Escitalopram Treatment of Geriatric Depression. American Journal of Geriatric Psychiatry, 2011; : 1 DOI: 10.1097/JGP.0b013e31820ee9ef

Depression is associated with an increased risk of developing kidney failure in the future, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN). Approximately 10% of the US population will suffer from depression at some point during their lifetime.

Lead investigator, Dr. Willem Kop (Department of Medical Psychology and Neuropsychology at the University of Tilburg, the Netherlands) and colleagues studied 5,785 people from four counties across the United States for 10 years. The participants were 65 years and older and not yet on dialysis. They completed a questionnaire measuring depressive symptoms and a broad range of medical measurements, including estimated glomerular filtration rate (eGFR) and risk factors for kidney and heart diseases. The investigators examined whether depression predicted the onset of kidney disease or other medical problems in which the kidneys play a critical role.

According to the results, depression coincided with the presence of chronic kidney disease (CKD) and was 20% more common in individuals with kidney disease than those without kidney disease. The study shows that depression predicted subsequent rapid decline in kidney function, new onset clinically severe kidney disease (or end-stage renal disease), and hospitalizations that were complicated by acute kidney injury. When the investigators corrected for the long-term effects of other medical measures, the predictive value of depression for hospitalizations with acute kidney injury remained high.

Take home message: "People with elevated depressive symptoms have a higher risk of subsequent adverse kidney disease outcomes. This is partially explained by other medical factors related to depression and kidney disease. But, the association with depression was stronger in patients who were otherwise healthy compared to those who had co-existing medical disorders such as diabetes or heart disease," explains Kop.

The investigators are currently analyzing which factors may explain the association with depression, which could include delayed seeking of medical care and miscommunications between patient and physicians and important biological processes associated with depression, such as the immune and nervous systems.

Study co-authors include Stephen Seliger (University of Maryland, Nephrology); Jeffrey Fink (University of Maryland Medical System, Department of Medicine, Division of Nephrology); Ronit Katz (University of Washington, Biostatistics); Michelle Odden (University of California, Berkeley, Department of Epidemiology); Linda Fried (Veterans Affairs Pittsburgh Health System); Dena Rifkin (UCSD and VASDHS, Medicine); Mark Sarnak (Tufts-New England Medical Center, Medicine); and John Gottdiener (University of Maryland, School of Medicine, Medicine).

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Journal Reference:

1. Willem J. Kop, Stephen L. Seliger, Jeffrey C. Fink, Ronit Katz, Michelle C. Odden, Linda F. Fried, Dena E. Rifkin, Mark J. Sarnak, John S. Gottdiener. Longitudinal Association of Depressive Symptoms with Rapid Kidney Function Decline and Adverse Clinical Renal Disease Outcomes. Clinical Journal of the American Society Nephrology, 2011; DOI: 10.2215/CJN.03840510

Participants in the first hospital-initiated, low-intensity collaborative care program to treat depression in heart patients showed significant improvements in their depression, anxiety and emotional quality of life after 6 and 12 weeks, researchers report in Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal.

Depression is a common condition in cardiovascular disease (CVD) patients which can result in poor prognosis and quality of life.

Collaborative care depression management programs use a non-physician care manager to coordinate depression evaluation and treatment among the patient, primary medical physician and a psychiatrist.

In their trial, researchers randomized 175 depressed heart patients (mostly Caucasian and about half women) to either "usual care" (a recommendation for depressive treatment) or "collaborative care," which includes receiving written and verbal education about depression and its impact on cardiac disease, scheduling pleasurable leisure activities post-discharge, receiving detailed treatment options (medicines or counseling referral), and coordinating follow-up care after discharge.

"Collaborative care depression-management programs have been used in the outpatient setting, but such a program had never been initiated in the hospital or used for patients with a wide range of cardiac illnesses," said Jeff C. Huffman, M.D., lead author of the study, assistant professor of psychiatry at Harvard Medical School and director of the Cardiac Psychiatry Research Program at Massachusetts General Hospital in Boston.

"In the real world this program would be applied on cardiac floors and would be much more easily applied to a large group of patients rather than a small subset or single diagnosis," said Huffman. "This kind of economy of scale may make it much more feasible from a resource and cost standpoint."

Six weeks after leaving the hospital, nearly twice as many of the collaborative care patients reported their depression symptoms were cut by half or more, compared to those receiving usual care (59.7 percent vs 33.7 percent). The differences at 12 weeks were also improved with a 51.5 percent depression response rate for collaborative care patients versus 34.4 percent for patients receiving usual care.

Those effects decreased once the intervention ended at 12 weeks and between-group differences lost their statistical significance by the six-month follow-up call, which came three months after the patients' last contact with the researchers.

Although rehospitalization rates were similar between groups, the collaborative care patients' self-reported significantly fewer and less severe cardiac symptoms and better adherence to healthy activities like diet and exercise at six months compared to the usual care group. "These improvements are relevant medical outcomes in themselves, and suggest this type of program may have broad effects on overall health," Huffman said.

Those in the collaborative care group got only a little more attention — three phone calls at most and stronger recommendations from their doctors — than those in the usual care group, which is a less intense follow-up.

The study is a first-step for hospital-initiated collaborative care, Huffman said. "While improved mental health is a start, a program may require more intensity to see improved medical outcomes, and larger studies will be needed to see results in a more diverse patient population."

"Patients with heart disease who have depression are more likely to be rehospitalized, have poorer quality of life and are more likely to die from their heart disease than are people without depression. If an efficient program like this one can be used to identify, treat and monitor depression in heart disease patients, this might lead to lower rates of rehospitalization or death in these patients, though this remains to be proven."

The American Heart Association recommends that CVD patients be screened for depression and receive coordinated follow-up care for heart disease and depression if they have both conditions.

Co-authors are: Carol A. Mastromauro, LICSW; Gillian Sowden, B.A.; Gregory L. Fricchione, M.D.; Brian C. Healy, Ph.D.; and James L. Januzzi, M.D. Author disclosures are on the manuscript.

The study was partly funded by an American Heart Association Scientist Development Grant.

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Journal Reference:

1. Jeff C. Huffman, Carol A. Mastromauro, Gillian Sowden, Gregory L. Fricchione, Brian C. Healy and James L. Januzzi. Impact of a Depression Care Management Program for Hospitalized Cardiac Patients. Circ Cardiovasc Qual Outcomes, March 8 2011 DOI: 10.1161/CIRCOUTCOMES.110.959379

Depression is a common problem in patients with chronic rhinosinusitis (CRS) and negatively impacts patients' symptom burden, ability to function, and quality of life (QOL), according to new research published in the March 2011 issue of Otolaryngology — Head and Neck Surgery.

Nearly 14 percent of Americans suffer from chronic sinusitis and may have the following symptoms for 12 weeks or more; facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, thick nasal discharge/discolored post-nasal drainage, and periodic high fever. If antibiotics are not effective, these symptoms can lead to endoscopic sinus surgery to clear clogged sinuses.

Depression negatively impacts outcomes of care in chronic disease and has been associated with increased risk of morbidity and mortality. The prevalence of depression in patients with CRS is estimated to be in the range of 20-25%. High levels of depression in patients with CRS have been associated with increased utilization of healthcare resources, including more antibiotic use, physician visits, and missed workdays.

The study included face-to-face interviews with 76 patients who were enrolled prior to having endoscopic sinus surgery and followed postoperatively for at least 6 months post-operatively, including 8 patients with depression and 45 patients without depression.

Patients completed standard medical history intake documentation and underwent a physical examination. Demographic data and presence or absence of other clinical characteristics including nasal polyposis, asthma, allergies, aspirin intolerance, and smoking were documented and confirmed through physical examination when appropriate. Computed tomography and endoscopy findings were recorded and patients were asked to report a history of depression on the intake form and any anti-depressant medication they were using.

"Depression is common and underreported in patients with CRS. Depression significantly impacts patients' quality of life," said study author Jamie Litvack, MD, MS. "Depressed patients with CRS report worse disease-specific and general health-related QOL than other CRS patients, but experience comparable post-operative improvement in quality of life after endoscopic sinus surgery. Perhaps with better diagnosis and treatment of depression in this subset of patients, their outcomes of care can be further improved."

The Institutional Review Board at Oregon Health & Science University provided approval of study protocol and the informed consent process.

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Journal Reference:

1. J. R. Litvack, J. Mace, T. L. Smith. Role of Depression in Outcomes of Endoscopic Sinus Surgery. Otolaryngology — Head and Neck Surgery, 2011; DOI: 10.1177/0194599810391625

Scientists at the U.S. Department of Energy's (DOE) Brookhaven National Laboratory, Cold Spring Harbor Laboratory, and the University of California, San Diego School of Medicine, have identified hyperactive cells in a tiny brain structure that may play an important role in depression. The study, conducted in rats and appearing in the February 24, 2011, issue of Nature, is helping to reveal a cellular mechanism for depressive disorders that could lead to new, effective treatments.

The research provides evidence that inhibition of this particular brain region — the lateral habenula — using implanted electrodes can reverse certain behaviors associated with depression, and also provides a mechanism to explain this effect. These findings lend support to the use of deep brain stimulation as a clinical treatment for people with long-standing, treatment-resistant depression.

"This research identifies a new anatomical circuit in the brain that mediates depression, and shows how it interacts with the brain's reward system to trigger a constant disappointment signal — which certainly would be depressing," said Fritz Henn, a neurobiologist and psychiatrist at Brookhaven and Cold Spring Harbor laboratories and a co-investigator on the research. "But," he added, optimistically, "identifying this circuit and how it works may open new doors to reversing these effects."

For example, said co-investigator Roberto Malinow, a professor of neurosciences at the UCSD School of Medicine, "it's possible that the genes specifically expressed in these neurons could be targeted genetically or pharmacologically in order to manipulate them and reduce depression."

Scientists have known that cells in the lateral habenula are activated by negative or unpleasant events, including punishment and disappointment, such as when you don't get an expected reward. It may seem intuitive that such negative stimuli can lead to depression, but not everyone who experiences disappointment collapses into a state of helplessness. To explore this connection, the scientists wanted to take a closer look at the brain circuits.

They examined the sensitivity of lateral habenula brain cells — particularly those that connect and send signals to the brain's reward centers — in two animal models of "learned helplessness," a form of depression, as well as in control animals that weren't helpless.

Overall, the scientists found that these lateral habenula nerve cells were hyperactive in the depressed animals but not in the controls. Furthermore, the degree of hyperactivity coincided with the degree of helplessness.

"The activation of the lateral habenula is known to influence the release of serotonin and norepinepherine, two targets of current antidepressant medications," said Henn. "The current study looked at the role of the lateral habenula in terms of the dopamine system, the system involved in reward signaling. We found that hyperactivity in the lateral habenula due to stress-induced helplessness shuts off the brain's reward system."

To explore whether electrical stimulation could potentially reverse this reward-dampening effect, the researchers placed a stimulating electrode in the lateral habenula and measured the effects on the brain cells leading to the reward center. This was a study of rat brain cells that simulated the effects of deep brain stimulation, a technique that is currently being explored as a treatment for clinical depression, which has shown promising results. The scientists found that electrical stimulation of hyperactive habenula brain cells markedly decreased excitatory activity leading to the reward center.

Next the scientists tested to see if deep brain stimulation in living rats that exhibited helplessness would affect their behavior. The result was a marked reduction in helpless behavior that was dependent on both placement of the electrode in the lateral habenula (not adjacent brain regions), and the intensity of the stimulation.

"Our results clearly show that suppression of synaptic transmission at the lateral habenula through deep brain stimulation can acutely reverse helpless behavior in rats," said Henn. "It's very likely that this beneficial effect was mediated by a suppression of excitatory nerve cells leading to the brain's reward system, as we observed in the cellular studies."

"Our study provides a cellular mechanism that may explain the hyperactivity of lateral habenula nerve cells observed in depressed humans and animal models of depression, as well as why 'silencing' these circuits, whether surgically or pharmacologically, can reduce depression-like symptoms in animals," Henn said.

Identifying these specific brain circuits and their dysfunction in depression may open the door to new effective treatments, including, potentially, lateral-habenula-targeted deep brain stimulation.

This research was supported through Laboratory Directed Research and Development funding at Brookhaven Lab, and by the Simons Foundation, the Dana Foundation, the National Institute of Mental Health, and a Shiley-Marcos endowment at UCSD.

In addition to Henn and Malinow, co-authors include: Bo Li (UCSD and Cold Spring Harbor), Joaquin Piriz (UCSD), Martine Mirrione (Cold Spring Harbor and Brookhaven), Chihye Chung (UCSD), Christophe Proulx (UCSD), and Daniela Schulz (Brookhaven).

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Journal Reference:

1. Bo Li, Joaquin Piriz, Martine Mirrione, ChiHye Chung, Christophe D. Proulx, Daniela Schulz, Fritz Henn, Roberto Malinow. Synaptic potentiation onto habenula neurons in the learned helplessness model of depression. Nature, 2011; 470 (7335): 535 DOI: 10.1038/nature09742

Mothers who are depressed respond differently to their crying babies than do non-depressed moms. In fact, their reaction, according to brain scans at the University of Oregon, is much more muted than the robust brain activity in non-depressed moms.

An infant crying is normal, but how mothers respond can affect a child's development, says Jennifer C. Ablow, professor of psychology. For years, Ablow has studied the relationship of behavior and physiological responses such as heart rate and respiration of mothers, both depressed and not, when they respond to their infants' crying.

A new study — online in advance of publication in the journal Social Cognitive and Affective Neuroscience — provides the first look at brain activity of depressed women responding to recordings of crying infants, either their own or someone else's. The brains of 22 women were scrutinized using functional magnetic resonance imaging (fMRI).

Non-invasive fMRI, when focused on the brain, measures blood flow changes using a magnetic field and radio frequency pulses, producing detailed images that provide scientists with information about brain activity or help medical staff diagnose disease.

Researchers considered both group differences between women with chronic histories of depression and those with no clinical diagnoses, and more subtle variations in the women's brain activity related to current levels of depressive symptoms. All were first time mothers whose babies were 18 months old.

"It looks as though depressed mothers are not responding in a more negative way than non-depressed mothers, which has been one hypothesis," said Heidemarie K. Laurent, assistant professor at the University of Wyoming, who led the study as a postdoctoral researcher in Ablow's lab. "What we saw was really more of a lack of responding in a positive way."

As a group, brain responses in non-depressed mothers responding to the sound of their own babies' cries were seen on both sides of the brain's lateral paralimbic areas and core limbic sub-cortical regions including the striatum, thalamus and midbrain; depressed mothers showed no unique response to their babies. Non-depressed mothers activated much more strongly than depressed mothers in a subcortical cluster involving the striatum — specifically the caudate and nucleus accumbens — and the medial thalamus. These areas are closely associated with the processing of rewards and motivation.

"In this context it was interesting to see that the non-depressed mothers were able to respond to this cry sound as a positive cue," Laurent said. "Their response was consistent with wanting to approach their infants. Depressed mothers were really lacking in that response. "

In a separate comparison, mothers who self-reported that they were more depressed at the time of their fMRI sessions displayed diminished prefrontal brain activity, particularly in the anterior cingulate cortex, when hearing their own baby's cries. This brain region, Laurent said, is associated with the abilities to evaluate information and to plan and regulate a response to emotional cues.

The important message of the study, Ablow and Laurent said, is that depression can exert long-lasting effects on mother-infant relationships by blunting the mother's response to her infant's emotional cues.

"A mother who is able to process and act upon relevant information will have more sensitive interactions with her infant, which, in turn, will allow the infant to develop its own regulation capacities," Ablow said. "Some mothers are unable to respond optimally to their infant's emotional cues. A mother's emotional response requires a coordination of multiple cortical and sub-cortical systems of the brain. How that plays out has not been well known."

The findings may suggest new implications for treating depression symptoms in mothers, Laurent said. "Some of these prefrontal problems may be changed more easily by addressing current symptoms, but there may be deeper, longer-lasting deficits at the motivational levels of the brain that will take more time to overcome," she said.

We regard the findings as a "jumping-off point" to better understand the neurobiology of the mothering brain, said Ablow, co-director of the UO's Developmental Sociobiology Lab. "In our next study, we plan to follow women from the prenatal period through their first-year of motherhood to get a fuller picture of how these brain responses shape mother-infant relationships during a critical period of their babies' development."

The National Science Foundation, through a grant to Ablow, and a National Institute of Mental Health postdoctoral fellowship to Laurent, funded the research. The project also received a pilot grant from the UO Brain Biology Machine Initiative through the Lewis Center for Neuroimaging.

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Journal Reference:

1. H. K. Laurent, J. C. Ablow. A cry in the dark: depressed mothers show reduced neural activation to their own infant's cry. Social Cognitive and Affective Neuroscience, 2011; DOI: 10.1093/scan/nsq091

Scientists have discovered the first evidence linking brain function variations between the left and right sides of the brain to size at birth and the weight of the placenta. The finding could shed new light on the causes of mental health problems in later life.

The research, conducted at the University of Southampton and the Medical Research Council (MRC) Lifecourse Epidemiology Unit at Southampton General Hospital, reveals that children who were born small, with relatively large placentas, showed more activity on the right side of their brains than the left. It is this pattern of brain activity that has been linked with mood disorders such as depression.

The study adds to a growing body of evidence showing that adverse environments experienced by fetuses during pregnancy (indicated by smaller birth size and larger placental size) can cause long-term changes in the function of the brain.

"The way we grow before birth is influenced by many things including what our mothers eat during pregnancy and how much stress they are experiencing. This can have long-lasting implications for our mental and physical health in later life," explains Dr Alexander Jones, an epidemiologist, who led the study at the University of Southampton.

"This is the first time we've been able to link growth before birth to brain activity many years later. We hope this research can begin to shed new light on why certain people are more prone to diseases such as depression."

The neurological responses of 140 children from Southampton, aged between eight and nine, were monitored for the study. Tests evaluated blood flow to the brain in response to increased brain activity, exposing differences in the activity of the two sides. Dr Jones measured tiny fluctuations in the temperature of the tympanic membrane in each ear, which indicate blood flow into different parts of the brain.

Disproportionate growth of the placenta and the fetus is thought to occur in pregnancies where the mother has been experiencing stress or where there have been problems with the availability of nutrients. Previous research has linked this pattern of growth to other diseases such as hypertension and greater physical responses to stress in later life.

The research by Dr Jones and colleagues, has been published in the online science journal, PLoS ONE.

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Journal Reference:

1. Alexander Jones, Clive Osmond, Keith M. Godfrey, David I. W. Phillips. Evidence for Developmental Programming of Cerebral Laterality in Humans. PLoS ONE, 2011; 6 (2): e17071 DOI: 10.1371/journal.pone.0017071

Peer support offers promise as an effective, low-cost tool for fighting depression, a new study by the VA Ann Arbor Healthcare System and University of Michigan Health System finds.

Programs in which patients and volunteers share information were found to reduce symptoms of depression better than traditional care alone and were about as effective as cognitive behavioral therapy, researchers found after analyzing 10 randomized trials of peer support interventions for depression dating from 1987 to 2009.

The analysis was the first of its kind to look at peer support specifically for depression, says lead author Paul Pfeiffer, M.D., M.S., an assistant professor of psychiatry at the University of Michigan Medical School and researcher at the VA Ann Arbor Healthcare System.

"Peer support is much less likely to be incorporated into the treatment of depression than for other conditions such as alcohol or substance abuse," Pfeiffer says. "Our study combined data from small randomized trials and found peer support seems to be as effective for treating depression as some of the more established treatments."

The findings were recently published online ahead of print publication in General Hospital Psychiatry.

Peer support has been found to decrease isolation, reduce stress, increase the sharing of health information and provide role models, the study points out.

Since peer support programs often use volunteers and nonprofessionals — and can be done over the phone or Internet as well as in person — they have the potential to be widely available at relatively low cost, Pfeiffer says.

The need for additional coping options is important when one considers that one third of patients taking anti-depressants for major depressive disorder still experience significant symptoms after trying four medicines, and more than half of people who achieve remission of their symptoms relapse within a year, he adds.

"As a field, we should be looking at how to integrate peer support components into primary care and specialty treatment of depression," Pfeiffer says, noting that additional, larger studies could also provide more insight.

This research was supported by VA Health Services Research and Development Service, Michigan Diabetes Research and Training Center and the Michigan Institute for Clinical and Health Research.

Additional U-M authors include Michele Heisler, M.D., John D. Piette, Ph.D., Mary A.M. Rogers, Ph.D., Marcia Valenstein, M.D. Heisler, Piette and Valenstein have VA appointments.

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Journal Reference:

1. Paul N. Pfeiffer, Michele Heisler, John D. Piette, Mary A.M. Rogers, Marcia Valenstein. Efficacy of peer support interventions for depression: a meta-analysis. General Hospital Psychiatry, 2010; DOI: 10.1016/j.genhosppsych.2010.10.002

A study in the Feb. 15 issue of the Journal of Clinical Sleep Medicine found that poor sleep quality correlated with higher levels of depressive symptoms, greater pain severity, increased fatigue, and greater functional disability in patients with rheumatoid arthritis (RA). The study suggests that addressing sleep problems via pharmacological or behavioral interventions may have a critical impact on the health and lives of patients with RA.

The study represents a cross-sectional examination of the relationship between sleep quality and functional disability in 162 patients with RA. The sample had an average age of 58.5 years, and 76 percent were female. All patients had been diagnosed with RA for at least two years; on average, patients had RA for 14 years.

Participants completed the following questionnaires: Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory-II, Medical Outcomes Study Short Form — 36, and the Health Assessment Questionnaire. The results provided input on their sleep quality, depression, fatigue, and functional disability and pain severity, respectively. Patients also provided sociodemographic information and their medical history.

Results show that sleep quality has an indirect effect on functional disability after controlling for age, gender and number of comorbities. According to the PSQI results, 61 percent of patients were poor sleepers and 33 percent reported having pain that disturbed their sleep three or more times per week.

"The primary finding of our study is that poor sleep quality is associated with greater functional disability among patients with RA and this relationship may be explained by pain severity and fatigue," said lead author Dr. Faith S. Luyster, research assistant professor at the University of Pittsburgh School of Nursing in Pittsburgh, Pa. "These results highlight the importance of addressing sleep complaints among patients with RA. By treating sleep problems either pharmacologically or behaviorally, symptoms and activity limitations associated with RA may be reduced."

The study's finding that poorer sleep quality is associated with greater pain severity is consistent with recent evidence suggesting that sleep disruption may lower pain threshold and enhance pain in RA and otherwise healthy adults.

According to the National Institute of Health, RA is an inflammatory disease affecting about 1.3 million U.S. adults, and causes pain, swelling, stiffness, and loss of function in the joints. Disturbed sleep has been found to be a major concern among persons with RA.

Physical disability resulting from polyarticular joint disease in patients with RA may limit their ability to carry out daily activities such as dressing, walking, grooming, and writing — tasks that can be further restricted by fatigue, pain severity, and depression.

It is possible that functional disability may affect depression, pain severity and fatigue, which in turn may affect sleep quality. It is likely that the relationships are bidirectional to some extent.

"Not sleeping well at night can contribute to greater pain sensitivity and fatigue during the day which in turn can limit a patient's ability to engage in activities of daily living and discretionary activities," Luyster said.

Luyster noted that treating sleep disturbances in RA patients might have beneficial effects beyond improving sleep.

The study was supported by grants from the National Institute of Health.

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Journal Reference:

1. Faith S. Luyster, Eileen R. Chasens, Mary Chester M. Wasko, Jacqueline Dunbar-Jacob. Sleep quality and functional disability in patients with rheumatoid arthritis. Journal of Clinical Sleep Medicine, 2011; (accepted)