Heart attack patients prescribed antidepressants have worse one-year survival

March 3, 2018

Science Daily/European Society of Cardiology (ESC)

Heart attack patients prescribed antidepressants have lower one-year survival rates, according to new research.

The observational study of nearly 9,000 patients found that those prescribed antidepressants at discharge from hospital after a heart attack had a 66% greater risk of mortality one year later than patients not prescribed the drugs, although they noted the cause is not necessarily related directly to the antidepressants.

Lead author Ms Nadia Fehr, a medical student at the University of Zurich, Switzerland, said: "Previous studies have suggested that cardiovascular disease may increase the likelihood of being depressed. On the other hand, depression appears to increase the probability of developing cardiovascular risk factors. However, little is known about the impact of depression on outcome after a heart attack."

This study assessed the association of antidepressant prescription at hospital discharge with the one-year outcomes of patients with acute myocardial infarction (heart attack).

Data from AMIS Plus, the Swiss nationwide registry for acute myocardial infarction, were used to analyse 8,911 heart attack patients admitted to hospitals in Switzerland between March 2005 and August 2016. Patients were followed up by telephone 12 months after discharge.

The researchers compared patients who received antidepressant medication at discharge with those who did not with regard to baseline characteristics and one-year outcomes including mortality, a subsequent heart attack, and stroke.

A total of 565 (6.3%) patients received antidepressants at discharge from hospital. Compared to those who did not receive the drugs, patients prescribed antidepressants were predominantly female, older, and more likely to have hypertension, diabetes, dyslipidaemia, obesity and comorbidities. They were less likely to undergo percutaneous coronary intervention or receive P2Y12 blockers or statins, and stayed in hospital longer.

After adjusting for baseline characteristics the researchers found that the rates of stroke and subsequent heart attacks were similar between the two groups, but patients prescribed antidepressants had significantly worse survival. The rate of all-cause mortality at one-year after discharge was 7.4% in patients prescribed antidepressants compared to 3.4% for those not prescribed antidepressants (p<0.001).

Antidepressant prescription was an independent predictor for mortality, and increased the odds by 66% (odds ratio: 1.66; 95% confidence interval: 1.16 to 2.39).

"This was an observational study so we cannot conclude that antidepressants caused the higher death rate," noted Ms Fehr.

She concluded: "Our study showed that many patients are treated with antidepressants after a heart attack. More research is needed to pinpoint the causes and underlying pathological mechanisms for the higher mortality we observed in this patient group."

https://www.sciencedaily.com/releases/2018/03/180303095445.htm

Screening for depression recommended for adults, including pregnant and postpartum women

January 26, 2016

Science Daily/The JAMA Network Journals

The US Preventive Services Task Force is recommending screening for depression in the general adult population, including pregnant and postpartum women, and that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

This recommendation is a USPSTF grade B recommendation, meaning that there is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

Depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting, and also common in postpartum and pregnant women. The U.S. Preventive Services Task Force (USPSTF) reviewed the evidence in the medical literature on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications. This report is an update of a 2009 USPSTF recommendation statement. The USPSTF continues to recommend that adults 18 and older be screened for depression.

Detection, and Benefits of Early Detection, Intervention and Treatment

The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women, and found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women. The USPSTF found convincing evidence that treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity. The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.

Harms of Early Detection, Intervention and Treatment

The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none and that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none. The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults age 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF also found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

Screening

The optimal timing and interval for screening for depression is not known. A pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted. Positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions.

Treatment and Interventions

Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches, alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider evidence-based counseling interventions when managing depression in pregnant or breastfeeding women.

USPSTF Assessment

The USPSTF concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in adults 18 years and older, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening. The USPSTF also concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in pregnant and postpartum women who receive care in clinical practices that have CBT or other evidence-based counseling available after screening.

Editorial: Recommendations for Screening for Depression in Adults

Michael E. Thase, M.D., of the University of Pennsylvania, Philadelphia, comments on the USPSTF recommendations in an accompanying editorial.

"Until there are better methods to match patients with specific forms of treatment, the best hope to improve on a B grade for patients with depression may be to adapt care systems to respond more flexibly and decisively to key events that are associated with nonadherence or treatment failure. For example, if the clinicians working within a collaborative care model could rapidly incorporate the information that an initial prescription was not filled or was not refilled, it may be possible to diminish the chances that nonadherence will compromise treatment outcome."

"Likewise, given evidence that nonresponse is predicted by a lack of symptom improvement during the first 14 days of therapy, web-based monitoring of symptoms early in the course of therapy may enable physicians and other mental health professionals to intervene more rapidly and reduce the chances of treatment failure. The same approach to ongoing care could be used to facilitate a more timely transition through treatment algorithms and more expeditious referral to specialty care."

http://www.sciencedaily.com/releases/2016/01/160126125228.htm

PTSD doubles diabetes risk in women

January 7, 2015

Science Daily/Columbia University's Mailman School of Public Health

Women with post-traumatic stress disorder are nearly twice as likely to develop type 2 diabetes compared with women who don't have PTSD, according to new research. The longitudinal cohort study provides the strongest evidence to date of a causal relationship between PTSD and type 2 diabetes.

The longitudinal cohort study provides the strongest evidence to date of a causal relationship between PTSD and type 2 diabetes. Results are published online in the journal JAMA Psychiatry.

The researchers analyzed survey data collected between 1989 and 2011 from 49,739 women enrolled in the Nurses Health Study II and found a dose-response relationship: the greater the number and severity of PTSD symptoms, the greater a woman's risk of type 2 diabetes. Four percent of the nurses reported the highest number of PTSD symptoms. By age 60, nearly 12 percent of women with the highest number of PTSD symptoms had developed type 2 diabetes, whereas fewer than 7 percent of women with no trauma exposure had diabetes.

Antidepressant use and elevated body mass index accounted for nearly half of the increased risk of type 2 diabetes, or 34 and 14 percent, respectively. On the other hand, smoking, diet quality, alcohol intake, and physical activity did not explain the association.

One in nine women will have PTSD at sometime over the course of her lifetime--twice the rate of men. Women are also more likely to experience extreme traumatic events like rape that carry a high risk for the disorder.

"Not only is PTSD devastating to mental health, but it affects physical health too, raising risk for cardiovascular disease, diabetes, and obesity," said senior author Karestan C. Koenen, PhD, professor in the Department of Epidemiology at the Mailman School.

"Women with PTSD and the health professionals who care for them should be aware that these women are at greater risk for diabetes," said first author Andrea L. Roberts, PhD, research associate in the Department of Social and Behavioral Sciences at Harvard School of Public Health. "As fewer than half of Americans with PTSD receive treatment, our study adds urgency to the effort to improve access to mental health care to address factors that contribute to diabetes and other chronic diseases."

To assess type 2 diabetes, the researchers used a validated survey method that first asked women whether they had been diagnosed by a doctor, then confirmed diagnosis with information about test results, symptoms, and medications. PTSD was assessed using the Short Screening Scale. The nurses reported a range of trauma, including sexual assault, domestic violence, car accidents, and unexpected death of a loved one.

The study builds on past findings by the researchers, including a 2013 study that reported a link between PTSD and obesity. Other research has shown a link between mental health issues like anxiety, social phobia, and agoraphobia and type 2 diabetes.

Further research is needed to identify the biochemical and possible additional behavioral changes, such as sleep disturbance, that mediate the relationship between PTSD and type 2 diabetes.

http://www.sciencedaily.com/releases/2015/01/150107122906.htm

Early exposure to antidepressants affects adult anxiety, serotonin transmission

December 19, 2014

Science Daily/University of California - Los Angeles Health Sciences

http://images.sciencedaily.com/2014/12/141219160606-large.jpg

Early developmental exposure to two different antidepressants, Prozac and Lexapro, has been studied by researchers in a mouse model that mimics human third trimester medication exposure. They found that, although these serotonin-selective reuptake inhibiting antidepressants were thought to work the same way, they did not produce the same long-term changes in anxiety behavior in the adult mice.

About 15 percent of women in the United States suffer from anxiety disorders and depression during their pregnancies, and many are prescribed antidepressants. However little is known about how early exposure to these medications might affect their offspring as they mature into adults.

The answer to that question is vital, as 5 percent of all babies born in the U.S. -- more than 200,000 a year -- are exposed to antidepressants during gestation via transmission from their mothers.

Now, a UCLA team has studied early developmental exposure to two different antidepressants, Prozac and Lexapro, in a mouse model that mimics human third trimester medication exposure. They found that, although these serotonin-selective reuptake inhibiting antidepressants (SSRIs) were thought to work the same way, they did not produce the same long-term changes in anxiety behavior in the adult mice.

"This was quite surprising, since these medications belong to the same drug class and are believed to work by the same mechanism. The implications of these findings are that with additional investigation, it may be possible to identify specific antidepressants that are safer for pregnant women," Andrews said. "It's important to recognize that major depressive disorders and anxiety disorders are serious medical conditions that often require therapeutic intervention. Prescribing the safest medication for mother and child is paramount."

Genetic reductions in serotonin transporters are thought to be a risk factor, particularly when combined with stressful life experiences, for developing anxiety and mood disorders. And in fact, the genetically engineered mice Andrews studied showed more anxiety as adults.

"It might be possible that when mothers are treated for depression or anxiety during pregnancy that certain SSRIs may promote resilience to developing these disorders in children later in life," Andrews said. "However, it will take much more research for us to understand whether this is true and whether certain SSRIs may be better at promoting these effects."

Going forward, Andrews and her team plan to investigate the effects of early exposure to antidepressants on the architectures of serotonin neurons. Based on the current findings, they suspect that early exposure to Lexapro may alter the way serotonin neurons innervate brain regions involved in mood and anxiety behavior. They also plan to investigate other SSRIs such as Paxil and Zoloft.

"Current antidepressant therapies are ineffective in treating anxiety and depression in large numbers of patients, and advances in predicting individual responses are hindered by difficulties associated with characterizing complex influences of genetic and environmental factors on serotonergic transmission in humans," the study states. "Highly controlled animal models, such as those studied here, represent avenues by which to identify factors potentially influencing behavioral domains associated with emotion-related disorders."

http://www.sciencedaily.com/releases/2014/12/141219160606.htm

Sleep drunkenness disorder may affect one in seven

August 25, 2014

Science Daily/American Academy of Neurology (AAN)

A study is shining new light on a sleep disorder called “sleep drunkenness.” The disorder may be as prevalent as affecting one in every seven people. Sleep drunkenness disorder involves confusion or inappropriate behavior, such as answering the phone instead of turning off the alarm, during or following arousals from sleep, either during the first part of the night or in the morning. An episode, often triggered by a forced awakening, may even cause violent behavior during sleep or amnesia of the episode.

Sleep drunkenness disorder involves confusion or inappropriate behavior, such as answering the phone instead of turning off the alarm, during or following arousals from sleep, either during the first part of the night or in the morning. An episode, often triggered by a forced awakening, may even cause violent behavior during sleep or amnesia of the episode.

Among those who had an episode, 37.4 percent also had a mental disorder. People with depression, bipolar disorder, alcoholism, panic or post-traumatic stress disorder and anxiety were more likely to experience sleep drunkenness.

The research also found that about 31 percent of people with sleep drunkenness were taking psychotropic medications such as antidepressants. Both long and short sleep times were associated with the sleep disorder. About 20 percent of those getting less than six hours of sleep per night and 15 percent of those getting at least nine hours experienced sleep drunkenness. People with sleep apnea also were more likely to have the disorder.

"These episodes of confused awakening have not gotten much attention, but given that they occur at a high rate in the general population, more research should be done on when they occur and whether they can be treated," said Ohayon. "People with sleep disorders or mental health issues should also be aware that they may be at greater risk of these episodes."

http://www.sciencedaily.com/releases/2014/08/140825185311.htm