Search PubMed⌕ Search

Biomedical subjects

M A Dew

Publications and source records attributed to M A Dew.

At least 37 records · Page 2Linked to original sources
PubMed1999

Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years.

CONTEXT: Elderly patients with major depression are at high risk for recurrence, increased mortality, and chronic disability. OBJECTIVE: To determine the efficacy of maintenance nortriptyline hydrochloride and interpersonal psychotherapy (IPT) in preventing recurrence of major depressive episodes in patients older than 59 years. DESIGN: A 2 x 2 randomized, double-blind, placebo-controlled clinical trial, stratified by therapist. SETTING: University-based psychiatric research clinic. PATIENTS: Of a total of 187 patients with recurrent nonpsychotic unipolar major depression (average age, 67 years; one third aged > or =70 years) recruited through clinical referral and media announcements, 107 were fully recovered after open acute and treatment continuation with nortriptyline and IPT. These patients were randomly assigned to 1 of 4 maintenance therapy conditions. INTERVENTIONS: Monthly medication clinic with nortriptyline hydrochloride (80-120 ng/mL steady-state levels) (n = 24); medication clinic with placebo (n = 29); monthly maintenance IPT with placebo (n = 21); and monthly maintenance IPT with nortriptyline (n = 22). MAIN OUTCOME MEASURE: Recurrence of major depressive episode. RESULTS: The time to recurrence of a major depressive episode for all 3 active treatments was significantly better than for placebo. Recurrence rates over 3 years were as follows: nortriptyline and IPT, 20% (95% confidence interval [CI], 4%-36%); nortriptyline and medication clinic visits, 43 % (95% CI, 25%-61%); IPT and placebo, 64% (95% CI, 45%-83%); and placebo and medication clinic visits, 90% (95% CI, 79%-100%). Combined treatment with nortriptyline and IPT was superior to IPT and placebo and showed a trend to superior efficacy over nortriptyline monotherapy (Wald chi2 = 3.56; P = .06). Subjects aged 70 years and older had a higher and more rapid rate of recurrence than those aged 60 to 69 years. CONCLUSION: In geriatric patients with recurrent major depression, maintenance treatment with nortriptyline or IPT is superior to placebo in preventing or delaying recurrence. Combined treatment using both appears to be the optimal clinical strategy in preserving recovery.

Adrenergic Uptake Inhibitors↗
PubMed1999

Combined effects of HIV-infection status and psychosocial vulnerability on mental health in homosexual men.

The present study examines psychiatric symptomatology and syndromal depression among 174 HIV+ and 760 HIV- homosexual men enrolled in the Pittsburgh site of the Multicenter AIDS Cohort Study (MACS). A central study goal was to determine whether men's psychosocial status in the areas of demographics, social supports, and coping, in combination with their HIV-infection status, was associated with mental health. Cross-sectional analyses indicated that HIV+ men had significantly higher levels of psychiatric symptomatology and syndromal depression than HIV- men. However, multivariate analyses showed that these associations only appeared among HIV+ men with certain psychosocial characteristics. HIV+ men who were younger, lacked full-time employment, claimed relatively high support from their relatives, and demonstrated high use of active behavioral coping strategies were at greater risk for psychiatric symptomatology and/or syndromal depression. Further, sense of mastery and frequent use of avoidant coping strategies were highly predictive of psychiatric outcomes irrespective of HIV status. The findings suggest that knowledge of an individual's HIV status per se will be inadequate for valid assessment of psychological risks. Rather, any association of HIV status and mental health will depend largely on other psychosocial characteristics that foster vulnerability or resistance to distress in these men.

Adaptation, Psychological↗
PubMed1999

Selecting, developing, and evaluating research instruments.

The goal of this paper is to provide researchers who are not experts in psychometric theory with a concise guide to instrument selection, development and evaluation. Issues of context - factors related to the setting or population in which an instrument will be used - and psychometrics - the functioning of an instrument within a given context - are reviewed and discussed. Finally, four categories or types of instruments, and the psychometric analyses that are necessary for establishing the reliability and validity of each type, are described.

Humans↗
PubMed1999

Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation.

BACKGROUND: Poor medical compliance has been held responsible for a large proportion of deaths occurring subsequent to initial postoperative recovery. However, beyond clinical reports, there has been little empirical examination of this issue, or of the extent to which major psychiatric disorder and failure to adjust to the transplant predict long-term physical morbidity and mortality. We prospectively examined whether a full range of compliance behaviors and psychiatric outcomes during the first year post-transplant predicted subsequent mortality and physical morbidity through 3 years post-transplant. METHODS: A total of 145 heart recipients who had received detailed compliance and mental health assessments during the first year post-transplant were followed up at 3 years post-transplant. Interview data and corroborative information from family members were used to determine compliance in multiple domains, psychiatric diagnoses, and psychiatric symptomatology during the first year post-surgery. Medical record reviews were performed to abstract data on acute graft rejection episodes, incident cardiac allograft disease (CAD) and mortality from 1 to 3 years post-transplant. RESULTS: After controlling for known transplant-related predictors of outcome, multivariate analyses yielded the following significant (p < 0.05) results: (a) risk of acute graft rejection was 4.17 times greater among recipients who were not compliant with medications; (b) risk of incident CAD was elevated by persistent depression (Odds Ratio, OR = 4.67), persistent anger-hostility (OR = 8.00), medication noncompliance (OR = 6.91), and obesity (OR = 9.92); and (c) risk of mortality was increased if recipients met criteria for Post-Traumatic Stress Disorder related to the transplant (OR = 13.74). CONCLUSIONS: The findings, plus data we have previously reported that showed which patients are most likely to have compliance and psychiatric problems early post-transplant, suggest that interventions focused on maximizing patients' psychosocial status in these areas may further improve long-term physical health outcomes in this population.

Adult↗
PubMed1999

Posttraumatic stress disorder and service utilization among urban mental health center clients.

Although the urban poor are at high risk for exposure to trauma, community mental health clinics rarely diagnose clients with PTSD. Failure to diagnose PTSD may undermine the effectiveness of services provided. Our objectives were to (1) assess prevalence of traumatic experiences and PTSD, and (2) examine differences in service utilization between those who had PTSD and those who did not. Interview data were gathered from 181 urban psychiatric outpatients. A substantial number of clients had experienced at least one lifetime trauma (94%), and of those, 42% had PTSD during the past year. Analyses comparing service use between PTSD and nonPTSD clients supported our expectation that clients with PTSD would use more mental health services, and would be less satisfied with services than their nonPTSD counterparts.

Attitude to Health↗
PubMed1999

Factors associated with attrition from a national bone marrow registry.

During its 10-year existence, the National Marrow Donor Program (NMDP) has been extremely successful at recruiting potential bone marrow donors to join the volunteer registry. Due in part to successful recruitment and the longevity of the registry, the focus of the NMDP has now shifted to decreasing potential attrition when volunteers are recontacted for additional testing to determine whether they would be the optimal donor for a specific patient. Our own interest in the bone marrow donation process led us to examine four domains of variables - demographic characteristics, volunteer history, recruitment-related characteristics and donation-related concerns - that we hypothesized would be associated with increased likelihood of donor attrition at a key donor decision-point (DR-stage blood typing). Questionnaires were mailed to potential donors after they were contacted at the DR-stage, and had made the decision of whether or not to continue with blood typing. Our final sample included 756 volunteers who decided to continue with typing, and 258 individuals who declined further participation in the registry. In the bivariate analyses, factors in three of the four domains (all except demographic characteristics) were found to be substantially correlated with likelihood of attrition. Logistic regression indicated that nine central variables across the three domains produced the majority of increased attrition likelihood. Finally, a dose-response analysis suggested that as the number of attrition-related factors endorsed by an individual increased, his/her likelihood of dropping out of the registry also increased. Implications for future research and interventions to reduce potential donor attrition are discussed.

Adult↗
PubMed1999

Neurological characteristics of HIV-infected men and women seeking primary medical care.

We examined the neurological differences between human immunodeficiency virus (HIV)-infected men (n = 193) and women (n = 41) receiving primary medical care. There was no difference between men and women in the rate of HIV-related neurological syndromes (i.e. polyneuropathy, myelopathy, myopathy, HIV- dementia [HAD]). A logistic regression analysis indicated that low CD4+ cell count predicted all neurological syndromes. In addition, HAD was predicted by intravenous-drug use and lower education level, while neuropathy was associated with older age and with race. These findings indicate that there are no differences in the rate of neuropsychiatric disorders attributable to gender. The presence of other factors (e.g. drug abuse) could explain previously reported gender differences in neurological manifestations of HIV infection.

AIDS Dementia Complex↗
PubMed1999

Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy.

OBJECTIVE: The authors tested the hypothesis that nortriptyline and interpersonal psychotherapy, alone and in combination, are superior to placebo in achieving remission of bereavement-related major depressive episodes. METHOD: Eighty subjects, aged 50 years and older, with major depressive episodes that began within 6 months before or 12 months after the loss of a spouse or significant other were randomly assigned to a 16-week doubleblind trial of one of four treatment conditions: nortriptyline plus interpersonal psychotherapy (N = 16), nortriptyline alone in a medication clinic (N = 25), placebo plus interpersonal psychotherapy (N = 17), or placebo alone in a medication clinic (N = 22). The protocol required that the acute-phase double-blind treatment be ended after 8 weeks if Hamilton depression scale ratings had not improved by 50%. Remission was defined as a 17-item Hamilton scale score of 7 or lower for 3 consecutive weeks. RESULTS: The rate of remission for nortriptyline plus interpersonal psychotherapy was 69% (N = 11); for medication clinic, nortriptyline, 56% (N = 14); for placebo plus interpersonal psychotherapy, 29% (N = 5); and for medication clinic, placebo, 45% (N = 10). In a generalized logit model, there was a significant effect of nortriptyline over placebo but no interpersonal psychotherapy effect and no nortriptyline-by-interpersonal psychotherapy interaction. Rates of all-cause attrition were lowest in the nortriptyline plus interpersonal psychotherapy group. CONCLUSIONS: Nortriptyline was superior to placebo in achieving remission of bereavement-related major depressive episodes. The combination of medication and psychotherapy was associated with the highest rate of treatment completion. These results support the use of pharmacologic treatment of major depressive episodes in the wake of a serious life stressor such as bereavement.

Aged↗
PubMed1999

Cerebral glucose metabolic response to combined total sleep deprivation and antidepressant treatment in geriatric depression.

OBJECTIVE: The treatment of geriatric depression is complicated by a variable and delayed response to antidepressant treatment. The present study was undertaken to test the hypothesis that combined total sleep deprivation and paroxetine treatment would produce a persistent reduction in glucose metabolism in the anterior cingulate cortex similar to that reported after long-term antidepressant treatment. METHOD: Six elderly depressed patients who met the DSM-IV criteria for major depressive disorder and six age-matched comparison subjects underwent serial positron emission tomography (PET) studies at baseline, after total sleep deprivation, after recovery sleep (after the initial paroxetine dose), and after 2 weeks of paroxetine treatment (patients only). The PET data were analyzed by using statistical parametric mapping methods. RESULTS: The patients' scores on a 13-item version of the Hamilton Depression Rating Scale were decreased after total sleep deprivation, after recovery sleep, and after 2 weeks of treatment. The Hamilton depression scores of the comparison subjects were not significantly altered. In the patients, the greatest reductions in normalized, relative glucose metabolism after sleep deprivation were observed in the anterior cingulate cortex (Brodmann area 24), and they persisted after recovery sleep and antidepressant treatment. The comparison subjects demonstrated increased metabolism in these areas. CONCLUSIONS: Improvement in the patients' depressive symptoms was accompanied by reduced glucose metabolism in the right anterior cingulate cortex and right medial frontal cortex. These preliminary data indicate that in elderly depressed patients, total sleep deprivation may accelerate the clinical and glucose metabolic response to antidepressant treatment.

Age Factors↗
PubMed1999

Three-year outcomes of maintenance nortriptyline treatment in late-life depression: a study of two fixed plasma levels.

OBJECTIVE: This study compared the long-term efficacy of two fixed plasma levels of nortriptyline in preventing or delaying recurrence of major depression in elderly patients and in minimizing residual depressive symptoms and somatic complaints. METHOD: The authors randomly assigned 41 elderly patients with histories of recurrent major depression to 3-year, double-blind maintenance pharmacotherapy using nortriptyline, with controlled plasma concentrations of 80-120 ng/ml versus 40-60 ng/ml. The authors compared times to, and rates of, recurrence of major depression. They also compared frequencies of side effects, noncompliance episodes, and subsyndromal symptomatic flare-ups. RESULTS: Major depressive episodes recurred for six (29%) of 21 subjects in the 80-120-ng/ml condition and eight (40%) of 20 subjects in the 40-60-ng/ml condition, a nonsignificant difference. Most recurrences took place in the first year of maintenance treatment. Hamilton depression scores in the subsyndromal range (higher than either 10 or 7) occurred significantly more often at 40-60 ng/ml, while constipation occurred significantly more often at 80-120 ng/ml. The proportions of patients reporting missed doses did not differ. CONCLUSIONS: Maintenance pharmacotherapy with nortriptyline at 80-120 ng/ml is associated with fewer residual depressive symptoms, that is, a less variable long-term response, than pharmacotherapy at 40-60 ng/ml, but constipation is more frequent and there is no difference in recurrence of syndromal major depressive episodes. Treatment at 80-120 ng/ml may be preferable, because of fewer residual symptoms and less variability of response, as long as side effect burden can be managed successfully.

Aged↗
PubMed1999

Accelerating antidepressant response in geriatric depression: a post hoc comparison of combined sleep deprivation and paroxetine versus monotherapy with paroxetine, nortriptyline, or placebo.

Speed of response is an important clinical issue in the treatment of depressed elderly patients. Our objective was to compare rapid response rates in a study combining therapeutic sleep deprivation (TSD) with paroxetine with two earlier randomized, double-blind studies in late-life depression, one of paroxetine versus nortriptyline and another of nortriptyline versus placebo. We measured depressive symptoms with the 17-item Hamilton Rating Scale of Depression (HRSD), defining rapid response as an HRSD < or = 10 by 2 weeks. With combination therapy (TSD + paroxetine), 9 of 13 patients (69%) experienced a rapid response. In the nortriptyline versus paroxetine study, nortriptyline brought about rapid response in 12 of 37 (32%) and paroxetine in 11 of 43 patients (26%). In the third study, rapid response to nortriptyline occurred in 10 of 41 patients (24%) and to placebo in 6 of 39 patients (15%). The overall chi square, including the rate of rapid response to placebo, was 14.87 (P = .005). The chi square on the four active treatment groups, excluding placebo, was 10.28 (P = .016). This preliminary observation suggests that combined therapy with TSD plus paroxetine may be twice as successful at achieving rapid response in elderly depressed patients than conventional monotherapy with medication or placebo. A prospective, placebo-controlled evaluation of this dual therapy is warranted.

Aged↗
PubMed1999

Paroxetine in the treatment of primary insomnia: preliminary clinical and electroencephalogram sleep data.

BACKGROUND: Primary insomnia is a persistent and recurrent disorder as well as a risk factor for depression. The goal of this study was to determine whether paroxetine, a nonsedating antidepressant, would be effective in the treatment of patients with primary insomnia. METHOD: Fifteen patients meeting DSM-IV criteria for primary insomnia received paroxetine at bedtime for 6 weeks in an open, flexible-dose trial (median dose = 20 mg). Patients were assessed with daily sleep diaries, baseline and treatment polysomnography, and weekly standardized clinical evaluations. RESULTS: Of the 14 patients who completed the study (1 dropped out owing to side effects), 11 improved with treatment, and 7 of these 11 no longer met diagnostic criteria for insomnia. Although self-reported sleep quality (measured by the Pittsburgh Sleep Quality Index) and daytime well-being (measured by the Profile of Mood States) improved with treatment, the quantity of sleep, measured by diary and by polysomnography, did not change consistently with these improvements. Power spectral analysis suggested that paroxetine treatment may be associated with decreases in power in frequencies within the delta and alpha frequency ranges. CONCLUSION: These results support the effectiveness of paroxetine in the acute treatment of primary insomnia. Further evaluation with controlled and longitudinal designs is warranted.

Adult↗
PubMed1999

Which elderly depressed patients remain well on maintenance interpersonal psychotherapy alone?: report from the Pittsburgh study of maintenance therapies in late-life depression.

The aim of this study was to identify elderly depressed patients who can remain well on maintenance Interpersonal Psychotherapy (IPT) alone, after discontinuation of antidepressant medication. Using Cox proportional hazards models, increased severity of depression at pretreatment was associated with increased recurrence rates, to an extent greater in patients maintained on monthly IPT than in those maintained on nortriptyline. The long-term response to maintenance IPT was correctly identified in 20/25 cases by a pretreatment Hamilton score of > or = 20. Fourteen of sixteen patients with pretreatment scores of > or = 20 experienced recurrence of major depression on maintenance IPT, while 6/9 patients with pretreatment scores of less than 20 did not. (Fisher exact P = .01). The same pattern of recurrence in relation to severity was not evident in maintenance placebo, nortriptyline, or combination treatment. In addition, Hamilton scores during continuation treatment were lower (< or = 7) among those who remained well on maintenance IPT than among those who had recurrences. Elderly patients whose depressions are milder at baseline and who show excellent symptomatic remission during acute and continuation therapy may be good candidates for monthly maintenance IPT after initial successful treatment with antidepressant medication and psychotherapy.

Age Factors↗
PubMed1999

EEG sleep measures in later-life bereavement depression. A randomized, double-blind, placebo-controlled evaluation of nortriptyline.

The authors examined 1) effects of nortriptyline (NT) on electroencephalographic (EEG) sleep measures in elderly patients with bereavement-related depression in remission under randomized, double-blind, placebo-controlled conditions, and 2) the effects of clinical remission on sleep after discontinuation of medication. Subjects were classified as responders to placebo (n = 9) or NT (n = 18) and had EEG sleep studies at three time-points: before treatment (T1), remitted on medication or placebo (T2), and remitted off medication or placebo (T3). As compared with placebo, NT was differentially associated with decreases in REM sleep time and percent and increases in REM sleep density (T2). No changes in EEG sleep measures occurred in placebo responders. REM sleep measures in NT responders reverted to T1 levels after T3, with persistence of robust clinical remission and normal subjective sleep quality. These data suggest that NT alters REM sleep, but that EEG sleep characteristics in bereavement-related depression persist into remission.

Aged↗
PubMed1999

Treatment of 70(+)-year-olds with recurrent major depression. Excellent short-term but brittle long-term response.

The authors compared response rates, by age (60-69 vs. 70+), to acute, continuation, and 1-year maintenance depression treatment. Patients (N = 180) received open combined treatment with nortriptyline (NT)/placebo and interpersonal psychotherapy (IPT). Patients who recovered then entered randomized, double-blind maintenance treatment with NT or placebo or received maintenance monthly IPT (combined with NT or placebo). Comparison of time-to-remission and recovery and absolute rates of remission, relapse, recovery, and recurrence yielded similar times to/rates of remission and recovery; however, older patients had far more recurrence during the first year of maintenance therapy. Although responses to acute and continuation treatment with combined NT and psychotherapy were similar, the older group had more recurrence in the first year of maintenance. Continuation of combined medication and psychotherapy may represent the best long-term treatment.

Age Factors↗
PubMed1998

Temporal profiles of physical health in family members of heart transplant recipients: predictors of health change during caregiving.

This study examined patterns of change in the physical health and well-being of 133 family caregivers to heart transplant recipients during the 1st year after transplant. Caregivers were assessed at 2, 7, and 12 months after transplant. Cluster analysis was used to identify temporal profiles reflecting unique patterns of change in the direction and nature of caregivers' physical health; their temporal profiles showed either (a) a worsening of general medical condition, with weight gain (14% of the sample); (b) worsening medical condition with weight loss (15%); (c) weight gain with stable medical condition (41%); (d) weight loss with slightly improving medical condition (21%); or (e) worsening health perceptions with relatively little objective evidence of change in medical condition or weight (8%). Subsequent multivariate analyses indicated that caregiver characteristics measured at baseline and reflecting caregiving burden, coping styles, demographics, and health history reliably predicted membership in the pattern-of-health-change groups. Among the findings, caregivers who showed a pattern of medical decline with weight loss had a poorer health history and weaker coping styles (lower mastery and higher use of avoidance coping) than other caregivers. Caregivers who experienced medical decline with weight gain had the greatest levels of caregiver burden. These findings are relevant to the design of interventions to maximize not only caregivers' health, but the health of the family members for whom they provide care.

Activities of Daily Living↗
PubMed1998

The effects of bereavement on adult sibling bone marrow donors' psychological well-being and reactions to donation.

As living organ, tissue, and bone marrow donation become increasingly prevalent treatments for a variety of diseases, better understanding of living donors' experiences, especially when the recipient does not survive after the transplant, also becomes more critical. Although some psychological outcome data exist concerning living donation, there have been no systematic prospective investigations, to date, of the psychological impact of bereavement among sibling bone marrow donors. Studies of bereavement effects in other donation settings such as unrelated bone marrow donation and related kidney donation, suggest that bereavement may have a significant impact on donors' reactions. The present investigation studied a panel of sibling bone marrow donors at three key points in the donation process in order to (1) examine donor psychological well-being across time, and (2) investigate the effect of the sibling recipient's death on donor well-being. We surveyed sibling donors by mail 1-2 weeks prior to donation, 1-2 weeks following donation, and again 1 year after their donation. In general, all donors reported high levels of predonation self-esteem, mastery, happiness and life satisfaction. As might be expected, bereaved donors felt less as if their donation had really helped their sibling as time passed. However, despite such donation-specific perceptions, bereaved donors experienced global psychological gains following bereavement including enhanced self-esteem, happiness, and life satisfaction compared to donors whose siblings were still living. These findings suggest that physicians and mental health practitioners should monitor donors' psychological well-being for extended periods post-donation, and should consider clinical interventions for bereaved and nonbereaved sibling donors.

Adult↗