THE EMERGING PROBLEM OF DIABETES IN THE SERIOUSLY MENTALLY ILL

We describe the increasing prevalence of chronic illnesses such as obesity and type 2 diabetes have markedly increased in both developed and developing countries. We describe the relationship between type 2 diabetes and mental illness. The extant literature suggests a critical need for innovative treatments targeted to individuals with comorbid diabetes and mental illness. Given the complexity and challenge of both of these disorders in tandem with the interactive challenges and burdens of psychiatric and medical comorbidity, it is essential that interventions address the issue of mental and medical health from the perspective of the individual with the disorder, engage individuals to actively participate in illness self-management, and include consideration of the multiple barriers to care

Medication treatment perceptions, concerns and expectations among depressed individuals with Type I Bipolar Disorder

BACKGROUND: Subjective experience of illness affects outcomes among populations with bipolar disorder (BD). This cross-sectional study combined qualitative and quantitative approaches to evaluate perceived treatment effects, concerns and expectations among 90 individuals with BD. METHODS: Adults with type I BD, mean age 36.6 years, 51% women, completed a semi-structured interview that was audio taped, transcribed, coded and analyzed along emergent themes. Quantitative scales measured depressive symptoms (Hamilton Depression Scale/HAMD), psychopathology (Clinical Global Impression/CGI), and insight and treatment attitudes (Insight and Treatment Attitudes Questionnaire/ITAQ). RESULTS: Individuals had moderate depression and psychopathology with good insight into need for treatment. Drug treatment was perceived as beneficial, by “stabilizing” or “balancing” mood (42%, N=38), decreasing anxiety/depressive symptoms (19%, N=17) and improving sleep (10%, N=9). While 39%, (N=35) of individuals denied medication concerns, nearly 29%, (N=26) feared possible long-term effects, particularly diabetes or liver/kidney damage. Media stories and advertisements contributed to medication fears. Hopes and expectations for treatment ranged from those that were symptom or functional status-based, such as desiring mood stabilization and elimination of specific symptoms (23%, N=21), to more global hopes such as “being normal” (20%, N=18) or “cured” (18%, N=16). LIMITATIONS: Limitations include relatively small sample, lack of a comparator, inclusion of only depressed individuals and those willing to discuss their illness experience. CONCLUSIONS: While individuals with BD appreciate the effects of medications, concerns regarding adverse effects and discrepancy between actual and hoped-for outcomes can be substantial. Subjective experience with medications using qualitative and quantitative methods should be explored in order to optimize treatment collaboration and outcomes

ASSESSMENT AND MANAGEMENT OF MAJOR DEPRESSIVE DISORDER IN OLDER ADULTS

Background: Major depression disorder (MDD) is one of the most common mental disorders world-wide and is prevalent throughout the lifespan, with prevalence estimates of 1-5% in those 65 years of age and older. Methods: The aim of this mini-review is to briefly summarize clinically relevant topics within the domain of later-life MDD. Results: The mini-review presents an overview of epidemiology, complications of late life MDD, risk factors and clinical presentation, clinical assessment, general issues relevant to the treatment of the older adult with MDD, drug treatments, discussion of how medical complexity affects drug treatment and other treatment modalities. Conclusion: The mini-review concludes with a short discussion of clinical and research implications. Treatment of depression in the geriatric population is a complex endeavor and clinicians often are faced with medical, social, and environmental issues which can impede the treatment process. Antidepressant drugs, particularly the SSRI and SNRI antidepressants are helpful, but dosing titration needs to be considered against the backdrop of comorbidity and concomitant medications. Psychotherapy and other approaches are additional avenues to consider in the older individuals with MDD. Future research in particular needs to address older people with more extensive medical complexity as well as the “oldest-old”, individuals in their 80’s and beyond

DEPRESSION IN LATER-LIFE: AN OVERVIEW OF ASSESSMENT AND MANAGEMENT

The elderly are the fastest growing segment of the global population with the number of people age 60 or older having doubled since 1980 and the number of people age 80 or older expected to increase more than 4-fold (to 395 million) by the year 2050. While depression is overall less common in older people compared to younger people, there are sub-groups of elderly, such as those with significant medical comorbidity, who are at greatly elevated risk for depression. Negative consequences of late-life depression include functional decline and disability, increased use of non-mental health services, increased mortality rates due to cardiovascular causes, increased cancer rates, and substantially greater risk for suicide. Geriatric suicide is a global epidemic, which is worsened in many countries and cultures by socioeconomic disparities and cultural/social upheaval. Geriatric depression should be carefully assessed and treated. Treatments for geriatric depression include biological modalities such as antidepressant medications and Electroconvulsive therapy (ECT) as well as psychotherapy and psychosocial interventions. When they are prescribed pharmacotherapies for depression, older adults are especially likely to experience adverse drug effects as a result of their multiple chronic diseases, use of multiple concomitant medications, and the pharmacokinetic and pharmacodynamic changes that accompany aging. Antidepressants that minimize side effects are generally preferred in elderly individuals although the expected therapeutic response to drug treatment is generally modest. Psychosocial and psychotherapeutic measures can also be effective in late-life depression. Complexities of assessment and treatment include the risk of missing a bipolar depressive diagnosis, which would contra-indicate the use of antidepressant monotherapy. Given the projected increased proportions and overall numbers of older people with mental disorders there is a need for all clinicians to be familiar with mental health issues in elderly patients

Role of extended release quetiapine in the management of bipolar disorders

Atypical antipsychotics have become a widely utilized component of the bipolar disorder treatment armamentarium, with approximately 45% of bipolar patients prescribed atypicals. Over the last decade all atypical drugs except for clozapine have received a Food and Drug Administration (FDA) bipolar indication. In October 2008, the FDA approved quetiapine XR monotherapy for the treatment of acute depressive episodes of bipolar disorder and acute manic or mixed episodes in bipolar I disorder based on two placebo-control trials. Quetiapine was also approved as adjunct therapy with lithium and divalproex for the treatment of acute manic or mixed episodes as well as maintenance of bipolar I disorder. In contrast to immediate release quetiapine which may require a twice-daily regimen, the XR formulation is intended for once-daily administration. This drug profile of quetiapine XR will address chemistry, pharmacodynamics, pharmacokinetics, metabolism, safety and tolerability and clinical trials in bipolar disorder

Recruiting and Retaining Individuals with Serious Mental Illness and Diabetes in Clinical Research: Lessons Learned from a Randomized, Controlled Trial.

Abstract: Recruitment and retention of individuals with serious mental illness (SMI) and comorbid diabetes mellitus (DM) in research studies can be challenging with major impediments being difficulties reaching participants via telephone contact, logistic difficulties due to lack of transportation, ongoing psychiatric symptoms, and significant medical complications. Research staff directly involved in recruitment and retention processes of this study reviewed their experiences. The largest barriers at the macro, mediator, and micro levels identified in this study were inclement weather, transportation difficulties, and intermittent and inaccessible telephone contact. Barrier work-around practices included using the health system’s EHR to obtain current phone numbers, providing transportation assistance (bus passes or parking reimbursement), and flexible scheduling of appointments. Suggestions are intended to assist in planning for recruitment and retention strategies

Prevalence, patterns and factors associated with hypertensive crises in Mulago hospital emergency department; a cross-sectional study

Background: Hypertension is increasing in sub-Saharan Africa (SSA) and it’s the single most important modifiable stroke risk factor, yet it’s control is not routinely emphasized. The prevalence, pattern and factors associated with hypertensive urgencies and emergencies in Uganda is not well established. A cross-sectional study, was conducted between November 2015 and February 2016, using a complete clinical examination and pre-tested standardized questionnaire subjects were enrolled. The prevalence of hypertensive crises and associations of demo- graphic and clinical factors determined using logistic regression.Results: The prevalence of hypertensive crises was 5.1%, (203/4000) of all admissions at the medical section of the accident and emergency ward of Mulago National Referral  Hospital.  The hypertensive urgencies and emergencies accounted for 32.5% and 67.5% respectively among study subjects with hypertension. Among those with hypertensive crises, 41.1% were aged 45-65 years and half were female. Self-reported compliance was significantly different between those with hypertensive crisis compared to non-hypertensive crisis with OR; (95% CI) 52.4; (24.5 – 111.7), p-value =<0.001. Acute stroke was the commonest hyper- tensive emergency.Conclusion: Hypertensive emergencies are common and significantly associated with poor compliance to prescribed anti-hy- pertensive drugs. Acute stroke is the commonest presentation in our setting.Keywords: Hypertensive crises, prevalence, factors associated

Influence of Dietary Salt Knowledge, Perceptions, and Beliefs on Consumption Choices After Stroke in Uganda

Background Previous research on Uganda\u27s poststroke population revealed that their level of dietary salt knowledge did not lead to healthier consumption choices. Purpose Identify barriers and motivators for healthy dietary behaviors and evaluate the understanding of widely accepted salt regulation mechanisms among poststroke patients in Uganda. Methods Convergent parallel mixed methods triangulation design comprised a cross-sectional survey (n = 81) and 8 focus group discussions with 7-10 poststroke participants in each group. We assessed participant characteristics and obtained insights into their salt consumption attitudes, perceptions, and knowledge. Qualitative responses were analyzed using an inductive approach with thematic analytic procedures. Relationships between healthy dietary salt compliance, dietary salt knowledge, and participant characteristics were assessed using logistic regression analyses. Results Healthy dietary salt consumption behaviors were associated with basic salt knowledge (P \u3c  .0001), but no association was found between compliance and salt disease-related knowledge (P = .314). Only 20% and 7% obtained health-related salt knowledge from their health facility and educational sources, respectively, whereas 44% obtained this information from media personalities; 92% of participants had no understanding of nutrition labels, and only 25% of the study population consumed potash—an inexpensive salt substitute that is both rich in potassium and low in sodium. Conclusion One barrier to healthy dietary consumption choices among Uganda\u27s stroke survivors is a lack of credible disease-related information. Improving health-care provider stroke-related dietary knowledge in Uganda and encouraging the use of potash as a salt substitute would help reduce hypertension and thereby lower the risk of stroke