Background

Patients with post-traumatic stress disorder (PTSD) are at increased risk for adverse outcomes from comorbid medical conditions. Medication non-adherence is a potential mechanism explaining this increased risk.

Methods

We examined the association between PTSD and medication adherence in a cross-sectional study of 724 patients recruited from two Department of Veterans Affairs Medical Centers between 2008 and 2010. PTSD was assessed using the Clinician Administered PTSD Scale. Medication adherence was assessed using a standardized questionnaire. Ordinal logistic regression models were used to calculate the odds ratios (ORs) for medication non-adherence in patients with versus without PTSD, adjusting for potential confounders.

Results

A total of 252 patients (35%) had PTSD. Twelve percent of patients with PTSD reported not taking their medications as prescribed compared to 9% of patients without PTSD (unadjusted OR 1.85, 95% CI 1.37-2.50, P<0.001). Forty-one percent of patients with PTSD compared to 29% of patients without PTSD reported forgetting medications (unadjusted OR 1.90, 95% CI 1.44-2.52, P<0.001). Patients with PTSD were also more likely to report skipping medications (24% versus 13%; unadjusted OR 2.01, 95% CI 1.44-2.82, P<0.001). The association between PTSD and non-adherence remained significant after adjusting for demographics, depression, alcohol use, social support, and medical comorbidities (adjusted OR 1.47, 95% CI 1.03-2.10, P=0.04 for not taking medications as prescribed and 1.95, 95% CI 1.31-2.91, P=0.001 for skipping medications).

Conclusions

PTSD was associated with medication non-adherence independent of psychiatric and medical comorbidities. Medication non-adherence may contribute to the increased morbidity and mortality observed in patients with PTSD.

The notion that psychological states can influence physical health is hardly new, and perhaps nowhere has the mind-body connection been better studied than in cardiovascular disease (CVD). Recently, large prospective epidemiologic studies and smaller basic science studies have firmly established a connection between CVD and several psychological conditions, including depression, chronic psychological stress, posttraumatic stress disorder (PTSD), and anxiety. In addition, numerous clinical trials have been conducted to attempt to prevent or lessen the impact of these conditions on cardiovascular health. In this article, we review studies connecting depression, stress/PTSD, and anxiety to CVD, focusing on findings from the last 5 years. For each mental health condition, we first examine the epidemiologic evidence establishing a link with CVD. We then describe studies of potential underlying mechanisms and finally discuss treatment trials and directions for future research.

Objective

To determine the association between PTSD symptoms due to prior trauma and prior trauma type with PTSD symptoms after suspected acute coronary syndrome (ACS).

Method

A consecutive sample of patients presenting to the emergency department (ED) for suspected ACS were surveyed. Logistic regression was used to estimate the odds of elevated ACS-related PTSD symptoms [PCL-S ≥ 33] at 1-month associated with PTSD symptoms due to prior trauma and prior trauma type at the time of suspected ACS, adjusting for demographics, comorbidities, depression, and etiology of ACS symptoms.

Results

Of 984 patients, 81.6% reported ≥1 prior trauma type and 22.5% reported PTSD symptoms due to prior trauma at the time of suspected ACS. One month later, 18.0% had ACS-related PTSD symptoms. Patients with versus without PTSD symptoms due to prior trauma at the time of the suspected ACS had increased odds of ACS-related PTSD symptoms one month later (42.1% vs 9.9%; aOR 4.49, 95% CI:3.05-6.60; p < .001). Prior life-threatening illness was the only trauma type significantly associated with ACS-related PTSD symptoms (aOR 1.57, 95% CI:1.03-2.39; p = .04).

Conclusions

PTSD symptoms from prior trauma and history of life-threatening medical illness at the time of suspected ACS increased risk of ACS-related PTSD symptoms one month later.

Objective

Medical events such as myocardial infarction and cancer diagnosis can induce symptoms of posttraumatic stress disorder (PTSD). The optimal treatment of PTSD symptoms in this context is unknown.

Methods

A literature search of 6 biomedical electronic databases was conducted from database inception to November 2018. Studies were eligible if they used a randomized design and evaluated the effect of treatments on medical event-induced PTSD symptoms in adults. A random effects model was used to pool data when two or more comparable studies were available.

Results

Six trials met full inclusion criteria. Studies ranged in size from 21 to 81 patients, and included patients with PTSD induced by cardiac events, cancer, HIV, multiple sclerosis, and stem cell transplantation. All trials assessed psychological interventions. Two trials comparing a form of exposure-based cognitive behavioral therapy (CBT) with assessment-only control found that CBT resulted in lower PTSD symptoms [Hedges's g = -0.47, (95% CI -0.82 - -0.12), p = .009]. A third trial compared imaginal exposure (another form of exposure-based CBT) with an attention control and found a trend toward reduced PTSD symptoms. Three trials compared eye movement desensitization and reprocessing (EMDR) with active psychological treatments (imaginal exposure, conventional CBT, and relaxation therapy), and found that EMDR was more effective.

Conclusion

CBT and EMDR may be promising approaches to reducing PTSD symptoms due to medical events. However, additional trials are needed in this patient population.

Climate change is the greatest threat to global health in human history. It has been declared a public health emergency by the World Health Organization and leading researchers from academic institutions around the globe. Structural racism disproportionately exposes communities targeted for marginalization to the harmful consequences of climate change through greater risk of exposure and sensitivity to climate hazards and less adaptive capacity to the health threats of climate change. Given its interdisciplinary approach to integrating behavioral, psychosocial, and biomedical knowledge, the discipline of behavioral medicine is uniquely qualified to address the systemic causes of climate change-related health inequities and can offer a perspective that is currently missing from many climate and health equity efforts. In this article, we summarize relevant concepts, describe how climate change and structural racism intersect to exacerbate health inequities, and recommend six strategies with the greatest potential for addressing climate-related health inequities.

Background

Posttraumatic stress disorder (PTSD) symptoms can develop following acute, life-threatening medical events. This study explores a potential biomarker of PTSD risk that is novel to a medical trauma population: a noninvasive, mobile skin conductance (SC) measurement.

Methods

Participants (N=64) were enrolled in-hospital following a stroke or transient ischemic attack (TIA). Mobile measurement of SC reactivity to recalling the stroke/TIA traumatic event was conducted at hospital bedside in the days following the stroke/TIA. PTSD symptoms that developed in response to the stroke/TIA were measured at 1-month follow-up. We tested the association between SC reactivity and total 1-month PTSD symptoms, as well as PTSD symptom dimensions of fear and dysphoria.

Results

In unadjusted analyses, there were significant positive associations between in-hospital SC reactivity to recalling the stroke/TIA traumatic event and higher-order fear-related symptoms (r=.30, p=.016), as well as lower-order fear-related symptoms of anxious arousal (r=.27, p=.035) and avoidance (r=.25, p=.043) at 1 month. Associations between SC reactivity and the fear, anxious arousal, and avoidance symptom dimensions remained significant in multivariable regression models that adjusted for relevant covariates including age, gender, stroke severity, medical comorbidity, and psychosocial factors. Although there was a positive association observed between SC reactivity to recalling the stroke/TIA event and total PTSD symptom severity at 1-month follow-up, it did not reach the level of statistical significance (r=.23, p=.070). Further, no significant association was detected for dysphoria-related symptoms (r=.11, p=.393).

Conclusions

This is the first study to test the prospective association of SC reactivity with PTSD symptom development following a medical trauma. The findings indicate that mobile measures of SC reactivity may be useful for in-hospital identification of individuals at risk for fear-related PTSD symptom development following a medical event and highlight the potential mechanisms involved in the development of these symptoms following a medical event.

Background Self-monitoring of blood pressure (SMBP) improves blood pressure (BP) outcomes at 12-months, but information is lacking on how SMBP affects hypertension care processes and longer-term BP outcomes. Methods and Results We pooled individual participant data from 4 randomized clinical trials of SMBP in the United Kingdom (combined n=2590) with varying intensities of support. Multivariable random effects regression was used to estimate the probability of antihypertensive intensification at 12 months for usual care versus SMBP. Using these data, we simulated 5-year BP control rates using a validated mathematical model. Trial participants were mostly older adults (mean age 66.6 years, SD 9.5), male (53.9%), and predominantly white (95.6%); mean baseline BP was 151.8/85.0 mm Hg. Compared with usual care, the likelihood of antihypertensive intensification increased with both SMBP with feedback to patient or provider alone (odds ratio 1.8, 95% CI 1.2-2.6) and with telemonitoring or self-management (3.3, 2.5-4.2). Over 5 years, we estimated 33.4% BP control (<140/90 mm Hg) with usual care (95% uncertainty interval 27.7%-39.4%). One year of SMBP with feedback to patient or provider alone achieved 33.9% (28.3%-40.3%) BP control and SMBP with telemonitoring or self-management 39.0% (33.1%-45.2%) over 5 years. If SMBP interventions and associated BP control processes were extended to 5 years, BP control increased to 52.4% (45.4%-59.8 %) and 72.1% (66.5%-77.6%), respectively. Conclusions One year of SMBP plus telemonitoring or self-management increases the likelihood of antihypertensive intensification and could improve BP control rates at 5 years; continuing SMBP for 5 years could further improve BP control.

OBJECTIVE:Despite their promise for increasing treatment precision, Personalized Trials (i.e., N-of-1 trials) have not been widely adopted. We aimed to ascertain patient preferences for Personalized Trials. STUDY DESIGN AND SETTING:We recruited 501 adults with ≥2 common chronic conditions from Harris Poll Online. We used Sawtooth Software to generate 45 plausible Personalized Trial designs comprising combinations of eight key attributes (treatment selection, treatment type, clinician involvement, blinding, time commitment, self-monitoring frequency, duration, and cost) at different levels. Conditional logistic regression was used to assess relative importance of different attributes using a random utility maximization model. RESULTS:Overall, participants preferred Personalized Trials with no costs vs. $100 cost (utility difference 1.52 [standard error 0.07], P < 0.001) and with less vs. more time commitment/day (0.16 [0.07], P < 0.015) but did not hold preferences for the other six attributes. In subgroup analyses, participants ≥65 years, white, and with income ≤$50,000 were more averse to costs than their counterparts (P all <0.05). CONCLUSION:To optimize dissemination, Personalized Trial designers should seek to minimize out-of-pocket costs and time burden of self-monitoring. They should also consider adaptive designs that can accommodate subgroup differences in design preferences.