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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_358"
                     title="Poststroke Antidepressant Boosts Mental Agility (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18240?impressionId=1265748137033"
                     
      &lt;p&gt;Antidepressants in the first months after a stroke may aid cognitive recovery for patients without depression, according to a randomized trial analysis.&lt;/p&gt;
&lt;p&gt;Global cognitive function scores improved significantly more with escitalopram (Lexapro) than with problem-solving therapy or placebo (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), according to Ricardo E. Jorge, MD, of the University of Iowa in Iowa City, and colleagues.&lt;/p&gt;
&lt;p&gt;Memory scores rose significantly higher with the antidepressant as well (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01), with both effects independent of those on depression, they reported in the February &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Adjunctive restorative therapies administered during the first few months after stroke, the period with the greatest degree of spontaneous recovery, reduce the number of stroke patients with significant disability,&quot; the researchers concluded.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Strokes/9621&quot; target=&quot;_blank&quot;&gt;primary analysis&lt;/a&gt; of the trial, reported in the &lt;em&gt;Journal of the American Medical Association on&lt;/em&gt; May 28, 2008, showed that prophylactic escitalopram treatment would prevent poststroke depression in one patient for every 7.2 treated &lt;em&gt;(P&lt;/em&gt;&amp;lt;0.001 compared with placebo). That article ultimately raised a controversy over an undisclosed conflict of interest.&lt;/p&gt;
&lt;p&gt;Escitalopram is a selective serotonin reuptake inhibitor (SSRI). Since serotonin plays a role in neuroplastic changes in the developing brain as well as in depression, Jorge&apos;s group analyzed whether there might be such an effect after a stroke.&lt;/p&gt;
&lt;p&gt;The study randomized patients to double-blind treatment with escitalopram (10 mg/d under age 65 or 5 mg/day age 65 and older) or placebo or unblinded problem-solving therapy (12 sessions of going through steps to arrive at a course of action for a patient-selected problem).&lt;/p&gt;
&lt;p&gt;The intent-to-treat analysis included 129 patients treated starting within the first three months after their mild to moderate severity stroke and who did not meet criteria for major or minor depression.&lt;/p&gt;
&lt;p&gt;Overall, global cognitive functioning was significantly changed between groups as measured on the Repeatable Battery for the Assessment of Neuropsychological Status (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After controlling for change in depression score and type of stroke, escitalopram was associated with the best cognitive recovery, an adjusted mean change of 9.9 points compared with 1.9 for problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01) and 4.0 for placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;Similarly, for delayed memory scores on the same test battery, escitalopram came out on top (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;After adjustment for depression score change and stroke mechanism, the antidepressant was associated with an 11.2 point improvement in delayed memory, compared with a change of -0.7 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 3.9 with placebo (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;On test of immediate memory, escitalopram again yielded the best recovery.&lt;/p&gt;
&lt;p&gt;The researchers found mean improvement of 13.4 points with the antidepressant compared with 2.0 with problem-solving therapy (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) and 7.2 with placebo (&lt;em&gt;P&lt;/em&gt;=0.04), after adjustment for time between stroke and treatment, depression score change, and stroke type.&lt;/p&gt;
&lt;p&gt;These mental benefits appeared to have an impact on functional status as well.&lt;/p&gt;
&lt;p&gt;Cognitive domain scores on the Functional Independence Measure were better for escitalopram-treated patients than those who didn&apos;t get the drug (&lt;em&gt;P&lt;/em&gt;=0.05), as were memory domain scores on the same measure (&lt;em&gt;P&lt;/em&gt;=0.03).&lt;/p&gt;
&lt;p&gt;At baseline, the global cognitive functioning and delayed and immediate memory scores were nonsignificantly lower in the antidepressant group than in the other two groups, which could have biased the results.&lt;/p&gt;
&lt;p&gt;However, the treatment effects appeared to be real, Jorge explained in an interview.&lt;/p&gt;
&lt;p&gt;In an unpublished regression analysis, the baseline scores were not a significant covariate. &quot;If [the results were] related only to the difference in baseline, this would be significant but it wasn&apos;t,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Moreover, with an initially lower score it might have been expected that the escitalopram-treated group would have had a lower score at the end of the study than the other groups, added co-author Robert G. Robinson, MD, also of the University of Iowa.&lt;/p&gt;
&lt;p&gt;But that wasn&apos;t the case, he said in an interview. With regard to delayed memory, for example, &quot;the escitalopram-treated group went from the most impaired to the best performing.&quot;&lt;/p&gt;
&lt;p&gt;The researchers didn&apos;t compare end scores for the escitalopram, problem solving therapy, and placebo groups, but they were: &lt;ul&gt; &lt;li&gt;For global cognitive functioning 89.8, 89.1, and 91.0 points, respectively&lt;/li&gt; &lt;li&gt;For delayed memory, 96.6, 89.1, and 94.2, respectively&lt;/li&gt; &lt;li&gt;For immediate memory, 95.1, 94.9, and 98.5, respectively&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The treatment showed no effect on other individual cognitive measurements, including those for attention, language, and IQ. Nor were there significant differences in changes in occupational or living conditions.&lt;/p&gt;
&lt;p&gt;Although SSRIs such as escitalopram have been associated with hospitalization for GI bleeding and falls in prior studies, these complications did not occur in Jorge&apos;s study.&lt;/p&gt;
&lt;p&gt;&quot;Long-term administration of SSRIs appears to be an effective and safe treatment option to improve cognitive outcomes among patients with cerebrovascular disease,&quot; they concluded in the &lt;em&gt;Archives&lt;/em&gt; paper.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study was limited by lack of CT or MRI scans and the younger age of escitalopram-treated patients, compared with other groups. That may have been a source of bias, although age did not appear to be a significant factor in the trial results.&lt;/p&gt;
&lt;p&gt;In this analysis, the researchers emphasized that the trial was not financially supported in any way by any drug company  --  a declaration hinting at the controversy that brewed last year over failure of one of the authors of the original &lt;em&gt;JAMA&lt;/em&gt; article to &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/13391&quot; target=&quot;_blank&quot;&gt;properly disclose ties&lt;/a&gt; to Forest Pharmaceuticals, which makes escitalopram.&lt;/p&gt;
&lt;p&gt;Another scientist who discovered that omission published the information in a competing journal, inducing &lt;em&gt;JAMA&lt;/em&gt; to issue a gag rule on reporting of undisclosed conflicts of interest. That policy encourages those who discover such conflicts to report them to &lt;em&gt;JAMA&apos;s&lt;/em&gt; editors but prohibits them from disclosing the conflicts publicly pending an investigation by the journal.&lt;/p&gt;
&lt;p&gt;In the current analysis, the disclosure statement indicated that co-author Robertson, had received honoraria and speakers&apos; bureau fees from Forest, with the caveat that &quot;none of the design, analysis, or expenses (including the cost of medications) of this study were supported by monies, materials, or any intellectual input from Forest Laboratories.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported solely by a grant from the National Institute of Mental Health.&lt;/p&gt;&lt;p&gt;Jorge reported having received travel awards to participate in national meetings from the former Hamilton Pharmaceutical Company and Avanir Pharmaceutical Company.&lt;/p&gt;&lt;p&gt;Co-authors reported financial conflicts of interest with Merck, NMT Medical, Eli Lilly, Centocor, Sanofi-Bristol-Meyers-Squibb, Boerhringer-Ingelheim, Schering-Plough, AstraZeneca, and GlaxoSmithKline, the former Hamilton Pharmaceutical Company, Avanir Pharmaceutical Company, Lubeck, Forest Laboratories, and Pfizer.&lt;/p&gt;&lt;p&gt;No pharmaceutical company donated medications for or had any financial interest in the study.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3730"
                     title="AHA: Phone Calls Ease Post-CABG Depression (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/AHA/tb/17010?impressionId=1265748137033"
                     
      &lt;p&gt;For patients suffering depression after coronary artery bypass grafting (CABG), regular phone calls from a nurse may boost antidepressive therapy as much as psychotherapy and medication, researchers found.&lt;/p&gt;
&lt;p&gt;Depression symptom scores improved significantly more for patients who got phone-based management from a nurse than for those who got usual care (Hamilton Rating Scale for Depression score change 7.6 versus 4.5 points, &lt;em&gt;P&lt;/em&gt;=0.001), according to Bruce L. Rollman, MD, MPH, of the University of Pittsburgh, and colleagues.&lt;/p&gt;
&lt;p&gt;The number needed to treat with phone-based collaborative care in the trial was 4.9 to get at least a 50% drop in depression symptom score, Rollman&apos;s group reported here at the American Heart Association meeting and simultaneously online in the &lt;em&gt; Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This effect size resembled those seen in prior trials using more intensive forms of treatment, such as with citalopram (Celexa) or counseling in the &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/CoronaryArteryDisease/4912&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/CoronaryArteryDisease/4912&quot; target=&quot;_blank&quot;&gt;CREATE&lt;/a&gt; trial or sertraline (Zoloft) in the &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/15877&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/15877&quot; target=&quot;_blank&quot;&gt;SADHART&lt;/a&gt; trial (0.42 compared with 0.29, -0.22, and 0.14, respectively), they said.&lt;/p&gt;
&lt;p&gt;&quot;Our findings and mode of intervention delivery thus have major public health implications for medically frail individuals, those living in rural settings, and other individuals with physical challenges impeding face-to-face depression treatment,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;The Bypassing the Blues study was the first randomized trial treating postcardiac event depression with a collaborative care strategy as recommended by the National Institutes of Health.&lt;/p&gt;

 &lt;p&gt;But even the general population of post-CABG patients would likely benefit from more attention to depressive symptoms, commented Mariell Jessup, MD, of the University of Pennsylvania and program chair of the conference.
    &lt;p&gt;Although postop visits are typical, systematic screening for depression is not, she said. &quot;We get lost in the forest of anemia, wound healing, heart failure, edema . . . and we forget to think about depression.&quot;
    &lt;p&gt;Simply having someone designated to pay attention to symptoms and management of this complication may have accounted for its effectiveness, Jessup speculated. 
    &lt;p&gt;Whether this is a primary care role still needs to be defined, she said, especially since primary care is the setting least likely to have the kind of advanced practice nurses used in the trial.
    &lt;p&gt;In cardiology practice, there is already a precedent for this model of care, noted Roger Blumenthal, MD, director of preventive cardiology at Johns Hopkins.
    &lt;p&gt;Many patients like spending the majority of their follow-up visits with a nurse practitioner addressing lifestyle-type issues before the cardiologist comes in, he said.
    &lt;p&gt;Another option may be for psychologists and psychiatrists to partner with primary care or cardiology practices for true collaborative care, Blumenthal said.


&lt;p&gt;The trial included 302 post-CABG patients with depression hospitalized at university and community hospitals,&lt;strong&gt; &lt;/strong&gt;who were randomized postdischarge to single-blind treatment with usual care or the collaborative care intervention.&lt;/p&gt;
&lt;p&gt;The eight-month intervention was led by a nurse  --  under supervision by a psychiatrist and primary care physician  --  who called patients to provide basic information on depression and its effect on cardiac disease and to describe treatment options, which were: &lt;ul&gt; &lt;li&gt;A workbook on self-care for depression&lt;/li&gt; &lt;li&gt;Initiation or adjustment of antidepressant medication under direction of the primary care physician &lt;/li&gt; &lt;li&gt;Watchful waiting for mildly elevated mood symptoms&lt;/li&gt; &lt;li&gt;Referral to a local psychologist or psychiatrist&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The nurse conveyed treatment recommendations to patients and their primary care physicians, who made prescriptions and dose adjustments.&lt;/p&gt;
&lt;p&gt;After eight months of intervention, mental health-related quality of life measured by the mental component of the Short Form-36 questionnaire improved by an average 3.2 points more than was seen with usual care compared with baseline (change 6.8 versus 3.6 points, &lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;The effect size for this primary outcome was 0.30 for the telephone-based collaborative care intervention (&lt;em&gt;P&lt;/em&gt;=0.01).&lt;/p&gt;
&lt;p&gt;Half of intervention group patients had at least a 50% decline from baseline in depression symptoms measured by the Hamilton Rating Scale for Depression score whereas only 29.6% of usual care patients reached that level of improvement (&lt;em&gt;P&lt;/em&gt;=0.001).&lt;/p&gt;
&lt;p&gt;Physical functioning measured on the Duke Activity Status Index, another secondary endpoint, also showed greater improvements with the intervention compared with standard care (4.6 point difference, &lt;em&gt;P&lt;/em&gt;=0.001).&lt;/p&gt;
&lt;p&gt;The intervention appeared to be particularly effective for men with postbypass depression, with an average 5.7-point greater improvement in mental health-related quality of life over baseline at eight months compared with standard care (&lt;em&gt;P&lt;/em&gt;=0.001), whereas for women the difference between groups was only 0.7 points (&lt;em&gt;P&lt;/em&gt;=0.74).&lt;/p&gt;
&lt;p&gt;However, the intervention didn&apos;t return patients to normal, the researchers noted.&lt;/p&gt;
&lt;p&gt;Mean health-related quality of life and physical functioning scores remained below a comparison group of 151 randomly sampled post-CABG patients who did not have depression.&lt;/p&gt;
&lt;p&gt;The intervention&apos;s success may have been due in part to higher self-reported use of pharmacotherapy compared with usual care, although women in the intervention group were more likely to use antidepressants than men but still got less benefit.&lt;/p&gt;
&lt;p&gt;The researchers noted that generalizability may have been limited by selection bias if more severely depressed patients were less likely to be screened for enrollment and by inclusion of patients in only one region of the U.S.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by grants from the National Institutes of Health and by the University of Pittsburgh Medical Center Endowed Chair in Geriatric Psychiatry.&lt;/p&gt;&lt;p&gt;One co-author reported having received pharmaceutical supplies from Forest Laboratories, Pfizer, Bristol-Myers Squibb, Wyeth, and Eli Lilly. Another reported stock ownership in Forest Laboratories. Jessup and Blumenthal reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_3_231"
                     title="First Depression After MI Raises Risk for New Cardiovascular Events"
                     score="-0.005"
                     href="