Journal Digest

Collaborative Care Model Improves Depression in Patients With Heart Failure

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Patients with heart failure who received a collaborative care intervention showed no signs of improved heart status, but they did show improvements in depression and fatigue over time, reports a study in JAMA Internal Medicine. The findings demonstrate the benefit of a collaborative care intervention on two symptoms known to be difficult to treat in this patient population.

A total of 314 adult patients with heart failure were randomized to receive either Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) or their usual care. The CASA intervention includes medical symptom care provided by a nurse and psychosocial care provided by a social worker. Nurses and social workers also worked alongside a primary care clinician, cardiologist, and palliative care physician to review the patients’ care and provide tests and medications as needed.

After six months, the patients receiving CASA had greater improvements in depressive symptoms and fatigue compared with patients receiving usual care. There were no differences between the groups in their heart health or in overall symptom distress, shortness of breath, number of hospitalizations, or mortality.

The authors noted several potential explanations for the lack of heart-related improvements with CASA, including that the study participants had varying levels of depressive symptoms, and only 47 percent screened positive for depressive disorder.

“The improvement in depression without improvement in heart failure–specific health status raises questions about the relationship between these two facets of the patient experience,” the study authors wrote.

Prophylactic Haloperidol Does Not Increase Intensive Care Survival

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A study published February 20 in JAMA found no evidence to suggest prophylactic haloperidol improves survival rates in critically ill adults.

Investigators at the Radboud University Medical Center in Nijmegan, the Netherlands, and colleagues enrolled 1,789 critically ill adults at risk of delirium from 21 intensive care units (ICUs) in the Netherlands. The participants were randomly assigned to receive 1 mg haloperidol, 2 mg haloperidol, or placebo every eight hours for 28 days or until they were discharged or experienced delirium.

The investigators observed no differences in the primary outcome—median survival rate during the 28-day study period—or any of 15 secondary outcomes between the 2 mg haloperidol and placebo groups (the 1 mg haloperidol group was discontinued early after preliminary results showed no effect). The incidence of delirium was about 33 percent in both the treatment and placebo groups. Prophylactic haloperidol was not associated with haloperidol-induced adverse effects.

“[I]n demonstrating that haloperidol was not effective in preventing delirium or reducing the harms associated with delirium, [this] study challenges the current model that the addition of psychoactive medication to patients who are already receiving multiple interventions may be beneficial,” wrote the authors of an accompanying JAMA editorial.

Elementary School Students Can Benefit From Mental Health Services

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A meta-analysis conducted by researchers at Florida International University suggests that school-based mental health services can help reduce mental health problems in elementary school children.

The meta-analysis included 43 randomized clinical studies that evaluated nearly 50,000 children using various school-based programs, both prevention and intervention strategies. Overall, these programs demonstrated a small-to-modest effect size, though there was much variability as different programs target different problems. The authors found, for example, the largest improvements were associated with programs targeting externalizing problems, followed by internalizing problems, and attention problems.

The authors also found that mental health services integrated into students’ academic instruction, those that incorporated contingency management, and those implemented multiple times per week showed stronger than average effects.

“Recognizing the effective role school personnel can play in children’s mental health care and the serious problems in the accessibility and acceptability of office-based care, child psychiatrists are encouraged to increase referrals to school mental health programs for elementary school-age children,” the authors concluded.

The findings were published in the Journal of the American Academy of Child and Adolescent Psychiatry.

TBI May Be Linked to Intermittent Explosive Disorder

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People with intermittent explosive disorder (IED) appear to be more likely to have a history of mild traumatic brain injury (mTBI) than people with other psychiatric disorders, according to a study published in the Journal of Neuropsychiatry and Clinical Neurosciences.

These findings come from clinical interviews with over 1,600 participants at the University of Chicago Pritzker School of Medicine.

About 25 percent of participants who had been diagnosed with IED reported at least one mTBI, compared with 12 percent and 11 percent among people with another psychiatric disorder and healthy controls, respectively. The study authors also found that individuals who experienced a mTBI that resulted in a loss of consciousness were much more likely to have self-directed aggressive behavior (self-harm or suicide attempts).

“On the basis of these data alone, we cannot say whether the presence of high trait impulsivity and aggression led IED participants to be in circumstances that increase risk for mTBI or whether history of mTBI altered the brains of mTBI participants, leading to an increase in aggressive and impulsive behavior post-mTBI,” the authors wrote. “That said, impulsive-aggressive behaviors are present from very early life, and individuals with this temperament are likely to place themselves in circumstances associated with bodily injury, including mTBI.” ■