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Objective: Previous theoretical models predict that elevated inflammation may predict later depressive symptoms, but bidirectional associations are possible. We examined whether depressive symptoms or inflammation predicts change in the other for a 3-month period in a sample of adults with acute coronary syndromes (ACS). Methods: During hospitalization for their index ACS event (baseline) and then again 1 and 3 months later, 163 post-ACS patients completed the Beck Depression Inventory, a measure of depressive symptom severity with cognitive-affective and somatic-affective subscales. C-reactive protein (CRP) was also assessed at each visit; known correlates of depression and CRP were assessed at baseline. Path analyses were conducted to evaluate prospective associations between depressive symptoms and log-transformed CRP values and whether strength and/or directionality varied by specific depressive symptom dimensions. Results: Baseline total depressive symptom severity predicted a smaller decrease in CRP from baseline to 1 month (unstandardized parameter estimates [B] = 0.04, p < .001) controlling for all covariates, as did baseline cognitive-affective depressive symptom severity (B = 0.10, p = .02). Baseline somatic-affective depressive symptom severity did not predict change in CRP (B = −0.002, p = .94). CRP did not predict 1- or 3-month change in total, cognitive-affective, or somatic-affective depressive symptom severity. The results did not differ for men and women. Conclusions: Greater cognitive-affective and total depressive symptom severity at the time of a cardiac event predicts a smaller decrease in CRP 1 month later, but there was no evidence in this study that CRP predicts change in depressive symptoms.

Background: Persistent depressive symptoms after acute coronary syndrome (ACS) are common and increase the risk of recurrent cardiac events and mortality. However, the neurobiological correlates of post-ACS depressive symptoms have not yet been studied. Methods: Three months after ACS, 22 patients were scanned for the presence of cerebral deep white matter changes and microstructural abnormalities in the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex. We used the Coffey Rating Scale of deep white matter changes and measures of fractional anisotropy derived from diffusion tensor imaging. Patients also completed the Beck Depression Inventory, and the number of cardiovascular comorbidities as well as modifiable cardiovascular risk factors were assessed. Results: Controlling for cardiovascular comorbidity, depressive symptom severity at 3 months was negatively related to fractional anisotropy in the ACC (r = –0.72, p < 0.001), but this association disappeared when controlling for cardiovascular risk factors (p = 0.21). In comparison to patients who were non-depressed at 3 months after hospitalization (n = 14), patients with persistent depressive symptoms (n = 8) exhibited more advanced deep white matter changes overall (p < 0.02), but not when controlling for cardiovascular comorbidity. Persistently depressed patients also had lower fractional anisotropy in the ACC (p < 0.05), but this effect disappeared when controlling for modifiable cardiovascular risk factors. Conclusions: This study provides the first evidence that persistent depressive symptoms after ACS are associated with vascular brain changes. Longitudinal studies are needed to determine whether depressive symptoms precede these changes or vice versa.

There is recent evidence that acute coronary syndrome (ACS) patients with first time incident major depressive disorder (MDD) and those with recurrent MDD represent different subtypes among individuals with ACS and comorbid depression. However, few studies have examined whether or not these subtypes differ in coronary artery disease (CAD) severity. We assessed whether those with incident MDD (in-hospital MDD and negative for history of MDD) or recurrent MDD (in-hospital MDD and a positive history of MDD) differ in angiographically documented CAD severity. Within 1 week of admission for ACS, 88 patients completed a clinical interview to assess current and past diagnosis of MDD. CAD severity was assessed in all patients by coronary angiography. A hierarchical regression analysis showed that neither in-hospital MDD status, nor history of MDD were significant predictors of CAD severity, but the interaction term between in-hospital MDD status and history of MDD was a significant predictor of CAD severity, after controlling for age, sex and ethnicity. Follow-up analyses showed that patients with first-time, incident MDD had significantly more severe CAD compared to patients with recurrent MDD (p = 0.043). To conclude, our study adds to the growing evidence that patients with incident MDD should be considered as a clinically distinct subtype from those with recurrent MDD. Possible mechanisms for differing CAD severity by angiogram between these two subtypes are proposed and implications for prognosis and treatment are discussed.

Depression and sub-syndromal depressive symptoms are important predictors of morbidity and mortality after acute coronary syndrome (ACS). Prior trials of depression treatment in post-ACS patients have demonstrated no improvement for event-free survival, and only modest improvement in depression symptoms. These trials have raised a number of important issues regarding timing of depression intervention, acceptability of depression treatment to ACS patients, and safety for subsets of the treated population. This article describes Project COPES (Coronary Psychosocial Evaluation Studies), a multi-center Phase-I randomized clinical trial. Project COPES uses a patient preference depression treatment that has previously been found acceptable to medical patients, and a 3-month pre-randomization observation period to insure depression status. The study sample will include 200 post-ACS patients. The primary outcome is patient satisfaction with depression care. Secondary, exploratory aims include the acceptability of depression treatment, reduction in depressive symptoms, and the effects of treatment on two key pathways – medication adherence and inflammation – hypothesized to link depression to post-ACS prognosis. These analyses will provide important data to inform subsequent clinical trials with this population.

The Medication Adherence and BP Control Trial (ABC Trial) is a randomized, controlled, multi-site, medication adherence and blood pressure (BP) control trial in an economically disadvantaged and multi-cultural population of hypertensive patients followed in primary care practices. To date, no other such trial has been published in which objective measures of adherence (electronic pill bottles) were used to assess the effectiveness of these behavioral interventions for hypertension. This study tested a combination of commercially-available interventions that can be easily accessed by health care providers and patients, and therefore may provide a real-world solution to the problem of non-adherence among hypertensives. The aim of the ABC Trial was to test the effectiveness of a stepped care intervention in improving both medication adherence to an antihypertensive medication regimen and BP control. Step 1 of the intervention employed home Self-BP Monitoring (SBPM); at this stage, there were two arms: (1) Usual Care (UC) and (2) Intervention. At Step 2, patients in the intervention arm whose BP had not come under control after 3 months were further randomized to one of two conditions: (1) continuation of SBPM (alone) or (2) continuation of SBPM plus telephone-based nurse case management (SBPM+NCM). Electronic Medication Event Monitoring (MEMS) was the primary measure of medication adherence, and in-office BP was the primary measure of hypertension control. We present an overview of the study design, details of the administrative structure of the study and a description of clinical site recruitment, patient recruitment, and follow-up assessments.

The aim in this study was to identify predictors of perceived social support before and after cataract surgery. We hypothesized that physical (comorbidity and visual acuity) and mental (depressive symptoms) health indicators would be directly and indirectly (through actually received support) associated with perceived support. One hundred and thirty-six cataract patients (69% women; mean age = 71.6 years) completed questionnaires before and after cataract surgery. Results showed that received support partially mediated the association between depressive symptoms and perceived support. However, mental and physical health variables were also directly associated with perceived support. We conclude that health status might feedback to perceptions of available support.

In Germany, the smoking prevalence among adolescents is among the highest in Europe. Our aim was to evaluate the long-term effectiveness of a combined student-parent and a student-only smoking prevention programme to reduce the smoking prevalence among 7th grade students in Berlin.Three-armed cluster-randomized controlled trial (RCT). Schools as cluster units were randomized into (i) student intervention, (ii) combined student-parent intervention or (iii) control group, with follow-up after 12 and 24 months.High schools and integrated secondary schools in Berlin, Germany.Seventh grade students aged 11-16 years. We included 47 schools, 161 classes and 2801 students [50.1% girls, mean age ± standard deviation (SD) = 13.0 ± 0.6 years].The primary outcome was self-reported regular smoking (at least one cigarette per day) after 24 months (point prevalence). Further self-reported outcomes were other smoking behaviours as well as parental rules and attitudes towards smoking. Comparisons were calculated as odds ratios (OR) with 95% confidence intervals (CI).At baseline, 2.3% of the students reported that they smoked regularly. After 24 months, 7.8% and 7.0% were regular smokers in the student-only intervention and the student-parent intervention, respectively, compared with 10.1% in the control group. The OR for being a regular smoker was 0.81 (0.34-1.92) for the student-parent intervention versus control, 0.95 (CI = 0.41-2.22) for the student-only intervention versus control and 0.85 (0.38-1.89) for student-parent intervention versus student-only intervention.A combined student-parent smoking prevention intervention delivered via secondary schools in Berlin, Germany did not result in a statistically significant reduction in regular smoking compared with a control group or a student-only intervention. The student-only intervention did not result in a significant reduction in regular smoking compared with the control group.

Objective We evaluated the long-term effect of a smoking intervention embedded in an adherence program in patients with an increased risk for cardiovascular disease. Method Secondary analysis of a randomized controlled trial: In 2002–2004, 8108 patients with hypercholesterolemia were enrolled from general practices in Germany. Patients received a 12-month adherence program and statin medication (intervention) or statin medication only (control). The program aimed to improve adherence to medication and lifestyle by educational material, mailings, and phone calls. Smoking was self-reported at baseline and every 6 months during the 3-year follow-up. Results In total, 7640 patients were analyzed. At baseline, smoking prevalence was 21.7% in the intervention and 21.5% in the control group. Prevalence decreased in both groups to 16.6% vs. 19.5%, 15.3% vs. 16.8%, and 14.2% vs. 15.6% at the 12-, 24-, and 36-month follow-up. The intervention had a beneficial effect on smoking differing over time (group × time: P = 0.005). The effect was largest after 6 and 12 months [odds ratios (95% confidence intervals): 0.67 (0.54–0.82) and 0.63 (0.51–0.78)]. The effect decreased until the 18-month follow-up [0.72 (0.58–0.90)] and was not significant after 24 months. Conclusion A low-intensity smoking intervention embedded in an adherence program can contribute to smoking cessation although the intervention effect diminished over time. Trial Registration: ClinicalTrials.gov ( www.clinicaltrials.gov ): NCT00379249 .

Objective Demographic changes are increasing the pressure to improve therapeutic strategies against cognitive decline in Alzheimer disease (AD) and mild cognitive impairment (MCI). Besides drug treatment, physical activity seems to be a promising intervention target as epidemiological and clinical studies suggest beneficial effects of exercise training on cognition. Using comparable inclusion and exclusion criteria, we analyzed the efficacy of drug therapy (cholinesterase inhibitors, memantine, and Ginkgo biloba) and exercise interventions for improving cognition in AD and MCI populations. Methods We searched The Cochrane Library, EBSCO, OVID, Web of Science, and U.S Food and Drug Administration data from inception through October 30, 2013. Randomized controlled trials in which at least one treatment arm consisted of an exercise or a pharmacological intervention for AD or MCI patients, and which had either a non-exposed control condition or a control condition that received another intervention. Treatment discontinuation rates and Standardized Mean Change score using Raw score standardization (SMCR) of cognitive performance were calculated. Results Discontinuation rates varied substantially and ranged between 0% and 49% with a median of 18%. Significantly increased discontinuation rates were found for galantamine and rivastigmine as compared to placebo in AD studies. Drug treatments resulted in a small pooled effect on cognition (SMCR: 0.23, 95% CI: 0.20 to 0.25) in AD studies (N = 45, 18,434 patients) and no effect in any of the MCI studies (N = 5, 3,693 patients; SMCR: 0.03, 95% CI: 0.00 to 0.005). Exercise interventions had a moderate to strong pooled effect size (SMCR: 0.83, 95% CI: 0.59 to 1.07) in AD studies (N = 4, 119 patients), and a small effect size (SMCR: 0.20, 95% CI: 0.11 to 0.28) in MCI (N = 6, 443 patients). Conclusions Drug treatments have a small but significant impact on cognitive functioning in AD and exercise has the potential to improve cognition in AD and MCI. Head-to-head trials with sufficient statistical power are necessary to directly compare efficacy, safety, and acceptability. Combining these two approaches might further increase the efficacy of each individual intervention. Identifier PROSPERO (2013:CRD42013003910).

BACKGROUND: The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality. OBJECTIVE: To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later. DESIGN: Prospective observational cohort study. SETTING: Three university hospitals. PARTICIPANTS: Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up. MEASUREMENTS: We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used χ 2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI

This study examined the stability of symptoms of schizophrenia over time, focusing on the stability of symptom structure. Symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). The sample consisted of 215 chronic patients followed up for as long as 4 years. Exploratory factor analysis identified 6 factors. Several statistical techniques were used to examine the stability of these symptoms, including longitudinal confirmatory factor analysis. Low-to-moderate rank-order stability and high absolute stability of the factors were found, with the structure of the PANSS-assessed symptoms consistent over time. The results demonstrate that despite changes in the severity of symptoms in individual patients with schizophrenia, the factor structure and interrelatedness of symptoms have considerable stability over time.

Personality and coping were specified as predictors of emotional outcomes of a mildly stressful medical procedure. Situation‐specific coping was examined in contrast to dispositional coping, and it was tested whether one or the other would mediate the relationship between higher‐order personality factors and stress outcomes. Cataract patients (N=110) participated at four measurement points in time during a six‐week period surrounding their scheduled surgery. Dispositional coping did not mediate the personality–outcome relationship. In contrast, situation‐specific coping acquired a mediator status between personality and adaptational criteria and accounted for independent outcome variance once personality traits were included as predictors in the models. Thus, the data suggest that whether or not coping mediates between personality factors and affective outcomes may be related to the methodological approaches of its operationalization. Copyright © 2005 John Wiley & Sons, Ltd.

Zusammenfassung: Der MikroMental Test ist ein in Anlehnung an die Mini-Mental-Status Untersuchung (MMSE) entwickeltes Kurzverfahren zum Screening bei Verdacht auf eine demenzielle Erkrankung. In der vorliegenden Arbeit wurde die Reliabilität und die diagnostische Validität einer deutschsprachigen Version (MikroMental Test) untersucht. 125 gerontopsychiatrische Patienten mit einer Demenzdiagnose (mittleres Alter 77.8 ± 8.0 Jahre) und 77 Probanden ohne Demenzdiagnose (mittleres Alter 71.1 ± 7.0 Jahre), darunter 43 gesunde ältere Kontrollpersonen (mittleres Alter 69.7 ± 6.8 Jahre) wurden mittels der MMSE und des MikroMental Tests untersucht. Als Außenkriterium diente die Diagnose nach ICD-10. Die Durchführung des MikroMental Tests dauerte im Mittel 8 Minuten, für die MMSE wurden durchschnittlich 15 Minuten benötigt. Testwiederholungsanalysen zeigten eine befriedigende Reliabilität. Analysen der Sensitivität und Spezifität ergaben für den MikroMental Test Parameter diagnostischer Güte, die mit der MMSE vergleichbar, hinsichtlich einzelner Werte sogar statistisch bedeutsam überlegen sind. Für den ambulanten Bereich stellt der MikroMental Test aufgrund seiner Kürze und seiner diagnostischen Güte ein geeignetes Instrument zum Demenzscreening dar.

Objective There is an increasing interest in the usefulness of neurocognitive subtyping of schizophrenia. The classification of schizophrenia patients with cortical versus subcortical impairments has recently been validated with both neuropsychological and neurobiological measures. The authors examined the stability and correlations of these classifications with longitudinal assessments in older, chronically ill schizophrenia patients. Methods Older, chronically ill patients (N=589) were classified on the basis of their baseline profile, and a subset (N=243) was followed for periods up to 8 years, with data analyses conducted to evaluate the stability of these profiles, to determine whether classification into cortical or subcortical impairment at baseline predicts changes in self-care and social functioning at endpoint, up to 8 years later. Results Cortical profiles were most common and most stable over time, with the majority of patients with a subcortical profile at baseline found to have a cortical profile at follow-up. Those patients whose subcortical impairment profile was stable over time had less severe cognitive and functional impairments at baseline than those whose profile was found to be cortical at follow-up. Discussion Cortical profiles of memory impairment were associated with substantial cognitive impairments at baseline and did not predict risk for subsequent cognitive decline, whereas subcortical profiles were associated with worsening of cognitive impairments in about half of the cases. Those patients with more severe negative symptoms and cognitive and functional impairments within the subcortical group were most likely to decline.

Objective: To compare study quality and clinically meaningful effect sizes in behavioural medicine interventions and medication interventions for post-acute coronary syndrome (ACS) patients.

This study contributes to research on subjective age by examining the interplay of felt age with health, functional limitations, and personality. Individuals undergoing cataract surgery (N=134; 38 to 92 years of age) provided data for an assessment period of 6 weeks surrounding their scheduled surgery. Conscientiousness and repeated measurements of health indicators, functional limitations, and felt age were included in the analyses. Results indicated that functional limitations may be more important to the construction of felt age than their underlying health-related causes. Moreover, conscientious participants felt younger before and after surgery. Their functional status was less dependent on health than the functional status of less conscientious participants. This moderator effect is discussed along with health-related pathways leading to felt age.

Similar to depression, anxiety is common after acute coronary syndromes (ACS), and is an independent predictor of worse outcomes.1–3 Yet, post-ACS psychological interventions have focused on treating depression. We previously reported that an enhanced depression care intervention involving patient preference for problem-solving therapy (PST), antidepressant medications, or both followed by stepped care according to treatment response was effective at reducing depressive symptoms after ACS with an effect size of 0.59 SD.4 We report here the independent effect of this intervention on anxiety. The trial design is described elsewhere.5 Briefly, hospitalized ACS patients who were persistently depressed (Beck Depression Inventory (BDI)6 score ≥10 within 1-week of hospitalization and again 3 months later) were recruited from 5 US hospitals between 2005 and 2008 and randomized to enhanced depression care or to usual care on a 1:1 basis. Exclusion criteria were alcohol or drug dependency; dementia; psychosis or bipolar disorder; terminal illness; unavailability for follow-up; BDI score of ≥45; or suicidality. The institutional review boards at all institutions approved the protocol, and all participants provided written informed consent. Enhanced depression care consisted of patient preference for brief problem focused psychotherapy (i.e., PST) and/or pharmacotherapy and stepped-care in which symptom severity was reviewed every 8 weeks and treatment was augmented according to predetermined decision rules. Usual care was defined by the patient’s treating physician(s). Anxiety and depressive symptoms were assessed within 1-week of hospitalization, and at 3, 5, 7, and 9 months. Anxiety was measured using the 7-item anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A).7 Depressive symptoms were assessed by the BDI.6 Outcome assessors were blinded to group assignment. Given the low number and apparent randomness of missing assessments (Little’s MCAR χ2 = 13.97, p=0.12), mixed effects regression was used to generate estimates of treatment effects on anxiety from month 3 to 9 and t-test to assess the differential change in anxiety between groups (group × time interaction). Analyses were performed using SAS statistical software (version 9.2; SAS Institute Inc, Cary, NC). The mean age of patients in the trial was 60.1 SD 10.6 years and 54% were women. Enhanced and usual care patients were similar on demographic and baseline medical variables,4 on HADS-A score at baseline and 3 months (see Table), and in the percent with HADS-A in a range above normal (HADS-A>7; 61% vs 60%, respectively). Table Reduction in Anxiety Symptoms 0, 3 and 9 Months after Acute Coronary Syndrome* At 9 months, enhanced care patients showed a significant decrease in HADS-A compared to the 3 month pre-RCT assessment (−2.51; 95% CI, −3.77 to −1.26; p7) at 9 months. Accordingly, post-ACS patients with combined anxiety and depressive symptoms may benefit from a sequential approach in which anxiety symptoms are monitored alongside depressive symptoms, and are targeted by alternating treatment strategies (psychotherapy and pharmacotherapy), depending on the individual history, course, and severity of the patients’ symptoms and symptom profiles.16

Previous cross-sectional research has shown that older people who are rich in sensorimotor-cognitive and social-personality resources are better functioning in everyday life and exhibit fewer negative age differences than resource-poor adults. Longitudinal data from the Berlin Aging Study was used to examine these findings across a 4-year time interval and to compare cross-sectional indicators of adaptive everyday functioning among survivors and nonsurvivors. Apart from their higher survival rate, resource-rich older people (a) invest more social time with their family members, (b) reduce the diversity of activities within the most salient leisure domain, (c) sleep more often and longer during daytime, and (d) increase the variability of time investments across activities after 4 years. Overall, findings suggest a greater use of selection, compensation, and optimization strategies in everyday functioning among resource-rich older adults as compared with resource-poor older adults.

In survivors of acute coronary syndromes (ACS; unstable angina or myocardial infarction), depression is highly prevalent [1] and increases the risk of adverse medical outcomes, independent of other prognostic risk markers [2,3]. After ACS, adherence to recommended medications (e.g. aspirin, statins and β-blockers) is crucial to prevent recurrent events or mortality [4,5,6], yet rates of adherence to these medications are poor [7,8,9]. Depressed patients are especially likely to be poorly adherent [8,9,10,11]. Thus, poor medication adherence may explain some of the increased risk of depression and adverse clinical outcomes after ACS. We used data from 168 participants in the medication monitoring substudy [12] of the observational Coronary Psychosocial Evaluation Studies (COPES) [13] to test this hypothesis. This substudy included hospitalized ACS patients who were prescribed a daily dose of aspirin, neither used a weekly pillbox nor lived in a nursing home, and had a score of ≥10 or

Background: Policy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners’ (GPs) attitudes toward primary prevention. Methods: Mixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention. Results: Most respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs’ health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of “health policing”. GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions. Conclusions: The mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.

Background The Coronary Psychosocial Evaluation Studies trial demonstrated promising results for enhanced depression treatment to reduce cardiovascular risk of patients with acute coronary syndrome and comorbid depression, but the long-term effectiveness of this intervention is unclear. Methods A total of 157 participants with persistent depression after hospitalization for acute coronary syndromes were enrolled in the Coronary Psychosocial Evaluation Studies trial. A total of 80 participants were allocated to 6 months of enhanced depression treatment, and 77 participants were allocated to usual care. We report on an additional 12 months of observational follow-up for the composite outcome of death or first hospitalization for myocardial infarction or unstable angina. Results Although the intervention was previously shown to have favorable cardiovascular effects during the treatment period, we observed a significant time-by-treatment group interaction during extended follow-up ( P = .008). Specifically, during the 6-month treatment period, death or hospitalization for myocardial infarction/unstable angina occurred in 3 participants (4%) in the treatment group compared with 11 participants (14%) in the usual care group (hazard ratio, 0.25; 95% confidence interval, 0.07-0.90; P = .03). In contrast, during 12 months of additional observational follow-up, 11 participants (14%) in the treatment group experienced the composite outcome of death or hospitalization for myocardial infarction/unstable angina compared with 3 participants (4%) in the usual care group (hazard ratio, 2.91; 95% confidence interval, 0.80-10.56; P = .10). Conclusions Enhanced depression treatment was associated with a reduced risk of death or hospitalization for myocardial infarction/unstable angina during active treatment, but this effect did not persist after treatment ceased. Future research is needed to confirm our findings and to determine the optimal duration of depression treatment in patients with depression after acute coronary syndromes.

Background The hazardous health effects of smoking are established, but there remains a need to evaluate existing smoking prevention strategies and to increase their effectiveness in adolescents. Strategies focusing on parental attitudes and rule setting have been identified as a potentially effective approach. The present manuscript describes objectives, study design and methodology of the BEST Prevention study. Methods/design BEST Prevention is a three-armed cluster randomized-controlled trial among 7th grade (11–16 years) students in Berlin, Germany. Schools were enrolled between 2010 and 2011 and allocated using a centralized randomization list into 1) a student smoking prevention intervention (visit to an established interactive circuit), 2) the same intervention plus a parent intervention, and 3) a control group (visit to an established exercise and nutrition interactive circuit). Students were assessed at baseline, 12 and 24 months via self-report, as well as via carbon monoxide and cotinine in saliva at the 24 month follow-up. Statistical analyses uses multi-level regression models with cluster effects (school and class within school) based on the intention to treat population. Here we report descriptive baseline characteristics of recruited schools, and schools classes. Two schools from the control group dropped out after allocation. Hence, 47 secondary schools from all 12 districts of the city, including 161 school classes and 3023 students are participating in the study. Of those, 2801 students completed the baseline assessment. Discussion The present manuscript provides details on the study design and methodology of a large school-based smoking prevention trial in a metropolitan area in Germany. Findings from this study will yield important insight into the long-term effectiveness of specific smoking prevention strategies, also in disadvantaged population groups. Trial registration NCT01306552 (January 2011).

Depression is associated with poor adherence to medications and worse prognosis in patients with acute coronary syndrome (ACS).To determine whether cognitive, behavioral, and/or psychosocial vulnerabilities for depression explain the association between depression and medication adherence among ACS patients.One hundred sixty-nine ACS patients who agreed to have their aspirin adherence measured using an electronic pill bottle for 3 months were enrolled within 1 week of hospitalization. Linear regression was used to determine whether depression vulnerabilities predicted aspirin adherence after adjustment for depressive symptoms, demographics, and comorbidity.Of the depression vulnerabilities, only role transitions (beta = -3.32; P = 0.02) and interpersonal conflict (beta -3.78; P = 0.03) predicted poor adherence. Depression vulnerabilities did not mediate the association between depressive symptoms and medication adherence.Key elements of the psychosocial context preceding the ACS including major role transitions and conflict with close contacts place ACS patients at increased risk for poor medication adherence independent of depressive symptoms.

To the editor: In coronary heart disease (CHD) patients, depression is highly prevalent (1). Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line antidepressant treatments for this population (2,3). While there is a long-standing notion that SSRIs may improve cardiac prognosis by inhibiting platelet aggregation, SSRI use may also worsen prognosis by increasing bleeding (4), or arrhythmia risk (5). Only a few small randomized clinical trials (RCTs) with a total of 801 patients have assessed the efficacy of SSRIs in patients with a cardiac condition (6,7). Although no evidence for harm was detected in two meta-analyses, the follow-up periods for adverse cardiac events in these RCTs did not extend beyond six months, and patient samples were highly selected (i.e. only patients not already receiving antidepressant therapy in usual care were included, and patients with comorbid conditions were excluded). Accordingly, we evaluated, in an observational cohort of patients with acute coronary syndromes (ACS), the association of SSRI and non-SSRI second-generation antidepressant use with the occurrence of cardiac events and mortality across a period of 42 months.