In this sample of veterans with no recent (24-month) history of depression or opioid analgesic use, the risk of development of depression increased as the duration of opioid analgesic exposure increased. The potential for depressogenic effect should be considered in risk-benefit discussions, and patients initiating opioid treatment should be monitored for development of depression.

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OBJECTIVETo investigate major depressive disorder (MDD), which complicates the course of type 2 diabetes and is associated with an increased risk of cardiovascular disease and death. This risk may be due to a greater susceptibility for myocardial infarction (MI) in depressed patients with type 2 diabetes compared with nondepressed patients with type 2 diabetes.RESEARCH DESIGN AND METHODSVeterans Administration electronic medical records were analyzed to identify a cohort free of cardiovascular disease in fiscal years 1999 and 2000, aged 25 to 80 years. ICD-9-CM codes were used to create a four-level risk group indicating 1) neither diabetes nor MDD (n = 214,749), 2) MDD alone (n = 77,568), 3) type 2 diabetes alone (n = 40,953), and 4) comorbid MDD and type 2 diabetes (n = 12,679). Age-adjusted Cox proportional hazards models were computed before and after adjusting for baseline sociodemographic and time-dependent covariates.RESULTSAfter adjusting for covariates, patients with type 2 diabetes alone and patients with MDD alone were at ∼30% increased risk for MI, and patients with type 2 diabetes and MDD were at 82% increased risk for MI (hazard ratio 1.82 [95% CI 1.69–1.97]) compared with patients without either condition.CONCLUSIONSCompared with patients with only diabetes or only MDD, individuals with type 2 diabetes and MDD are at increased risk for new-onset MI. Monitoring cardiovascular health in depressed patients with type 2 diabetes may reduce the risk of MI in this especially high-risk group.

All-cause mortality following an acute myocardial infarction is greatest in patients with depression who are insufficiently treated and is a risk in patients with treatment-resistant depression. However, the risk of mortality associated with treatment-resistant depression is partly explained by comorbid disorders. Further studies are warranted to determine whether changes in depression independently predict all-cause mortality.

Our results demonstrate the high prevalence of mental health diagnoses among HIV-infected veterans. In the era of highly active antiretroviral therapy, presence of psychiatric diagnoses impacted survival and development of ADI. More aggressive measures addressing substance abuse and severe mental illness in HIV-infected veterans are necessary.

Automated data missed several exceptions to care that are documented only in providers' notes, thus underestimating process of care. These results have implications for future quality assessment initiatives-most of which will likely rely on automated data for process-based quality reporting. After accounting for automated data and medical record reviews, vaccinations and antiviral treatment rates in the Veterans Administration left room for improvement.

BACKGROUND & AIMS Process of care–based measures are used commonly to assess the quality of medical care provided to patients with chronic hepatitis C virus (HCV) infection. However, the links between these processes and patient outcomes are not clear. METHODS We conducted a large retrospective cohort study of 34,749 patients with HCV infection identified from the national Veterans Administration HCV Clinical Case Registry between 2003 and 2006. We examined the relationship between meeting process–based measures of HCV care (categorized into pretreatment, preventive or comorbid care, and treatment monitoring domains) and antiviral treatment-related outcomes. For each domain, we defined optimum care as receipt of all indicated care processes in that domain. Study end points were rates of antiviral treatment, treatment completion, and sustained virologic response (SVR), adjusted for patient demographics, comorbidities, use of health services, and intrafacility clustering. RESULTS Patients who received optimum pretreatment care were significantly more likely to receive antiviral treatment (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.9–3.5), complete treatment (OR, 1.26; 95% CI, 1.13–1.43), and achieve an SVR (OR, 1.29; 95% CI, 1.01–1.65), than those with suboptimum pretreatment care. Optimum preventive or comorbidity care also independently was associated with receipt of antiviral treatment (OR, 1.36; 95% CI, 1.23–1.51), but not with completion of treatment or SVR. Optimum treatment monitoring was associated with a nonsignificant trend toward achieving an SVR (OR, 1.22; 95% CI, 0.95–1.56). CONCLUSIONS Optimum care for HCV infection—particularly the care delivered before treatment—is associated with increased rates of treatment and SVR. These data could be used to guide clinical policy as newer, more-effective treatments become available.