Mood symptoms, functional impairment, and disability in people with bipolar disorder: specific effects of mania and depression

OBJECTIVE

To examine the relationship between changes in mood symptoms and changes in functioning or disability in people treated for bipolar disorder.

METHOD

This study was a secondary analysis of data from 441 patients enrolled in a randomized trial of a care management and psychoeducational intervention for bipolar disorder (diagnosed according to DSM-IV). Study participants were enrolled between August 1999 and October 2000, and follow-up data were collected until October 2001. Five in-person assessments spaced 3 months apart included structured assessment of current mood symptoms (using the Structured Clinical Interview for DSM-IV), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) functional status questionnaire, and questions regarding days of disability during the past 3 months. Repeated-measures analyses examined the associations between each outcome measure and severity of mood symptoms. Additional analyses separated variability in mood symptoms into between-person variation (average symptom severity, or trait effects) and within-person variation (change from average symptom severity, or state effects).

RESULTS

Severity of depression symptoms showed a strong and consistent association with all 4 measures of impairment and disability (SF-36 Role-Emotional score, SF-36 Social Function score, days unable to perform household responsibilities, days disabled from other activities; p < .001 for all comparisons). These associations all remained highly significant (p < .001) after adjustment for co-occurring symptoms of mania. Severity of mania/ hypomania symptoms also showed significant association with all disability measures (p < .001 for all comparisons), but these associations were weaker after adjustment for co-occurring symptoms of depression (p < .001 for SF-36 Role-Emotional score, p = .004 for SF-36 Social Function score, p = .069 for days unable to perform household activities, p = .049 for days disabled from other activities). In analyses focused on within-person variation, change in depression was again strongly related to all measures of impairment and disability (p < .001 for all comparisons). After adjustment for co-occurring depression, change in mania/hypomania was not consistently associated with measures of impairment or disability (p = .02 for SF-36 Role-Emotional score; p > .40 for all other comparisons).

CONCLUSIONS

Among people treated for bipolar disorder, modest changes in severity of depression are associated with statistically and clinically significant changes in functional impairment and disability. In contrast, changes in severity of mania or hypomania are not consistently associated with differences in functioning. Conventional measures of functioning, however, may not be sensitive to the effects of mania symptoms.

A pilot study of telephone care management and structured disease self-management groups for chronic depression

OBJECTIVE

The authors developed, implemented, and pilot-tested intervention programs to provide effective care for chronic or recurrent depression.

METHODS

A total of 104 patients with chronic or recurrent depression were randomly assigned to one of four groups: continued usual behavioral health care, usual care plus telephone monitoring and care management by a care manager, usual care plus care management plus a peer-led chronic-disease self-management group program, or usual care plus care management plus a professionally led depression psychotherapy group. Outcomes in intent-to-treat analyses were assessed at three, six, nine, and 12 months and included treatment participation rates, Hopkins Symptom Checklist depression scale scores, major depression (Structured Clinical Interview for DSM-IV), Patient-Rated Global Improvement ratings, treatment satisfaction, and adequacy of medication.

RESULTS

Participation in care management was high in the three intervention groups. Close to 60% of participants invited to both group interventions attended at least an initial meeting, but a greater number assigned to the care management plus the professionally led group continued participation through the 12-month period. The sample was too small to reliably detect small or moderate differences in clinical outcomes, but various measures consistently favored the care management plus professionally led group.

CONCLUSIONS

It is feasible to direct additional intervention services to patients with persistent or recurring depression. A larger trial of organized self-management support for chronic depression will be necessary for a definitive evaluation of program effectiveness.

Relation of body mass index to depression and weighing frequency in overweight women

OBJECTIVE

Research suggests that overweight and obesity are associated with depressive symptoms, particularly among women. Evidence from weight control trials suggests that higher weighing frequency is associated with greater weight loss or less weight gain. As limited data exist on the effects of self-weighing on body mass index (BMI) among overweight adults with or without depression, this study seeks to examine this issue using data from a population-based epidemiologic survey.

METHODS

Data from a large population-based survey of 4655 women ages 40-65 in the greater Seattle area, surveyed from November 2003 to February 2005, were used to examine associations of depression and weight self-monitoring with BMI. Sample-weighted regression models were used to examine associations of depression, self-weighing frequency, and BMI, with demographic factors (race/ethnicity, employment status, smoking status, age, martial status, educational attainment) entered as covariates.

RESULTS

Regression models indicated that higher self-weighing frequency and negative depression status were independently associated with lower BMI, with no interaction observed between depression and self-weighing.

CONCLUSION

Frequent self-weighing appears to be associated with lower BMI in both depressed and non-depressed overweight women.

A randomized trial of telephone psychotherapy and pharmacotherapy for depression: continuation and durability of effects

Randomized trial evidence and expert guidelines are mixed regarding the value of combined pharmacotherapy and psychotherapy as initial treatment for depression. This study describes long-term results of a randomized trial (N = 393) evaluating telephone-based cognitive-behavioral therapy (CBT) plus care management for primary care patients beginning antidepressant treatment versus usual care. In a repeated measures linear model with adjustment for baseline scores, the phone therapy group showed significantly lower mean Hopkins Symptom Checklist (HSCL) Depression Scale scores (L. Derogatis, K. Rickels, E. Uhlenhuth, & L. Covi, 1974) from 6 months to 18 months versus usual care, F(1, 336) = 11.28, p = .001. Average HSCL depression scores over the period from 6 months to 18 months were 0.68 (SD = 0.55) in the telephone therapy group and 0.85 (SD = 0.65) in the usual-care comparison group. Addition of a brief, structured CBT program can significantly improve clinical outcomes for the large number of patients beginning antidepressant treatment in primary care.

Genetic information: Special or not? Responses from focus groups with members of a health maintenance organization

Genetic information is used increasingly in health care. Some experts have argued that genetic information is qualitatively different from other medical information and, therefore, raises unique social issues. This view, called "genetic exceptionalism," has importantly influenced recent policy efforts. Others have argued that genetic information is like other medical information and that treating it differently may actually result in unintended disparities. Little is known about how the general public views genetic information. To identify opinions about implications of genetic and other medical information among the general population, we conducted a series of focus groups in Seattle, WA. Participants were women and men between ages 18 and 74, living within 30 miles of Seattle and members of the Group Health Cooperative. A structured discussion guide was used to ensure coverage of all predetermined topics. Sessions lasted approximately 2 hr; were audio taped and transcribed. The transcripts formed the basis of the current analysis. Key findings included the theme that genetic information was much like other medical information and that all sensitive medical information should be well protected. Personal choice (i.e., the right to choose whether to know health risk information and to control who else knows) was reported to be of crucial importance. Participants had an understanding of the tensions involved in protecting privacy versus sharing medical information to help another person. These data may guide future research and policy concerning the use and protection of medical information, including genetic information.

Overcoming barriers to recruitment and retention in adolescent smoking cessation

Participant recruitment and retention have been identified as challenging aspects of adolescent smoking cessation interventions. Problems associated with low recruitment and retention include identifying smokers, obtaining active parental consent, protecting participants' privacy, respecting participants' autonomy, and making participation relevant and accessible to adolescents. This paper describes nine strategies for minimizing these recruitment and retention problems via a proactive telephone counseling intervention, and reports on their simultaneous implementation among 1,058 smokers from 25 high schools in Washington state. Results are as follows: (a) 85.9% of parents of minor-age seniors provided active consent for their teen's participation, (b) 89.8% of eligible smokers were successfully contacted by counselors, (c) 86.5% of contacted smokers consented to participate in the cessation counseling, (d) 93.8% of consented smokers participated in smoking cessation counseling calls, and (e) 72.2% of participating smokers completed their full intervention. These results demonstrate that older teens who smoke, and their parents, are receptive to confidential cessation counseling that is personally tailored, supportive of their autonomy, and proactively delivered via the telephone.

Cost-effectiveness of systematic depression treatment among people with diabetes mellitus

CONTEXT

Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services.

OBJECTIVE

To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes.

DESIGN

Randomized controlled trial comparing systematic depression treatment program with care as usual.

SETTING

Primary care clinics of group-model prepaid health plan.

PATIENTS

A 2-stage screening process identified 329 adults with diabetes and current depressive disorder.

INTERVENTION

Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response.

MAIN OUTCOME MEASURES

Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records.

RESULTS

Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660).

CONCLUSIONS

For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

Randomized trial of a telephone care management program for outpatients starting antidepressant treatment

OBJECTIVE

This study evaluated the effectiveness of a structured telephone-based care management program for patients in a prepaid health plan receiving new antidepressant prescriptions from psychiatrists.

METHODS

Potential participants were identified with computerized medical records and contacted by telephone. Eligible and consenting participants were randomly assigned to continued usual care (N=104) or to a three-session telephone care management program (N=103). Care management contacts included assessment of depressive symptoms, medication adherence, and medication side effects with structured feedback to treating psychiatrists. Effectiveness was assessed three and six months after randomization by blinded telephone assessments (depression scale on the Hopkins Symptom Checklist [SCL] and patient-rated global improvement). Computerized records were used to assess medication adherence and frequency of in-person follow-up visits.

RESULTS

Compared with usual care, the care management intervention had no significant effect on the mean score of the SCL depression scale at six months, on the probability of 50 percent improvement in depressive symptoms (41 percent for care management and 37 percent for usual care), or on the probability of patient-rated improvement (57 percent for care management and 52 percent for usual care). Patients assigned to care management made significantly more medication management visits over six months (2.4 visits compared with 2.0 visits; p=.035), but there were no significant differences in rates of adequate medication treatment.

CONCLUSIONS

This study found that a low-intensity telephone care management program did not appear to significantly improve clinical outcomes for patients starting antidepressant treatment. Compared with findings from earlier primary care studies, this study found that patients receiving care from a psychiatrist received more intensive treatment, although many still experienced poor outcomes.

Long-term Effectiveness and Cost of a Systematic Care Program for Bipolar Disorder

CONTEXT

Despite the availability of efficacious treatments, the long-term course of bipolar disorder is often unfavorable.

OBJECTIVE

To test the effectiveness of a multicomponent intervention program to improve the quality of care and long-term outcomes for persons with bipolar disorder.

DESIGN

Randomized controlled trial with allocation concealment and blinded outcome assessment.

SETTING

Mental health clinics of a group-model prepaid health plan.

PATIENTS

Of 785 patients in treatment for bipolar disorder who were invited to participate, 509 attended an evaluation appointment, 450 were found eligible to participate, and 441 enrolled in the trial.

INTERVENTIONS

Participants were randomly assigned to a multicomponent intervention program or to continued care as usual. Three nurse care managers provided a 2-year systematic intervention program, including the following: a structured group psychoeducational program, monthly telephone monitoring of mood symptoms and medication adherence, feedback to treating mental health providers, facilitation of appropriate follow-up care, and as-needed outreach and crisis intervention.

MAIN OUTCOME MEASURES

In-person blinded research interviews every 3 months assessed mood symptoms using the Longitudinal Interval Follow-up Examination. Health plan administrative records were used to assess the use and cost of mental health services.

RESULTS

Intent-to-treat analyses demonstrated that the intervention significantly reduced the mean level of mania symptoms (z = 2.09, P = .04) and the time with significant mania symptoms (19.2 vs 24.7 weeks; F(1) = 6.0, P = .01). There was no significant intervention effect on mean level of depressive symptoms (z = 0.19, P = .85) or time with significant depressive symptoms (47.6 vs 50.7 weeks; F(1) = 0.56, P = .45). Benefits of the intervention were found only in a subgroup of 343 persons with clinically significant mood symptoms at the baseline assessment. The incremental cost (adjusted) of the intervention was 1251 dollars (95% confidence interval, 55-2446 dollars), including approximately 800 dollars for the intervention program services and an approximate 500 dollars increase in the costs of other mental health services.

CONCLUSIONS

Population-based systematic care programs can significantly reduce the frequency and severity of mania in bipolar disorder, and cost increases are modest considering the clinical gains. The incorporation of more specific cognitive and behavioral content or more effective medication regimens may be necessary to significantly reduce the symptoms of depression.

The Association of Patient Relationship Style and Outcomes in Collaborative Care Treatment for Depression in Patients With Diabetes

PURPOSE

We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes.

METHODS

From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes.

RESULTS

Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style.

CONCLUSION

Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style.

Effects of enhanced depression treatment on diabetes self-care

PURPOSE

Among patients with diabetes, major depression is associated with more diabetic complications, lower medication adherence, and poorer self-care of diabetes. We reported earlier that enhanced depression care reduces depression symptoms but not hemoglobin A1c level. This study examined effects of depression interventions on self-management among depressed diabetic patients.

METHODS

A total of 329 patients in 9 primary care clinics were randomized to an evidence-based collaborative depression treatment (pharmacotherapy, problem-solving treatment, or both in combination) or usual primary care (routine medical services). Outcome measures included the Summary of Diabetes Self-Care Activities (SDSCA), reported at baseline and 3, 6, and 12 months, and medication non-adherence as assessed by automated pharmacy refill data of oral hypoglycemic agents, lipid-lowering agents, and angiotensin-converting enzyme inhibitors. We used mixed regression models adjusted for baseline differences to compare the intervention with usual care groups at follow-up assessments.

RESULTS

During the 12-month intervention period, enhanced depression care and outcomes were not associated with improved diabetes self-care behaviors (healthy nutrition, physical activity, or smoking cessation). Relative to the usual care group, the intervention group reported a small decrease in body mass index (mean difference = 0.70 kg/m2, 95% CI, 0.17 to 1.24 kg/m2) and a higher rate of nonadherence to oral hypoglycemic agents (mean difference = -6.3%, 95% CI, -11.91% to -0.71%). Adherence to lipid-lowering agents and to antihypertensive medicines was similar for the 2 groups.

CONCLUSIONS

In general, diabetes self-management did not improve among the enhanced depression treatment group during a 12-month period, except for small between-group differences of limited clinical importance. Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes.

Randomized trial of a population-based care program for people with bipolar disorder

BACKGROUND

Despite the availability of efficacious medications and psychotherapies, care of bipolar disorder in everyday practice is often deficient. This trial evaluated the effectiveness of a multi-component care management program in a population-based sample of people with bipolar disorder.

METHOD

Four hundred and forty-one patients treated for bipolar disorder during the prior year were randomly assigned to continued usual care or usual care plus a systematic care management program including: initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program--all provided by a nurse care manager. Blinded quarterly assessments generated week-by-week ratings of severity of depression and mania symptoms using the Longitudinal Interval Follow-Up Evaluation.

RESULTS

Participants assigned to the intervention group had significantly lower mean mania ratings averaged across the 12-month follow-up period (Z= 2.44, p=0.015) and approximately one-third less time in hypomanic or manic episode (2.59 weeks v. 1.69 weeks). Mean depression ratings across the entire follow-up period did not differ significantly between the two groups, but the intervention group showed a greater decline in depression ratings over time (Z statistic for group-by-time interaction = 1.98, p = 0.048).

CONCLUSIONS

A systematic care program for bipolar disorder significantly reduces risk of mania over 12 months. Preliminary results suggest a growing effect on depression over time, but longer follow-up will be needed.

Racial and Ethnic Differences in Microalbuminuria Prevalence in a Diabetes Population: The Pathways Study

The objective of this study was to determine whether racial or ethnic differences in prevalence of diabetic microalbuminuria were observed in a large primary care population in which comparable access to health care exists. A cross-sectional analysis of survey and automated laboratory data 2969 primary care diabetic patients of a large regional health maintenance organization was conducted. Study data were analyzed for racial/ethnic differences in microalbuminuria (30 to 300 mg albumin/g creatinine) and macroalbuminuria (>300 mg albumin/g creatinine) prevalence among diabetes registry-identified patients who completed a survey that assessed demographics, diabetes care, and depression. Computerized pharmacy, hospital, and laboratory data were linked to survey data for analysis. Racial/ethnic differences in the odds of microalbuminuria and macroalbuminuria were assessed by unconditional logistic regression, stratified by the presence of hypertension. Among those tested, the unadjusted prevalence of micro- or macroalbuminuria was 30.9%, which was similar among the various racial/ethnic groups. Among those without hypertension, microalbuminuria was twofold greater (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.14 to 3.53) and macroalbuminuria was threefold greater (OR 3.17; 95% CI 1.09 to 9.26) for Asians as compared with whites. Among those with hypertension, adjusted odds of microalbuminuria were greater for Hispanics (OR 3.82; 95% CI 1.16 to 12.57) than whites, whereas adjusted odds of macroalbuminuria were threefold greater for blacks (OR 3.32; 95% CI 1.26 to 8.76) than for whites. For most racial/ethnic minorities, hypertriglyceridemia was significantly associated with greater odds of micro- and macroalbuminuria. Among a large primary care population, racial/ethnic differences exist in the adjusted prevalence of microalbuminuria and macroalbuminuria depending on hypertension status. In this setting, racial/ethnic differences in early diabetic nephropathy were observed despite comparable access to diabetes care.

Depression and diabetes symptom burden

OBJECTIVE

To examine the relationship among patient-reported diabetes symptoms, severity of depressive illness and objective measures of diabetes control and severity among a population-based sample of patients with diabetes.

METHODS

A mailed survey was sent to all patients with diabetes from nine primary care clinics of a Health Maintenance Organization. The Patient Health Questionnaire (PHQ-9) was used to diagnose major depression, the Self-Completion Patient Outcome instrument assessed diabetes symptoms and automated medical record data were used to measure diabetes treatment intensity, HbA(1c) levels, diabetes complications and medical comorbidity. Analysis of covariance (ANCOVA) was used to determine if the number of diabetes symptoms was related to having major depression and to number of depressive symptoms. Logistic regression analyses determined the relative strengths of the associations between each individual diabetic symptom and presence of major depression, HbA(1c) levels above 8.0% and two or more diabetes complications.

RESULTS

Among 4168 patients with diabetes, those with major depression (N=487) reported significantly more diabetes symptoms (mean=4.40) than participants without depression (mean=2.46) after adjusting for demographic characteristics, objective measures of diabetes severity and medical comorbidity [F(1,4029)=339.31, P<.0001]. The overall number of diabetes symptoms was related to the number of depressive symptoms (from 0 to 9) endorsed by participants [F(9,4021)=110.05, P<.0001]. Logistic regression analyses found that depression was significantly related to each of the 10 diabetes symptoms (all P<.001).

CONCLUSIONS

The depression-diabetes symptom association is stronger than the association of diabetes symptoms with measures of glycemic control and diabetes complications.

Relationship of depression and diabetes self-care, medication adherence, and preventive care

OBJECTIVE

We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services.

RESULTS

This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients.

CONCLUSIONS

In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.

Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: a randomized controlled trial

CONTEXT

Both antidepressant medication and structured psychotherapy have been proven efficacious, but less than one third of people with depressive disorders receive effective levels of either treatment.

OBJECTIVE

To compare usual primary care for depression with 2 intervention programs: telephone care management and telephone care management plus telephone psychotherapy.

DESIGN

Three-group randomized controlled trial with allocation concealment and blinded outcome assessment conducted between November 2000 and May 2002.

SETTING AND PARTICIPANTS

A total of 600 patients beginning antidepressant treatment for depression were systematically sampled from 7 group-model primary care clinics; patients already receiving psychotherapy were excluded.

INTERVENTIONS

Usual primary care; usual care plus a telephone care management program including at least 3 outreach calls, feedback to the treating physician, and care coordination; usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone.

MAIN OUTCOME MEASURES

Blinded telephone interviews at 6 weeks, 3 months, and 6 months assessed depression severity (Hopkins Symptom Checklist Depression Scale and the Patient Health Questionnaire), patient-rated improvement, and satisfaction with treatment. Computerized administrative data examined use of antidepressant medication and outpatient visits.

RESULTS

Treatment participation rates were 97% for telephone care management and 93% for telephone care management plus psychotherapy. Compared with usual care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom Checklist Depression Scale depression scores (P =.02), a higher proportion of patients reporting that depression was "much improved" (80% vs 55%, P<.001), and a higher proportion of patients "very satisfied" with depression treatment (59% vs 29%, P<.001). The telephone care management program had smaller effects on patient-rated improvement (66% vs 55%, P =.04) and satisfaction (47% vs 29%, P =.001); effects on mean depression scores were not statistically significant.

CONCLUSIONS

For primary care patients beginning antidepressant treatment, a telephone program integrating care management and structured cognitive-behavioral psychotherapy can significantly improve satisfaction and clinical outcomes. These findings suggest a new public health model of psychotherapy for depression including active outreach and vigorous efforts to improve access to and motivation for treatment.

Depressed mood and smoking experimentation among preteens

The authors examined children's depressed mood, parental depressed mood, and parental smoking in relation to children's smoking susceptibility and experimentation over 20 months in a cohort of 418 preteens (ages 10-12 at baseline) and their parents. Depressed mood in preteens was strongly related to experimentation but not to susceptibility. In cross-sectional analyses parental depressed mood was related to children's experimentation, but in longitudinal analyses parental depressed mood at baseline did not differentiate children who experimented from those who did not. Although parental smoking was strongly related to experimentation, it was not related to susceptibility either cross-sectionally or longitudinally. Depressed mood among preteens and parents appeared to be more strongly related to children's smoking behaviors than to their intentions to smoke.

A randomized trial of a family-based smoking prevention intervention in managed care

BACKGROUND

Each day more than 2000 youth under age 18 become daily smokers and the age of tobacco initiation has been going down. Health care settings can partner with families to encourage parent-child interactions that prevent youth tobacco use. This study evaluates a smoking prevention intervention package for parents and children (aged 10-12) provided through their managed care organization.

METHODS

A two-arm (usual care vs intervention) randomized trial was employed. The intervention included a mailed parental smoking prevention kit, outreach follow-up telephone calls to the parent by a health educator, child materials, medical record cues for physicians to deliver prevention messages, and parent newsletter. Outcome measures were susceptibility to smoking, experimentation with smoking, and smoking in the past 30 days as assessed by 20-month follow-up surveys of children.

RESULTS

A total of 4,026 families enrolled in the study. The response rate to the 20-month follow-up was 88%. There were no significant effects of the intervention on any of the primary outcomes. The intervention was associated with modest but statistically significant increases in parent-child discussions of smoking related topics.

CONCLUSIONS

A minimal-intensity family-based prevention program did not significantly reduce rates of susceptibility or tobacco use among youth aged 10-12 at baseline and 11 to 14 at follow-up. Development and evaluation of innovative approaches to tobacco use prevention must continue, despite our disappointing results. Parents and health care systems are too important to abandon as channels for prevention messages.

Enhancing adherence to prevent depression relapse in primary care

We performed a randomized trial to prevent depression relapse in primary care by evaluating intervention effects on medication attitudes and self-management of depression. Three hundred and eighty six primary care patients at high risk for recurrent depression were randomized to receive a 12-month intervention. Interviews at baseline, 3, 6, 9, and 12-months assessed attitudes about medication, confidence in managing side effects, and depression self-management. This depression relapse prevention program significantly increased: 1) favorable attitudes toward antidepressant medication [Beta =.26, 95% C.I. = (.18,.33)]; 2) self-confidence in managing medication side effects [Beta =.53, 95% C.I. = (.15,.91)]; 3) depressive symptom monitoring [O.R. = 4.08, 95% C.I. = (2.80, 5.94)]; 4) checking for early warning signs [O.R. = 3.27, 95% C.I. = (2.32, 4.61)]; and, 5) planful coping [O.R. = 2.01, 95% C.I. = (1.49, 2.72)]. Significant predictors of adherence to long-term pharmacotherapy were: favorable attitudes toward antidepressant treatment [OR = 2.20, 95% CI = (1.50, 3.22)], and increased confidence in managing medication side effects [OR = 1.10, 95% CI = (1.04, 1.68)]. Among primary care patients at high risk for depression relapse, enhanced attitudes towards antidepressant medicines and higher confidence in managing side effects were key factors associated with greater adherence to maintenance pharmacotherapy.

Pediatric-based smoking cessation intervention for low-income women: a randomized trial

BACKGROUND

Continued high rates of smoking among socioeconomically disadvantaged women lead to increases in children's health problems associated with exposure to tobacco smoke. The pediatric clinic is a "teachable setting" in which to provide advice and assistance to parents who smoke.

OBJECTIVE

To evaluate a smoking cessation intervention for women.

DESIGN

Two-arm (usual care vs intervention) randomized trial.

SETTING

Pediatric clinics serving an ethnically diverse population of low-income families in the greater Seattle, Wash, area.

INTERVENTION

During the clinic visit, women received a motivational message from the child's clinician, a guide to quitting smoking, and a 10-minute motivational interview with a nurse or study interventionist. Women received as many as 3 outreach telephone counseling calls from the clinic nurse or interventionist in the 3 months following the visit.

PARTICIPANTS

Self-identified women smokers (n = 303) whose children received care at participating clinics.

MAIN OUTCOME MEASURE

Self-reported abstinence from smoking 12 months after enrollment in the study, defined as not smoking, even a puff, during the 7 days prior to assessment.

RESULTS

Response rates at 3 and 12 months were 80% and 81%. At both follow-ups, abstinence rates were twice as great in the intervention group as in the control group (7.7% vs 3.4% and 13.5% vs 6.9%, respectively). The 12-month difference was statistically significant.

CONCLUSIONS

A pediatric clinic smoking cessation intervention has long-term effects in a socioeconomically disadvantaged sample of women smokers. The results encourage implementation of evidence-based clinical guidelines for smoking cessation in pediatric practice.

Self-administered treatment for smoking cessation

Self-administered treatment for smoking cessation has the potential to reach a broad spectrum of the population of smokers. This article focuses on self-administration of behavioral and pharmacological treatments for smoking cessation. Evidence for the effectiveness of written manuals to self-administer behavioral treatment is mixed. There is no evidence that self-help manuals alone are effective. However, they do increase quit rates when combined with personalized adjuncts such as written feedback and outreach telephone counseling. Efficacy trials of first-line pharmacotherapies (nicotine gum, nicotine patch, and bupropion) result in doubling of cessation rates compared to placebo. It is difficult to evaluate the effectiveness of pharmacotherapies when self-administered under real-world conditions. The general consensus is that they improve quit rates, although poor compliance and early discontinuation reduce their effectiveness. Areas for further research include randomized trials of the use of new technologies (e.g., hand-held computers and the Internet) to disseminate self-administered treatments as well as improved surveillance of the use of self-administered treatment in population-based health surveys.

A randomized trial of a brief primary-care-based intervention for reducing at-risk drinking practices

This randomized trial evaluated an intervention for reducing at-risk drinking practices in a sample of 307 patients. Eligible drinking patterns included chronic drinking (> or = 2 drinks per day in the past month), binge drinking (> or = 5 drinks per occasion at least twice in the past month), and drinking and driving (driving after > 2 drinks in the past month). Members of the intervention group received a message from their physician during their regularly scheduled visit, a self-help manual, written personalized feedback, and up to 3 telephone counseling calls. Dropout was significantly higher in the intervention than control group.

Cost-effectiveness of a program to prevent depression relapse in primary care

OBJECTIVE

Evaluate the incremental cost-effectiveness of a depression relapse prevention program in primary care.

MATERIALS AND METHODS

Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks later. Those recovered from the current episode but at high risk for relapse (based on history of recurrent depression or dysthymia) were offered randomization to usual care or a relapse prevention intervention. The intervention included systematic patient education, two psychoeducational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and telephone and mail monitoring of medication adherence and depressive symptoms. Outcomes in both groups were assessed via blinded telephone assessments at 3, 6, 9, and 12 months and health plan claims and accounting data.

RESULTS

Intervention patients experienced 13.9 additional depression-free days during a 12-month period (95% CI, -1.5 to 29.3). Incremental costs of the intervention were $273 (95% CI, $102 to $418) for depression treatment costs only and $160 (95% CI, -$173 to $512) for total outpatient costs. Incremental cost-effectiveness ratio was $24 per depression-free day (95% CI, -$59 to $496) for depression treatment costs only and $14 per depression-free day (95% CI, -$35 to $248) for total outpatient costs.

CONCLUSIONS

A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs. These modest differences reflect high rates of treatment in usual care. Along with other recent studies, these findings suggest that improved care of depression in primary care is a prudent investment of health care resources.

Depressive symptoms, stress, and weight concerns among African American and European American low-income female smokers

The relationships between perceived stress, depressive symptoms, concern about weight gain and smoking dependence were examined among 83 European American and 175 African American female smokers bringing children to pediatric clinics serving a low-income population. Among African American women, but not European American women, greater stress and more depressive symptoms predicted greater smoking dependence, and less concern about weight gain predicted greater smoking dependence. Multivariate analyses confirmed the bivariate relationships among stress, depressive symptoms, and smoking dependence among African American women but reduced the relationship between weight concern and smoking dependence. The stronger relationships among stress, depressive symptoms, and smoking dependence among African American women may be indicative of smoking patterns more associated with affect regulation than are the smoking patterns of European American women.

A measure for assessing patient perception of provider support for self-management of bipolar disorder

OBJECTIVES

Health care providers have an important role in acknowledging and supporting patients' self-management of chronic illnesses such as bipolar disorder. This report describes the development and evaluation of a brief measure for assessing patient perception of providers' support for self-management of bipolar disorder.

METHODS

A 10-item measure was developed combining generic items from an existing measure of providers' autonomy supportive versus controlling style with items specific to the self-management of bipolar disorder. The psychometric properties of the measure and its relation to clinical variables were evaluated in a sample of patients enrolled in an ongoing randomized intervention trial.

RESULTS

Data were obtained from 420 patients with a chart diagnosis of bipolar disorder (mean age=44, 68% female, 88% Caucasian). The proportion of missing responses for items ranged from 0 to 3%. Reliability coefficient alpha for the full scale was 0.94. Corrected item-total correlations for individual items ranged from 0.70 to 0.83. Factor analysis identified a single factor accounting for 67% of total variance. Factor loadings for individual items were all at least 0.75. The measure showed moderate positive correlations with measures of self-efficacy for managing bipolar disorder (r=0.34; p < 0.001), treatment satisfaction (r=0.63; p < 0.001), small negative correlations with measures of mania symptoms (r=-0.11; p < 0.03) and depressive symptoms (r=-0.09; p < 0.10).

CONCLUSIONS

This measure shows good psychometric properties and good evidence for convergent and discriminant validity. It is promising for assessing an important aspect of care for bipolar disorder.

Depressive symptoms, stress, and weight concerns among African American and European American low-income female smokers

The relationships between perceived stress, depressive symptoms, concern about weight gain and smoking dependence were examined among 83 European American and 175 African American female smokers bringing children to pediatric clinics serving a low-income population. Among African American women, but not European American women, greater stress and more depressive symptoms predicted greater smoking dependence, and less concern about weight gain predicted greater smoking dependence. Multivariate analyses confirmed the bivariate relationships among stress, depressive symptoms, and smoking dependence among African American women but reduced the relationship between weight concern and smoking dependence. The stronger relationships among stress, depressive symptoms, and smoking dependence among African American women may be indicative of smoking patterns more associated with affect regulation than are the smoking patterns of European American women.

A randomized trial of relapse prevention of depression in primary care

BACKGROUND

Despite high rates of relapse and recurrence, few primary care patients with recurrent or chronic depression are receiving continuation and maintenance-phase treatment. We hypothesized that a relapse prevention intervention would improve adherence to antidepressant medication and improve depression outcomes in high-risk patients compared with usual primary care.

METHODS

Three hundred eighty-six patients with recurrent major depression or dysthymia who had largely recovered after 8 weeks of antidepressant treatment by their primary care physicians were randomized to a relapse prevention program (n = 194) or usual primary care (n = 192). Patients in the intervention group received 2 primary care visits with a depression specialist and 3 telephone visits over a 1-year period aimed at enhancing adherence to antidepressant medication, recognition of prodromal symptoms, monitoring of symptoms, and development of a written relapse prevention plan. Follow-up assessments were completed at 3, 6, 9, and 12 months by a telephone survey team blinded to randomization status.

RESULTS

Those in the intervention group had significantly greater adherence to adequate dosage of antidepressant medication for 90 days or more within the first and second 6-month periods and were significantly more likely to refill medication prescriptions during the 12-month follow-up compared with usual care controls. Intervention patients had significantly fewer depressive symptoms, but not fewer episodes of relapse/recurrence over the 12-month follow-up period.

CONCLUSIONS

A relapse prevention program targeted to primary care patients with a high risk of relapse/recurrence who had largely recovered after antidepressant treatment significantly improved antidepressant adherence and depressive symptom outcomes.

Low-intensity treatment of depression in primary care: is it problematic?

The aim of this study was to examine patterns of care and outcomes of depressed patients under primary care during acute phase treatment. A cohort of depressed patients was assessed 6-8 weeks after starting pharmacotherapy in four large primary care clinics in a health maintenance organization. These patients (n = 1671) were receiving antidepressant treatment for a new episode of depression. To calculate main outcome measures, Structured Clinical Interview for Depression evaluated prior history and current depression status. Visit and pharmacy refill data described use of health services and antidepressant medication. Six to eight weeks after starting antidepressant therapy, 33.2% of patients had 0-3 depressive symptoms and no prior history of depression, an additional 42.3% also reported 0-3 symptoms but were at high risk of relapse, and 24. 5% were persistently depressed with 4 or more depressive symptoms. In the initial 6 weeks of treatment, these three groups showed similar use of antidepressant medication and health services. About 50% in each group had no follow-up visit for depression and 32%-42% had not refilled their antidepressant prescription. In general, depressed patients under primary care obtained low-intensity pharmacotherapy and inconsistent follow-up visits during initial acute phase treatment. Six weeks after starting antidepressant medicine, many were still symptomatic or recovered but had a high risk of depression relapse. Patients with unfavorable outcomes did not receive more intensive management than the one-third who had favorable outcomes.

Stress, depressive symptoms, and smoking cessation among pregnant women

Perceived stress and depressive symptoms were examined as correlates and predictors of smoking cessation during pregnancy in a sample of 819 pregnant smokers (454 baseline smokers and 365 baseline quitters). Women who quit early in pregnancy had lower levels of stress and depressive symptoms than baseline smokers. Adjusting for level of addiction and other demographic factors related to stress and depressive symptoms eliminated the significant association between depressive symptoms and smoking cessation. Lower levels of stress and depressive symptoms were not predictive of cessation in later pregnancy. Prenatal healthcare providers should continue to assess level of addiction and provide targeted intensive cessation interventions. Interventions that reduce stress and depression may also be of benefit to women who are continuing smokers in early pregnancy.

Implementation of outreach telephone counseling to promote mammography participation

To increase mammography participation, the authors implemented an outreach intervention translating concepts from expectancy value theory into a motivational interviewing telephone intervention that included the opportunity to schedule a screening appointment. Process data are presented from 491 women who had not scheduled a mammogram within 2 months of receiving a mailed invitation from a managed care organization's centralized breast cancer screening program. A total of 83% of targeted women accepted the counseling calls. Counselors rated 84% of completed calls as either receptive or neutral in tone. Women with prior mammography experience were more likely to be receptive and to schedule a screening appointment during the calls than were women with no prior experience. Topics discussed during the calls also differed between women with and without prior mammography experience. Implications for dissemination of counseling interventions in health care organizations are discussed.

Women's knowledge and attitudes about genetic testing for breast cancer susceptibility

OBJECTIVE

To assess female primary care patients' knowledge about breast cancer genetics and attitudes toward genetic testing.

DESIGN

Self-administered survey.

PARTICIPANTS

A convenience sample of 91 female patients awaiting appointments at a large primary care clinic of Group Health Cooperative in Seattle, Washington.

RESULTS

Forty-seven percent of women had read or heard almost nothing about genetic susceptibility testing, and most did not know the answers to questions that assessed knowledge about breast cancer genetics. Eighty-one percent "somewhat" or "strongly" agreed that testing should be offered to everyone; women who had heard or read about genetic testing for breast cancer were more likely to agree that genetic testing should be offered only to people who have a reason to think that they have an altered gene. When asked whether they planned to have genetic testing for breast cancer, many women said "probably or definitely yes" (71% would do so if insurance covered the cost; 44% would do so even if they had to pay out-of-pocket).

CONCLUSIONS

Although most women knew little about genetic testing, many expressed interest in being tested and believed that it should be offered to everyone. Primary care providers may be asked to educate women about cancer genetics and appropriate use of susceptibility testing.

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care

OBJECTIVE

The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted.

METHOD

They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy.

RESULTS

At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy.

CONCLUSIONS

Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.