A multifaceted intervention to improve treatment of depression in primary care

BACKGROUND

This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care.

METHODS

One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time.

RESULTS

At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients.

CONCLUSION

A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Immunocytochemical demonstration that human duodenal Brunner's glands may participate in intestinal defence

The immunocytochemical demonstration of IgA and IgM in some secretory units of human Brunner's glands, associated with the presence of secretory component in all secretory cells, indicates the possibility that these glands assist the function of the intestinal crypts in transporting immunoglobulins into the gut lumen. In addition, the presence of muramidase (lysozyme) in the cells of the secretory units suggests that Brunner's glands continuously secrete bactericidal enzyme, thus reinforcing the function of the Paneth cells as contributors to nonspecific defence (innate immunity) in the intestinal tract.

Developing staff nurse experts in nursing diagnosis-based care planning

In this article, the authors describe the Program to Increase Nursing Knowledge and Facilitate the Utilization of Nursing Diagnosis (PINK FUND) undertaken at the Medical College of Virginia Hospitals. The program prepared unit-based nurses to be facilitators for nursing diagnosis-based care planning. Major curriculum threads included theory of nursing diagnosis, planned change, and adult learning. Instructors modeled innovative instructional methodologies for participants. Program planners vigorously marketed the program to nurses within the institution. The program succeeded in preparing nurses to use the nursing process to deliver planned care. The program description will serve as a potential model for staff development educators seeking to increase staff competence in nursing care planning and documentation.

Increased urine catecholamines and cortisol in women with irritable bowel syndrome

OBJECTIVES

There are few data on the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis in individuals with chronic GI symptoms. The current study was designed to describe and compare urine catecholamine (norepinephrine, epinephrine) and cortisol levels in women diagnosed with irritable bowel syndrome (IBS-patients), women who report similar symptom levels but had not sought health care services (IBS-nonpatients; IBS-NP), and asymptomatic (control) women.

METHODS

Seventy-three women (24 IBS; 24 IBS-NP; 25 controls) were interviewed for demographic, GI, gynecological, and psychological data and then followed for two menstrual cycles with a daily health diary. Urine samples were obtained in the evening and morning at specific phases across two menstrual cycles.

RESULTS

Women in the IBS group had significantly higher PM and AM urine norepinephrine levels. Urine epinephrine and cortisol levels were also generally higher in women with IBS. Differences in neuroendocrine indicators of arousal were not accounted for by differences in demographic variables, lifestyle characteristics, menstrual distress, or average daily measures of anxiety or depression.

CONCLUSIONS

Increases in indicators of sympathetic nervous system activation in women seeking health care for IBS may reflect greater symptom distress or may contribute to increased symptom distress.

The sequence organization of Yp/proximal Xq homologous regions of the human sex chromosomes is highly conserved

Detailed deletion analysis of patients with breakpoints in Yp has allowed the definition of two distinct intervals on the Y chromosome short arm outside the pseudoautosomal region that are homologous to Xq2l.3. Detailed YAC contigs have been developed over these regions on both the X and Y chromosomes, and the relative order of markers has been compared to assess whether rearrangements on either sex chromosome have occurred since the transposition events creating these patterns of homology. On the X chromosome, the region forms almost one contiguous block of homology, whereas on the Y chromosome, there has been one major rearrangement leading to the two separate Yp-Xq2l blocks of homology. The rearrangement breakpoint has been mapped. Within these separate X-Y homologous blocks on Yp, the order of loci homologous to X has been conserved to a high degree between the sex chromosomes. With the exception of the amelogenin gene (proximal Yp block), all the XY homologous sequences in the two Yp blocks have homolognes in Xq2l.3, with the former having its X counterpart in Xp22.2. This suggests an independent evolutionary event leading to the formation of the amelogenin X-Y homology.

Outcomes of "inadequate" antidepressant treatment

OBJECTIVE

To examine outcomes of primary care patients receiving low levels of antidepressant treatment.

DESIGN

Cohort study comparing patients receiving anti-depressant treatment within and below the recommended dosing range.

SETTING

Primary care clinics of a staff-model health maintenance organization.

PATIENTS

Primary care patients initiating antidepressant treatment for depression.

MEASUREMENTS AND MAIN RESULTS

Of 88 patients beginning antidepressant treatment, 49 (56%) used "adequate" doses for 30 days or more. Likelihood of "adequate" pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using "adequate" pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square = 4.44; df = 1; p = 0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F = 1.45; df = 1.86; p = 0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square = 1.30; df = 1; p = 0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results.

CONCLUSIONS

While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving "inadequate" treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment.

Vascular trauma on the rise

Trauma is the leading cause of death in people under the age of 45. Guns, drugs, and street violence contribute to this growing epidemic. As a result, there is an increased incidence of lower extremity vascular trauma. The most common cause of vascular injury is gunshot wounds. This article presents two case studies to illustrate the complex nursing management of this patient population. It is important for nurses to be aware of the physiologic and psychological treatment of these patients. A detailed nursing plan of care is also included.

Daily gastrointestinal symptoms in women with and without a diagnosis of IBS

This study compared daily gastrointestinal symptoms and stool characteristics across two menstrual cycles, and recalled bowel symptoms and psychological distress in women with irritable bowel syndrome (IBS, N = 22), IBS nonpatients (IBS-NP, N = 22), and controls (N = 25). Daily reports of abdominal pain, bloating, intestinal gas, constipation, and diarrhea did not differ significantly between the IBS and IBS-NP groups but both groups reported significantly higher symptoms than the control group. Stool consistencies was significantly looser in the IBS group relative to the control group. Menstrual cycle effects on symptoms were noted in all the groups. There were no significant differences in psychological distress between women with IBS and IBS-NP, but both groups reported significantly higher global distress than the control group. The lack of difference between the IBS and IBS-NP groups in contrast to the results of others, can be understood in terms of differences in recruitment strategies.

Primary care physician use of cognitive behavioral techniques with depressed patients

BACKGROUND

Although researchers are paying more attention to the treatment of depression in the primary care setting, little is known about the nature of psychotherapeutic interactions that occur between primary care physicians and their patients in the context of a visit for depression. In recent years, brief cognitive behavioral therapy has been demonstrated to be efficacious, and the public has become more familiar with these techniques through media exposure and self-help books.

METHODS

Depressed primary care patients were surveyed regarding the extent to which cognitive behavioral (CB) techniques were suggested during the primary care visit in which antidepressant medication was initially prescribed. One hundred fifty-five patients completed responses to phone surveys 1 month and 4 months after the visit. Patients were also surveyed regarding the recommendation of counseling by the primary care physician.

RESULTS

The majority of patients (61%) reported that their physician advised them to identify activities they were already doing that helped them feel better. Physician recommendations regarding planning pleasurable activities, problem solving, challenging depressive thoughts, and planning activities that boost confidence were reported by 22% to 40% of study patients. Older patients reported fewer interactions about CB strategies. Primary care physicians' suggestion of CB strategies was associated with both patient use of CB strategies in the months following the visit and better adherence to recommended medication therapy during the first month of treatment.

CONCLUSIONS

Many patients seem to recognize the occurrence of psychotherapeutic interactions during visits to their primary care physician in which an antidepressant medication was prescribed, and patients' recognition of these interactions is associated with increased adherence to the recommended course of antidepressant prescriptions.

Immunoreactivity of canine transitional cell carcinoma of the urinary bladder with monoclonal antibodies to tumor-associated glycoprotein 72

Tumor-associated glycoprotein 72 (TAG-72) is a large, high molecular weight, mucinlike antigen that is expressed in a wide variety of human carcinomas. Three different TAG-72 monoclonal antibodies (MAbs), designated B72.3, CC49, and CC83, were applied to the following archived samples from the dog: 1) 51 transitional cell carcinomas of the urinary bladder, 2) 15 hyperplastic/inflamed urinary bladders, and 3) eight normal urinary bladders. Immunoreactivity was detected with an avidin-biotin complex immunoperoxidase method. Fifty-three percent (27/51) of transitional cell carcinomas were positive (> or = 5% staining) for MAb B72.3. MAb B72.3 staining of these transitional cell carcinomas did not statistically correlate with any of the examined features of malignancy, including histologic grade, clinical stage, DNA ploidy, or presence of vascular/lymphatic invasion. In regard to the staining of transitional cell carcinoma by the other two TAG-72 antibodies, 53% (27/51) of the samples were positive for MAb CC83 and 63% (32/51) were positive for MAb CC49. The finding that similar populations of neoplastic urothelial cells in serial sections from the same neoplasm stained with all three TAG-72 antibodies supports the hypothesis that an antigen similar to TAG-72 was expressed in canine transitional cell carcinoma. None of the normal urinary bladders nor any of the hyperplastic/inflamed urinary bladders stained with any of the three TAG-72 antibodies tested. The results of these studies demonstrated that the staining of canine transitional cell carcinoma with all three TAG-72 antibodies was specific for neoplastic urothelial cells and that an antigen similar to TAG-72 was expressed.

The relationship between cognitive functions and behavioral deviance in children at risk for psychopathology

Previous studies have generally found that children at risk for psychopathology (i.e. children characterized by risk factors such as parental psychopathology and maltreatment) display more deviant behavior and cognitive dysfunctions than children not at risk. The present study examined the relationship between behavioral deviance and cognition in children characterized by a variety of risk factors (parental schizophrenia, parental psychiatric disorders other than schizophrenia, parental maltreatment). The results indicated that the effects of parental schizophrenia could be distinguished from the more generalized effects of maltreatment and that cognitive deficits were associated with schizoid behavior in children at risk for schizophrenia. These findings suggest that cognitive ability may serve as a moderator of vulnerability to maladjustment in children at risk for schizophrenia.

The role of the primary care physician in patients' adherence to antidepressant therapy

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages--1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants--were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.