Case-finding instruments for depression. Two questions are as good as many

Prenatal depression leading to postpartum psychosis

Postpartum psychosis is a mood disorder occurring up to 3 months after delivery. Incidence is one to two women every 1,000 live births. If not detected and appropriately treated in time, it may have detrimental effects on both the mother and her baby. We report a case of puerperal psychosis in a patient with a history of depression. We have also reviewed the relevant literature discussing prediction, management and differential diagnosis of postpartum psychosis. We emphasise the importance of early detection and provision of care to all women at risk of mental illness by multidisciplinary team, including GPs, obstetricians, midwives and perinatal mental health professionals.

Unipolar depression: diagnostic and therapeutic recommendations from the current S3/National Clinical Practice Guideline

BACKGROUND

Depressive disorders are among the most common illnesses and reasons for obtaining health care. Their diagnosis and treatment are still in need of improvement. In Germany, a new S3/National Clinical Practice Guideline has been developed for this purpose.

METHODS

The existing guidelines on unipolar depression from Germany and other countries were synoptically compared and supplemented with systematic literature searches. After 14 consensus conferences, a total of 107 evidence-based recommendations were issued.

RESULTS

Unipolar depression should be diagnosed in accordance with ICD-10 criteria. Screening questionnaires are useful aids to diagnostic classification. When a treatment is chosen, shared decision-making with the patient is essential. Mild depressive episodes can be treated initially by watchful waiting for 14 days. For moderate depressive episodes, pharmacotherapy and psychotherapy are equally effective treatment options. For severe depression, a combination of pharmacotherapy and psychotherapy is recommended. If 4 to 6 weeks of acute therapy are insufficiently effective, lithium augmentation is recommended, rather than combination antidepressant therapy or a switch to another antidepressant. After remission, maintenance therapy should be continued for 4 to 9 months. In recurrent depression, pharmacotherapy and/or psychotherapy, where appropriate, should be continued for at least two years. Specific recommendations are given for patients who have somatic or mental comorbidities or are acutely suicidal, and recommendations are also given for coordination of care.

CONCLUSION

This guideline is a comprehensive set of evidence- and consensus-based recommendations for the diagnosis and treatment of unipolar depression. An improvement in the care of patients with unipolar depression will require broad implementation of the guideline, both in the inpatient and outpatient setting.

Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students

CONTEXT

Burnout is prevalent among medical students and is a predictor of subsequent serious consideration of dropping out of medical school and suicide ideation. Understanding of the factors that protect against burnout is needed to guide student wellness programmes.

METHODS

A total of 1321 medical students attending five institutions were studied longitudinally (2006-2007). The surveys included standardised instruments to evaluate burnout, quality of life, fatigue and stress. Additional items explored social support, learning climate, life events, employment status and demographics. Students who did not have burnout at either time-point (resilient students) were compared with those who indicated burnout at one or both time-points (vulnerable students) using a Wilcoxon-Mann-Whitney test or Fisher's exact test. Similarly, the differences between those who recovered and those who were chronically burned out were also compared in students with burnout at the first time-point. Logistic regression modelling was employed to evaluate associations between the independent variables and resiliency to and recovery from burnout.

RESULTS

Overall, 792 (60.0%) students completed the burnout inventory at both time-points. No differences in demographic characteristics were observed between resilient (290/792 [36.6%]) and vulnerable (502/792 [63.4%]) students. Resilient students were less likely to experience depression, had a higher quality of life, were less likely to be employed, had experienced fewer stressful life events, reported higher levels of social support, perceived their learning climate more positively and experienced less stress and fatigue (all p < 0.05) than vulnerable students. On multivariable analysis, perceiving student education as a priority for faculty staff, experiencing less stress, not being employed and being a minority were factors independently associated with recovery from burnout.

CONCLUSIONS

Modifiable individual factors and learning climate characteristics including employment status, stress level and perceptions of the prioritising of student education by faculty members relate to medical students' vulnerability to burnout.

Depression among adolescent mothers enrolled in a high school parenting program

Depressive symptoms in adolescent mothers have been associated with a variety of negative outcomes for both the adolescent mother and her child. The purpose of this article is to describe the dimensions of the Beck Depression Inventory®-II and to provide a discussion of how depression may appear in adolescent mothers. This descriptive study involved 45 adolescent mothers in a high school-based parent support program. The average score on the depression inventory for the adolescent mothers was 12.27 (SD = 8.57). One third (n = 15) of the adolescent mothers displayed depressive symptoms. All of the adolescent mothers reported experiencing increased symptoms related to loss of energy, changes in sleep patterns, changes in appetite, and tiredness/fatigue. It is important for nurses working with adolescent mothers to understand that what may be perceived as a normal adaptation to motherhood may in fact be a deeper emotional issue such as depression.

Disparities in self-reported postpartum depression among Asian, Hawaiian, and Pacific Islander Women in Hawaii: Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2007

Postpartum depression affects 10-20% of women and causes significant morbidity and mortality among mothers, children, families, and society, but little is known about postpartum depression among the individual Asian and Pacific Islander racial/ethnic groups. This study sought to indentify the prevalence of postpartum depression among common Asian and Pacific Islander racial/ethnic groups. Data from the Hawaii Pregnancy Risk Assessment and Monitoring System (PRAMS), a population-based surveillance system on maternal behaviors and experiences before, during, and after the birth of a live infant, were analyzed from 2004 through 2007 and included 7,154 women. Questions on mood and interest in activities since giving birth were combined to create a measure of Self-reported Postpartum Depressive Symptoms (SRPDS). A series of generalized logit models with maternal race or ethnicity adjusted for other sociodemographic characteristics evaluated associations between SRPDS and an intermediate level of symptoms as possible indicators of possible SRPDS. Of all women in Hawaii with a recent live birth, 14.5% had SRPDS, and 30.1% had possible SRPDS. The following Asian and Pacific Islander racial or ethnic groups were studied and found to have higher odds of SRPDS compared with white women: Korean (adjusted odds ratio [AOR] = 2.8;95% confidence interval [CI]: 2.0-4.0), Filipino (AOR = 2.2;95% CI: 1.7-2.8), Chinese (AOR = 2.0;95% CI: 1.5-2.7), Samoan (AOR = 1.9;95% CI: 1.2-3.2), Japanese (AOR = 1.6;95% CI: 1.2-2.2), Hawaiian (AOR = 1.7;95% CI: 1.3-2.1), other Asian (AOR = 3.3;95% CI: 1.9-5.9), other Pacific Islander (AOR = 2.2;95% CI: 1.5-3.4), and Hispanic (AOR = 1.9;95% CI: 1.1-3.4). Women who had unintended pregnancies (AOR = 1.4;95% CI: 1.2-1.6), experienced intimate partner violence (AOR = 3.7;95% CI: 2.6-5.5), smoked (AOR = 1.5;95% CI: 1.2-2.0), used illicit drugs (AOR = 1.9;95% CI: 1.3-3.9), or received Women, Infant, and Children (WIC) benefits during pregnancy (AOR = 1.4;95% CI: 1.2-2.6) were more likely to have SRPDS. Several groups also were at increased risk for possible SRPDS, although this risk was not as prominent as seen with the risk for SRPDS. One in seven women reported SRPDS, and close to a third reported possible SRPDS. Messages about postpartum depression should be incorporated into current programs to improve screening, treatment, and prevention of SRPDS for women at risk.

A study of the diagnostic accuracy of the PHQ-9 in primary care elderly

Background

The diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) for assessment of depression in elderly persons in primary care settings in the United States has not been previously addressed. Thus, the purpose of this study was to evaluate the test performance of the PHQ-9 for detecting major and minor depression in elderly patients in primary care.

Methods

A prospective study of diagnostic accuracy was conducted in two primary care, university-based clinics in the Pacific Northwest of the United States. Seventy-one patients aged 65 years or older participated; all completed the PHQ-9 and the 15-item Geriatric Depression Scale (GDS) and underwent the Structured Clinical Interview for Depression (SCID). Sensitivity, specificity, area under the receiver operating characteristic (ROC) curve, and likelihood ratios (LRs) were calculated for the PHQ-9, the PHQ-2, and the 15-item GDS for major depression alone and the combination of major plus minor depression.

Results

Two thirds of participants were female, with a mean age of 78 and two chronic health conditions. Twelve percent met SCID criteria for major depression and 13% minor depression. The PHQ-9 had an area under the curve (AUC) of 0.87 (95% confidence interval [CI], 0.74-1.00) for major depression, while the PHQ-2 and the 15-item GDS each had an AUC of 0.81 (95% CI for PHQ-2, 0.64-0.98, and for 15-item GDS, 0.70-0.91; P = 0.551). For major and minor depression combined, the AUC for the PHQ-9 was 0.85 (95% CI, 0.73-0.96), for the PHQ-2, 0.80 (95% CI, 0.68-0.93), and for the 15-item GDS, 0.71 (95% CI, 0.55-0.87; P = 0.187).

Conclusions

Based on AUC values, the PHQ-9 performs comparably to the PHQ-2 and the 15-item GDS in identifying depression among primary care elderly.

Can interactive skills-based seminars with standardized patients enhance clinicians' prevention skills? Measuring the impact of a CME program

OBJECTIVE

Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction.

METHODS

Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests.

RESULTS

OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants' patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction.

CONCLUSION

This curriculum improved clinicians' relevant skills and screening behavior.

PRACTICE IMPLICATIONS

Skills-oriented CME can improve clinicians' communication skills and screening and counseling practices.

Prevalence and incidence of postnatal depression: what can systematic reviews tell us?

BACKGROUND

Postnatal depression (PND) has a significant impact on maternal mental health. Systematic reviews provide a useful tool to summarise research, however little is known about the quantity and quality of existing systematic reviews of prevalence and incidence of PND.

OBJECTIVE

The objective of this paper is to provide a systematic overview of existing systematic reviews of prevalence and incidence of PND in the first 12 postnatal months.

METHOD

Medline, Embase, Cinahl, PsychInfo and the Cochrane Library were searched for systematic reviews of prevalence and incidence of PND which met the Database of Abstracts of Reviews of Effects (DARE) criteria. Characteristics of selected reviews, completeness of reporting results and methodological quality were evaluated.

RESULTS

Five reviews were selected for appraisal. Only one systematic review was identified; four reviews were non-systematic. Only two reviews provided a quantitative summary estimate of prevalence of PND. Completeness of reporting results using published guidelines was not undertaken by any review. The methodological quality of four reviews revealed limitations.

CONCLUSIONS

Limited generalisable evidence exists in the form of high-quality systematic reviews to inform current knowledge of the prevalence and incidence of PND. The implication of this represents an important limitation for health services planning and service delivery.

Psychological perspective on hand injury and pain

NARRATIVE REVIEW: Pain is considered a fundamental ramification of hand injury and has been identified as one of the most acutely stressful aspects of traumatic injuries and their treatment. Both comorbid psychiatric conditions and psychosocial factors have been shown to affect medical treatment outcome in patients with hand disorders and pain, further complicating recovery and potentially leading to significant psychological, social, and economic consequences for the individual. The purpose of this article was to assist hand therapists in developing a greater understanding of psychological constructs, psychosocial variables, and comorbid psychiatric conditions and thereby facilitate the more effective identification of such factors. A case study is included to illustrate these concepts. Circumstances in which referral for a comprehensive psychological evaluation is necessary are discussed. Many of the principles reviewed are also applicable to other upper extremity and musculoskeletal conditions.

Community-Based Versus Institutional Supportive Housing

Numerous options for residential supportive housing are available for people who need long-term care. Some options are categorized as institutional while others are designated community-based; the movement to rebalance the long-term care system emphasizes the latter category. This study examines the experiences of 150 residents of two types of community-based supportive housing—assisted living (AL) and residential care homes (RCHs)—and one institutional category—nursing homes (NHs). Examining a wide range of both quantitative and qualitative outcomes, overall results show that AL residents have the best experiences and NH residents report the worst outcomes, with RCHs residents varying in the middle. However, other factors such as age, perceived health, involvement in the decision to move to the residence, and length of time in the residence, eliminate the independent effect of housing type, per se. Efforts to provide high-quality supportive housing should focus on these key factors.

Self-report of depressive symptoms in African American and white women in primary care

OBJECTIVES

Depressive symptoms are frequently seen among female patients in primary care. The majority of screening instruments are cumbersome for a busy clinic.

METHOD

The effectiveness of a 2-item depression screening questionnaire was compared to the mental health section of the 36-Item Short Form Health Survey (SF-36). A total of 127 consecutive patients who presented for primary care service agreed to participate and completed the questionnaire.

RESULTS

Of the final sample, 65.4% were African American and 44.9% of all women reported having depressive symptoms, with no significant difference in the prevalence of reported depressive symptoms between African American and white women (chi2 = 1.97, p = .16). The women reporting depressive symptoms were more likely to be in the lower-income group (chi2 = 9.02, p = .01); however, in stratified analysis this was only significant for the African American women (chi2 = 8.69, p = .01). Analysis of variance demonstrated that the women with depressive symptoms were more likely to score low on the mental health subscales of the SF-36 when adjusted for income (F = 58.32, P < .0001). Within race groups, the mean Mental Health Index scores were higher among African American women (t = -6.45, P <.0001) and White women (t = -3.59, P = .002) who reported depressive symptoms than among those who did not report depressive symptoms. The sensitivity and specificity of the 2-item depression symptom questions compared to the overall SF-36 mental health score were 70% and 77%, respectively.

CONCLUSION

A simple 2-item questionnaire can be used to identify depressive symptoms in white and African American women in a primary care clinic.

The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review

BACKGROUND

Depression, anxiety and somatization are the most common mental disorders in primary care as well as medical specialty populations; each is present in at least 5-10% of patients and frequently comorbid with one another. An efficient means for measuring and monitoring all three conditions would be desirable.

METHODS

Evidence regarding the psychometric and pragmatic characteristics of the Patient Health Questionnaire (PHQ)-9 depression, generalized anxiety disorder (GAD)-7 anxiety and PHQ-15 somatic symptom scales are synthesized from two sources: (1) four multisite cross-sectional studies (three conducted in primary care and one in obstetric-gynecology practices) comprising 9740 patients, and (2) key studies from the literature that have studied these scales.

RESULTS

The PHQ-9 and its abbreviated eight-item (PHQ-8) and two-item (PHQ-2) versions have good sensitivity and specificity for detecting depressive disorders. Likewise, the GAD-7 and its abbreviated two-item (GAD-2) version have good operating characteristics for detecting generalized anxiety, panic, social anxiety and post-traumatic stress disorder. The optimal cutpoint is > or = 10 on the parent scales (PHQ-9 and GAD-7) and > or = 3 on the ultra-brief versions (PHQ-2 and GAD-2). The PHQ-15 is equal or superior to other brief measures for assessing somatic symptoms and screening for somatoform disorders. Cutpoints of 5, 10 and 15 represent mild, moderate and severe symptom levels on all three scales. Sensitivity to change is well-established for the PHQ-9 and emerging albeit not yet definitive for the GAD-7 and PHQ-15.

CONCLUSIONS

The PHQ-9, GAD-7 and PHQ-15 are brief well-validated measures for detecting and monitoring depression, anxiety and somatization.

Burnout and medical errors among American surgeons

OBJECTIVE

To evaluate the relationship between burnout and perceived major medical errors among American surgeons.

BACKGROUND

Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality.

METHODS

Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL).

RESULTS

Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0-33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0-54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis.

CONCLUSIONS

Major medical errors reported by surgeons are strongly related to a surgeon's degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

A generalist's guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy

This review provides a guide to the primary care physician for diagnosing and managing depression. To identify relevant articles, a PubMed search (ending date parameter, October 15, 2009) was conducted using the keywords depression, antidepressants, side effects, adverse effects, weight gain, sexual dysfunction, and sleep disturbance, and the reference lists of relevant articles were hand searched. This review explores the challenges in diagnosing depression that will and will not respond to antidepressants (ADs) and describes the value of 2-question screening instruments followed by in-depth questioning for positive screening results. It underscores the implications of veiled somatic presentations in which underlying depression is missed, leading to fruitless and expensive medical work-ups. Following this survey of the difficulties in diagnosing depression, the 4 options generalists have for treating a patient with depression are discussed: watchful waiting, antidepressant therapy, psychotherapy, and psychiatric referral. This review proposes that physicians, once they decide to prescribe, use AD side effects to advantage by selecting medications to minimize negative and maximize positive possibilities, thereby improving adherence. It focuses on the 3 most troubling adverse effects-sleep disturbance, sexual dysfunction, and weight gain. It provides AD-prescribing principles to assist primary care physicians in successfully managing depression and appropriately referring patients to a psychiatrist. Antidepressant therapy is not a panacea for treating patients with depression. An approach blending enlightened observation, medications, and psychotherapy often helps depressed patients recover to their former baselines.

Fish consumption and omega-3 polyunsaturated fatty acids in relation to depressive episodes: a cross-sectional analysis

High fish consumption and omega-3 polyunsaturated fatty acid (PUFA) intake are suggested to benefit mental well-being but the current evidence is conflicting. Our aim was to evaluate whether a higher level of fish consumption, a higher intake of omega-3 PUFAs, and a higher serum concentration of omega-3 PUFAs link to a lower 12-month prevalence of depressive episodes.We used data from the nationwide Health 2000 Survey (n = 5492) and the Fishermen Study on Finnish professional fishermen and their family members (n = 1265). Data were based on questionnaires, interviews, health examinations, and blood samples. Depressive episodes were assessed with the M-CIDI (the Munich version of the Composite International Diagnostic Interview) and a self-report of two CIDI probe questions, respectively. Fish consumption was measured by a food frequency questionnaire (g/day) and independent frequency questions (times/month). Dietary intake (g/day) and serum concentrations (% from fatty acids) of PUFAs were determined. Fish consumption was associated with prevalence of depressive episodes in men but not in women. The prevalence of depressive episodes decreased from 9% to 5% across the quartiles of fish consumption (g/day) in men of the Health 2000 Survey (p for linear trend = 0.01), and from17% to 3% across the quartiles of fish consumption (times/month) in men of the Fishermen Study (p for linear trend = 0.05). This association was modified by lifestyle; in the Health 2000 Survey a higher level of fish consumption was related to a lower prevalence of depressive episodes in men who consumed the most alcohol, were occasional or former smokers, or had intermediate physical activity. The associations between depressive episodes and the intake or serum concentrations of omega-3 PUFAs were not consistent.In men, fish consumption appears as a surrogate for underlying but unidentified lifestyle factors that protect against depression.

In the clinic. Depression

This issue provides a clinical overview of depression focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

'Do you think you suffer from depression?' Reevaluating the use of a single item question for the screening of depression in older primary care patients

OBJECTIVES

The majority of older adults seek depression treatment in primary care. Despite impressive efforts to integrate depression treatment into primary care, depression often remains undetected. The overall goal of the present study was to compare a single item screening for depression to existing depression screening tools.

METHODS

A cross sectional sample of 153 older primary care patients. Participants completed several depression-screening measures (e.g. a single depression screen, Patient Health Questionnaire-9, Major Depression Inventory, Visual Analogue Scale). Measures were evaluated against a depression diagnosis made by the Structured Clinical Interview for DSM-IV.

RESULTS

Overall, 3.9% of the sample was diagnosed with depression. The most notable finding was that the single-item question, 'do you think you suffer from depression?' had as good or better sensitivity (83%) than all other screens. Nonetheless, its specificity of 83% suggested that it has to be followed up by a through diagnostic interview. Additional sensitivity analyses concerning the use of a single depression item taken directly from the depression screening measures supported this finding.

CONCLUSIONS

An easy way to detect depression in older primary care patients would be asking the single question, 'do you think you suffer from depression?'

Brief self-rated screening for depression on the Internet

BACKGROUND

The Internet offers promising possibilities for the quick screening of depression for treatment and research purposes. This paper aims to validate three self-rated measures to screen for depression on the Internet: SID (single-item depression scale), CES-D (Center for Epidemiological Studies Depression scale) and K10 (Kessler psychological distress scale).

METHODS

Of the 502 subjects aged 18-80 who rated the SID, CES-D and K10 measures on the Internet, 157 (31%) subjects were also interviewed by telephone using the WHO Composite International Diagnostic Interview (C)IDI) for DSM-IV-disorders.

RESULTS

Cronbach's alpha for both web self-rated measures CES-D and K10 was 0.90. The SID correlated 0.68 (P<0.001) with the CES-D and with the K10. The CES-D correlated 0.84 with the K10 (P<0.001). Subjects with a DSM-IV diagnosis for any depressive disorder had significantly higher means (P<0.001) on the three self-rated measures for depressive symptoms than subjects without a diagnosis of any depressive disorder. Using any depressive disorder as the gold standard, the area under the curve (AUC) of the SID was 0.71 (95% CI: 0.63-0.79), which was significantly lower than the AUC of the CES-D (AUC: 0.84; 95% CI: 0.77-0.90, P=0.003) and of the K10 (AUC: 0.81; 95% CI: 0.73-0.88, P=0.0024). The AUCs for the K10 and CES-D did not differ significantly from each other.

LIMITATIONS

The CIDI interviews were not recorded, so inter-rater reliability could not be calculated.

CONCLUSIONS

The CES-D and K10 are reliable, valid tools for care providers to quickly screen depressive patients on the Internet and for researchers to collect data.

Trajectories of quality of life in older persons with advanced illness

OBJECTIVES

To examine subjective ratings of quality of life (QoL) in older adults with advanced illness.

DESIGN

Observational cohort study with interviews at least every 4 months for up to 2 years conducted between December 1999 and December 2002.

SETTING

Participants' homes.

PARTICIPANTS

One hundred eighty-five community-dwelling individuals aged 60 and older with advanced cancer, heart failure, or chronic obstructive pulmonary disease.

MEASUREMENTS

Participants were asked how they would rate their overall QoL.

RESULTS

Of participants who died, 46% reported good or best possible QoL at their final interview, 21% reported improvement in QoL from their penultimate to final interview, and 39% reported no change. Forty-nine percent of participants reported two or more changes in the direction of their QoL trajectories (e.g., QoL improved then declined). As measured over time in a multivariable longitudinal regression analysis, greater activity of daily living disability (adjusted odds ratio (AOR)=0.85, 95% confidence interval (CI)=0.75-0.95) and depressed mood (AOR=0.42, 95%CI=0.27-0.66) were associated with poorer QoL, whereas better self-rated health (AOR=4.79, 95% CI=2.99-7.69) and having grown closer to one's church (AOR=1.99, 95% CI=1.17-3.39) were associated with better QoL.

CONCLUSION

Although declining QoL is not an inevitable consequence of advancing illness, individuals' ratings of QoL are highly variable over time, suggesting that temporary factors may influence subjective QoL. Functional status, depression, and connection to one's religious community are shared determinants of QoL.

Can pediatricians accurately identify maternal depression at well-child visits?

BACKGROUND

The feasibility of a two-item screening tool for maternal depression in a pediatric setting was recently reported. We assessed whether the accuracy of pediatrician recognition of maternal depression during the one-month well-child visit could be improved by an educational intervention using the two-item screening tool.

METHODS

We conducted an educational intervention for pediatric residents in a suburban hospital in Tokyo, Japan, with outcome measurement before and after. Resident education included knowledge about postpartum depression and its impact on children, use of the two-item screening tool and available management strategies. Sixteen pediatric residents examined 267 mother-infant dyads during well-child visits. Residents documented the presence or absence of postpartum depressive symptoms on medical records. Depressive symptoms were also determined using the Edinburgh Postnatal Depression Scale (EPDS) survey; residents were not aware of the results. Using the EPDS as a "gold standard," improvement in sensitivity and specificity of resident recognition of maternal depressive symptoms was determined.

RESULTS

The overall prevalence of postpartum depressive symptoms based on the EPDS was 15.4%. The sensitivity of resident recognition was 8% and specificity 98% before intervention, and 12% and 96% afterwards, respectively. The difference was not statistically significant. Residents indicated fear of maternal stigmatization and mothers' receptiveness to discussing depressive symptoms, as well as lack of time and skills, as major barriers to the identification of maternal depression.

CONCLUSIONS

A simple educational intervention using a two-item screening tool did not improve the pediatrician's accuracy in detecting depressive symptoms in mothers. Additional strategies to address perceived barriers may be needed.

Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and 70% of the cost of COPD is due to hospitalizations. Self-reported daily physical activity and health status have been reported as predictors of a hospitalization in COPD but are not routinely assessed.

OBJECTIVES

We tested the hypothesis that self-reported daily physical activity and health status assessed by a simple question were predictors of a hospitalization in a well-characterized cohort of patients with severe emphysema.

METHODS

Investigators gathered daily physical activity and health status data assessed by a simple question in 597 patients with severe emphysema and tested the association of those patient-reported outcomes to the occurrence of a hospitalization in the following year. Multiple logistic regression analyses were used to determine predictors of hospitalization during the first 12 months after randomization.

RESULTS

The two variables tested in the hypothesis were significant predictors of a hospitalization after adjusting for all univariable significant predictors: >2 h of physical activity per week had a protective effect [odds ratio (OR) 0.60; 95% confidence interval (95% CI) 0.41-0.88] and self-reported health status as fair or poor had a deleterious effect (OR 1.57; 95% CI 1.10-2.23). In addition, two other variables became significant in the multivariate model: total lung capacity (every 10% increase) had a protective effect (OR 0.88; 95% CI 0.78-0.99) and self-reported anxiety had a deleterious effect (OR 1.75; 95% CI 1.13-2.70).

CONCLUSION

Self-reported daily physical activity and health status are independently associated with COPD hospitalizations. Our findings, assessed by simple questions, suggest the value of patient-reported outcomes in developing risk assessment tools that are easy to use.

Academic psychiatry's responsibility for increasing the recognition of mood disorders and risk for suicide in primary care

PURPOSE OF REVIEW

The authors seek solutions to better meet the healthcare needs of depressed patients in primary care by improving the recognition of depression, other mood disorders and of a risk for suicide.

RECENT FINDINGS

For 25 years academic psychiatry and primary care have known that only 10-50% of depressed patients are adequately treated, primarily because of the failure to recognize depression. There are substantial negative consequences including suicide. Suicide occurs during depression so the recognition of depression is the critical first step to preventing suicide. Recently noted is that one barrier to recognition is the traditional, comprehensive, psychiatric interview taught in academic departments of psychiatry that is impractical in primary care settings because it takes too much time. Some brief, initial psychiatric techniques have been developed but these typically have been introduced in primary care training programs and not by departments of psychiatry.

SUMMARY

A verbal four-question, 90 s screen for depression may be acceptable for routine use in primary care because it typically requires only seconds to a few minutes. Introduction of such a screening instrument to medical students on psychiatry and primary care clerkships could increase the recognition of depression and reduce death by suicide.

Informal and formal care infrastructure and perceived need for caregiver training for frail US veterans referred to home and community-based services

OBJECTIVES

To describe the informal care network of US veterans referred to home and community-based services (Homemaker Home Health services, H/HHA, or Home-Based Primary Care, HBPC) at the Durham Veterans Affairs Medical Center (VAMC), including: quantity and types of tasks provided and desired content for caregiver training programs.

METHODS

All primary care patients referred to H/HHA or HBPC during the preceding 3 months were sent questionnaires in May 2007. Additionally, caregivers were sent questionnaires if a patient gave permission. Descriptive statistics and chi-squared tests were performed.

RESULTS

On average, patients received 5.6 hours of VA care and 47 hours of informal care per week. 26% of patients (38% of patients with caregiver proxy respondents) and 59% of caregivers indicated the caregiver would be interested in participating in a training program by phone or on-site. Significant barriers to participation existed. The most common barriers were: transportation; no time due to caregiving or work demands; caregiver's own health limitations; and no need.

CONCLUSIONS

Caregiver training needs to be tailored to overcome barriers to participate. Overcoming these barriers may be possible through in-home phone or internet training outside traditional business hours, and by tailoring training to accommodate limiting health problems among caregivers.

Instruments to identify post-natal depression: Which methods have been the most extensively validated, in what setting and in which language?

Abstract Objectives. To investigate which methods to identify post-natal depression are the most extensively validated, in what setting and in what language. Methods. A systematic search of the literature was undertaken to retrieve English and non-English language articles available until February 2007. This included searching 16 electronic databases, forward citation searching, personal communication with authors and inspection of reference lists. Results. A total of 60 studies (published in 64 articles) met the inclusion criteria. Four PND specific measures and nine generic depression (and sometimes anxiety) measures were found to have been validated against a diagnostic reference standard in pregnant or post-natal populations. The Edinburgh Post-natal Depression Scale (EPDS) was the most frequently validated method to identify women with PND. The EPDS has been translated and validated in 20 different languages. The majority of studies were undertaken at ante-natal clinics (n=15), after the birth in post-natal wards (n=12) or during post-natal visits or follow-up clinics (n=16). Conclusions. The EPDS is the most frequently researched method to identify PND and has been translated and validated in multiple different languages.

Detection of depression in patients with low vision

PURPOSE

Depression is common in people with vision impairment and further reduces levels of functioning independent of vision loss. However, depression most often remains undetected and untreated this group. Eye health professionals (EHPs) (ophthalmic nurses, ophthalmologists, optometrists, and orthoptists) and rehabilitation workers (RWs) may be able to play a role in detecting depression. This study aimed to identify current practice and investigate factors associated with depression management strategies.

METHODS

A self-administered cross-sectional survey of EHPs and RWs assessed current practice including confidence in working with depressed people with vision impairment; barriers to recognition, assessment, and management of depression; beliefs about the consequences, duration, and efficacy of treatment for depression in individuals with vision impairment.

RESULTS

Ninety-four participants aged 23 to 69 years took part. Thirty-seven participants (39.8%) stated that they attempted to identify depression as part of patient management, with RWs significantly more likely to do so (n = 17, 60.7%) than EHPs (n = 20, 30.8%; p = 0.007). Intention to identify depression was not associated with sociodemographic factors, professional experience in eye care services, or the length and number of patient consultations, but a significant relationship was found for confidence, barriers, and beliefs about depression (p < 0.05). No consistent depression management strategy emerged and a range of barriers were highlighted.

CONCLUSIONS

Training programs are needed to provide EHPs and RWs with the skills and resources to address depression in people with vision loss under their care and to support the development of procedures by which concerns about depression can be identified objectively, documented, and included as part of a referral to appropriate services.

Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents

BACKGROUND

The use of short screening questionnaires may be a promising option for identifying children at risk for depression in a community setting. The objective of this study was to assess the validity of the Short Mood and Feelings Questionnaire (SMFQ) and one- and two-item screening instruments for depressive disorders in a school-based sample of young adolescents.

METHODS

Participants were 521 sixth-grade students attending public middle schools. Child and parent versions of the SMFQ were administered to evaluate the child's depressive symptoms. The presence of any depressive disorder during the previous month was assessed using the Diagnostic Interview Schedule for Children (DISC) as the criterion standard. First, we assessed the diagnostic accuracy of child, parent, and combined scores of the full 13-item SMFQ by calculating the area under the receiver operating characteristic curve (AUC), sensitivity and specificity. The same approach was then used to evaluate the accuracy of a two-item scale consisting of only depressed mood and anhedonia items, and a single depressed mood item.

RESULTS

The combined child + parent SMFQ score showed the highest accuracy (AUC = 0.86). Diagnostic accuracy was lower for child (AUC = 0.73) and parent (AUC = 0.74) SMFQ versions. Corresponding versions of one- and two-item screens had lower AUC estimates, but the combined versions of the brief screens each still showed moderate accuracy. Furthermore, child and combined versions of the two-item screen demonstrated higher sensitivity (although lower specificity) than either the one-item screen or the full SMFQ.

CONCLUSIONS

Under conditions where parents accompany children to screening settings (e.g. primary care), use of a child + parent version of the SMFQ is recommended. However, when parents are not available, and the cost of a false positive result is minimal, then a one- or two-item screen may be useful for initial identification of at-risk youth.

Nonmedical use of prescription stimulants and depressed mood among college students: frequency and routes of administration

Studies demonstrate associations between nonmedical use of prescription stimulants (NMUPS) and depressed mood; however, relevance of NMUPS route of administration and frequency of use have not been examined. We hypothesized frequent NMUPS and nonoral routes would be significantly associated with depressed mood. A Web survey was self-administered by a probability sample of 3,639 undergraduate students at a large U.S. university. The survey contained substance use (e.g., frequency, route of administration) and depressed mood measurement. Past-year prevalence of NMUPS was 6.0% (n = 212). Approximately 50% of frequent or nonoral NMUPS reported depressed mood. Adjusted odds of depressed mood were over two times greater among frequent monthly NMUPS (adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = 1.01-5.15) and nonoral routes of administration (AOR = 2.2, 95% CI = 1.36-3.70), after controlling for other variables. Nonmedical users of prescription stimulants should be screened for depressed mood, especially those who report frequent and nonoral routes of administration.

Depressive symptoms and birth outcomes among pregnant teenagers

STUDY OBJECTIVE

Few studies have examined the effects of maternal depressive symptoms among adolescent women. The purpose of this study was to investigate the impact of depressive symptoms on birth outcomes of infants born to adolescent mothers.

DESIGN

The medical records of pregnant adolescent patients were examined. Information about maternal depressive symptoms and birth outcomes was collected.

SETTING

Data were collected at Washington Hospital Center, a nonprofit, community-based hospital that serves residents throughout the Washington, DC area.

PARTICIPANTS

Participants were 294 African-American and Latina adolescent mothers. Mean age was 16.2 years (standard deviation [SD] 1.4). Based on self-reports of depressive symptoms, adolescents were categorized by the following: no reported symptoms, depressive symptoms without SI/SA (suicidal ideation or attempt), and depressive symptoms with SI/SA.

MAIN OUTCOME MEASURES

Infant birth weight and gestational age at delivery.

RESULTS

Over one-quarter of pregnant adolescents in this study reported symptoms of depression. Adolescents reporting depressive symptoms with SI/SA delivered babies that weighed 239.5 grams (98.3% confidence interval [CI] 3.9 to 475.1) less than babies born to mothers reporting depressive symptoms without SI/SA. There was no association between reported symptoms and gestational age.

CONCLUSIONS

Results suggest that compared to nonpregnant teens and adults, pregnant teens may have an increased risk for depression. Additionally, pregnant adolescents with suicidal ideation are at greater risk for delivering infants of lower birth weight compared with teens reporting depressive symptoms without SI/SA and teens reporting no symptoms. This study supports the need for early screening and treatment of depression for young pregnant women.

Associations of Psychosocial Factors with Maternal Confidence Among Japanese and Vietnamese Mothers

We conducted this cross-sectional study among 392 Japanese and 294 Vietnamese mothers who attended routine child health visits in a Japanese city and at a tertiary hospital in Vietnam, in order to investigate the prevalence and associated sociodemographic, parenting, and psychological characteristics of low maternal confidence in child rearing among them. All data were collected from medical files in Japan, and from medical files and self-administered questionnaires in Vietnam. The proportion of mothers without secure feeling of confidence in the present study was 22% in Japan and 66% in Vietnam. Significant factors associated with a lack of confidence were first-time motherhood and unintended pregnancy in the Japanese dataset and younger age in the Vietnamese dataset. In both groups, a higher proportion of mothers who lacked confidence reported negative parenting outcomes than did confident mothers. Among the three psychological measurements (mood, self-efficacy and depression), higher self-efficacy was associated independently with a significantly reduced risk of not having confidence in child rearing. These results suggest the importance of developing parenting support programs to help Japanese and Vietnamese mothers, particularly those who are young, first-time mothers or who became pregnant unexpectedly, improve their self-efficacy.

Development and preliminary psychometric properties of a well-being index for medical students

BACKGROUND

Psychological distress is common among medical students but manifests in a variety of forms. Currently, no brief, practical tool exists to simultaneously evaluate these domains of distress among medical students. The authors describe the development of a subject-reported assessment (Medical Student Well-Being Index, MSWBI) intended to screen for medical student distress across a variety of domains and examine its preliminary psychometric properties.

METHODS

Relevant domains of distress were identified, items generated, and a screening instrument formed using a process of literature review, nominal group technique, input from deans and medical students, and correlation analysis from previously administered assessments. Eleven experts judged the clarity, relevance, and representativeness of the items. A Content Validity Index (CVI) was calculated. Interrater agreement was assessed using pair-wise percent agreement adjusted for chance agreement. Data from 2248 medical students who completed the MSWBI along with validated full-length instruments assessing domains of interest was used to calculate reliability and explore internal structure validity.

RESULTS

Burnout (emotional exhaustion and depersonalization), depression, mental quality of life (QOL), physical QOL, stress, and fatigue were domains identified for inclusion in the MSWBI. Six of 7 items received item CVI-relevance and CVI-representativeness of >or=0.82. Overall scale CVI-relevance and CVI-representativeness was 0.94 and 0.91. Overall pair-wise percent agreement between raters was >or=85% for clarity, relevance, and representativeness. Cronbach's alpha was 0.68. Item by item percent pair-wise agreements and Phi were low, suggesting little overlap between items. The majority of MSWBI items had a >or=74% sensitivity and specificity for detecting distress within the intended domain.

CONCLUSIONS

The results of this study provide evidence of reliability and content-related validity of the MSWBI. Further research is needed to assess remaining psychometric properties and establish scores for which intervention is warranted.

Inverse intensity weighting in generalized linear models as an option for analyzing longitudinal data with triggered observations

Longitudinal epidemiologic studies with irregularly observed categorical outcomes present considerable analytical challenges. Generalized linear models (GLMs) tolerate without bias only values missing completely at random and assume that all observations contribute equally. A triggered sampling study design and an analysis using inverse intensity weights in a GLM offer promise of effectively addressing both shortcomings. A triggered sampling design generates irregularly spaced outcomes because, in addition to regularly scheduled follow-up interviews, it specifies that data be collected after a "trigger" (a decline in health status during follow-up) occurs. It is intended to mitigate bias introduced by study participant loss to follow-up. For each observation, an inverse intensity weight is calculated from an Anderson-Gill recurrent-event regression model whose events of interest are observed interviews; the weights help to equalize observation contributions. Investigators in the Longitudinal Examination of Attitudes and Preferences (LEAP) Study (1999-2002), a Connecticut study of seriously ill older adults at the end of life, used a triggered sampling design. In this paper, the authors analyze data from the LEAP Study to illustrate the methods and benefits of inverse intensity weighting in GLMs. An additional benefit of the analytical approach presented is that it allows for assessment of the utility of triggered sampling in longitudinal studies.

Training nursing staff to recognize depression in home healthcare

OBJECTIVES

To describe the implementation and acceptability of the TRaining In the Assessment of Depression (TRIAD) intervention, which has been tested in a randomized trial. The primary aim of TRIAD is to improve the ability of homecare nurses to detect depression in medically ill, older adult homecare patients.

DESIGN

Description of the important components of TRIAD, its implementation, and evaluation results from nurse surveys.

SETTING

Three certified home healthcare agencies in Westchester County, New York.

PARTICIPANTS

Thirty-six homecare nurses.

INTERVENTION

Participants randomly assigned to TRIAD (n=17) were provided with the opportunity to observe and practice patient interviewing. The approach focused on clinically meaningful identification of the two "gateway" symptoms of depression and is consistent with the newly revised Medicare mandatory Outcome and Assessment Information Set (OASIS-C). Control group participants (n=19) received no training beyond that which agencies may have provided routinely.

MEASUREMENTS

Baseline and 1-year nurse confidence in depression detection, and postintervention acceptability ratings of the TRIAD intervention.

RESULTS

Participants randomized to the TRIAD intervention reported a statistically significant increase in confidence in assessing for depression mood (P<.001), whereas the usual care group's confidence remained unchanged (P=.34) 1 year later.

CONCLUSION

An educational program designed to improve depression detection by giving nurses the skills and confidence to integrate depression assessment into the context of routine care can be successfully implemented with homecare agency support. The authors discuss the intervention in terms of OASIS-C and the "real world" realities of intervention implementation.

Burnout and serious thoughts of dropping out of medical school: a multi-institutional study

PURPOSE

Little is known about students who seriously consider dropping out of medical school. The authors assessed the severity of thoughts of dropping out and explored the relationship of such thoughts with burnout and other indicators of distress.

METHOD

The authors surveyed medical students attending five medical schools in 2006 and 2007 (prospective cohort) and included two additional medical schools in 2007 (cross-sectional cohort). The survey included questions about thoughts of dropping out, life events in the previous 12 months, and validated instruments evaluating burnout, depression symptoms, and quality of life (QOL).

RESULTS

Data were provided by 858 (65%) students in the prospective cohort and 2,248 (52%) in the cross-sectional cohort. Of 2,222 respondents, 243 (11%) indicated having serious thoughts of dropping out within the last year. Burnout (P < .0001), QOL (P < .003 each domain), and depressive symptoms (P < .0001) at baseline predicted serious thoughts of dropping out during the following year. Each one-point increase in emotional exhaustion and depersonalization score and one-point decrease in personal accomplishment score at baseline was associated with a 7% increase in the odds of serious thoughts of dropping out during the following year. On subsequent confirmatory multivariable analysis, low scores for personal accomplishment, lower mental and physical QOL, and having children were independent predictors of students having serious thoughts of dropping out during the following year.

CONCLUSIONS

Approximately 11% of students have serious thoughts of dropping out of medical school each year. Burnout seems to be associated with increased likelihood of serious thoughts of dropping out.

Childbirth and mental disorders

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?

Impact of resident well-being and empathy on assessments of faculty physicians

BACKGROUND

Teaching effectiveness is an important criterion for promoting clinician-educators. However, the relationship between residents' psychological characteristics and their assessments of faculty physicians is unknown.

OBJECTIVE

To determine whether residents' well-being and empathy influenced their assessments of faculty physicians.

DESIGN, SETTING, AND PARTICIPANTS

We studied 1,191 assessments of 356 faculty physicians by 209 internal medicine residents at a large academic medical center from 2007 to 2008. A repeated measures design with multivariate generalized estimating equations was used to evaluate associations between resident well-being and empathy, and residents' assessments of faculty.

MEASUREMENTS

Resident surveys included standardized measures of quality of life, burnout, depression, and empathy. Residents assessed faculty members' teaching performance with a validated 16-item instrument.

RESULTS

149 residents (71%) provided well-being, empathy, and assessment data. In multivariate models, faculty assessments from the previous year were the strongest predictor of current resident-of-faculty assessment scores. Residents' Jefferson Scale of Physician Empathy (JSPE) scores were also associated with faculty assessments (beta = 0.0063, 95% CI = 0.0018-0.0108; p = .0061). On this 140-point, 20-item scale, a 10-point increase in empathy correlated with a 0.063-point increase in residents' assessments of faculty on a 5-point scale. There were no significant associations between residents' assessments of faculty and quality of life, burnout, or depression.

CONCLUSIONS

This study demonstrates that residents' well-being does not influence their assessments of faculty physicians, thus supporting the trustworthiness of these assessments as a criterion for promoting clinician-educators. However, the association between residents' empathy and resident-of-faculty assessments suggests that faculty assessments may be modestly influenced by residents' intrinsic characteristics.

Comorbidity of depression and type 2 diabetes: Risk factors and clinical significance

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Combating stress and burnout in surgical practice: a review

The practice of surgery offers the potential for tremendous personal and professional satisfaction. Few careers provide the opportunity to have such a profound effect on the lives of others and to derive meaning from work. Surgeons choose this arduous task to change the lives of individuals facing serious health problems, to experience the joy of facilitating healing, and to help support those patients for whom medicine does not yet have curative treatments. Despite its virtues, a career in surgery brings with it significant challenges, which can lead to substantial personal distress for the individual surgeons and their family. By identifying the priorities of their personal and professional life, surgeons can identify values, choose the optimal practice type, manage the stressors unique to that career path, determine the optimal personal work-life balance, and nurture their personal wellness. Being proactive is better than reacting to burnout after it has damaged one's professional life or personal wellness. Studies like the ACS survey can benefit surgeons going through a personal crisis by helping them to know that they are not alone and that many of their colleagues face similar issues. It is important that surgeons do not make the mistake of thinking: "I must not be tough enough," or "no one could possibly experience what I am going through." The available evidence suggests that those surgeons most dedicated to their profession and their patient may very well be most susceptible to burnout. Silence on career distress, as a strategy, simply does not work among professionals whose careers, well-being, and level of patient care may be in jeopardy. Additional research in these areas is needed to elucidate evidence-based interventions to address physician distress at both the individual and organizational level to benefit the individual surgeon and the patient they care for. Surgeons must also be able to recognize how and when their personal distress affects the quality of care they provide (both in the delivery of care and in the emotional support of patients and their families). There is no single formula for achieving a satisfying career in surgery. All surgeons deal with stressful times in their personal and professional life and must cultivate habits of personal renewal, emotional self-awareness, connection with colleagues, adequate support systems, and the ability to find meaning in work to combat these challenges. As surgeons, we also need to set an example of good health to our patients and future generations of surgeons. To provide the best care for our patients, we need to be alert, interested in our work, and ready to provide for our patient's needs. Maintaining these values and healthy habits is the work of a lifetime.

Effect of pharmacological treatment of depression on A1C and quality of life in low-income Hispanics and African Americans with diabetes: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine whether pharmacological treatment of depression in low-income minorities with diabetes improves A1C and quality of life (QOL).

RESEARCH DESIGN AND METHODS

This was a 6-month, randomized, double-blind, placebo-controlled trial. Patients were screened for depression using Whooley's two-question tool at a county diabetes clinic. Depression was confirmed (or not) with the Computerized Diagnostic Interview Survey (CDIS) software program, and the severity of depression was assessed monthly by the Hamilton Depression Scale (HAM-D). Depressed subjects with A1C levels >or=8.0% were randomly assigned to receive either sertraline or placebo. Diabetes care was provided by nurses following detailed treatment algorithms who were unaware of therapy for depression.

RESULTS

A total of 150 subjects answered positively to at least one question on Whooley's questionnaire. The positive predictive value for depression diagnosed by CDIS was 69, 67, and 84% for positive answers to question 1 only, question 2 only, or both, respectively. Of the 89 subjects who entered the study, 75 completed. An intention-to-treat analysis revealed significant differences between baseline and 6 months in HAM-D and pain scores, QOL, and A1C and systolic blood pressure levels in both groups, with no differences between groups for the first three but a significantly greater decrease with sertraline in A1C and systolic blood pressure levels. Changes in HAM-D scores and A1C levels were significantly correlated in all subjects (P = 0.45 [P < 10(-6)]).

CONCLUSIONS

In this low-income minority population, pharmacological treatment of depression significantly improved A1C and systolic blood pressure levels compared with placebo.

Screening for maternal depression in primary care pediatrics

PURPOSE OF REVIEW

An estimated 10-20% of mothers suffer from postpartum depression. Given its profound impact on both mother and infant and the availability of effective interventions, pediatricians can improve identification and referral of mothers with postpartum depression by screening regularly during well child visits. The purpose of this paper is to review and assess recently developed screening tools.

RECENT FINDINGS

Since the development of the Edinburgh Postnatal Depression Scale in 1987, several shorter screening tools have been introduced. Although further innovation to optimize appropriate identification of postpartum depression is critical, these brief tools have been shown to be useful in improving pediatrician recognition of depression in mothers and referral to psychiatric specialists.

SUMMARY

Recently developed brief screening tools are recommended for routine use by pediatricians during well child visits to identify mothers who need additional evaluation for depression. Screening should be conducted repeatedly during the first year of child rearing as symptoms of postpartum depression may appear at any time and its progression may help differentiate between mild and more severe forms of depression. Pediatricians can also provide appropriate follow-up of the family.

Development and validity of two-question screening test for depressive disorders in Northeastern Thai community

OBJECTIVES

(1) To develop a screening test for depressive disorders which is simple and short. (2) To determine the diagnostic accuracy of this screening test in Northeastern Thai community.

METHODS

From August 2006 through October 2006, two phases of tool development were conducted. The first phase, a two-question screening test of depressive disorders was developed by selecting the dialect words to express depressive mood among Northeastern Thai population. The first item represented depressive mood and the second item represented loss of interest or pleasure in doing things. The second phase, a cross-sectional criterion standard validation study was conducted using stratified cluster randomization to identify 1002 subjects ≥18 years of age in 17 villages in nine districts of Yasothorn province. The two-question screening test was used to identify subgroups of subjects positive of both, positive of either one, and negative of both items. Psychiatrists then determined their diagnoses of mood disorders by administering a structured psychiatric examination (M.I.N.I.) that employed Diagnostic and Statistical Manual of Mental Disorder Text Revision (DSM-IV-TR). Data analysis used STATA 8.0 to calculate the sensitivity, specificity, positive predictive value, negative predictive value, percent of correct classified, and prevalence of depressive disorders with 95% confidence interval.

RESULTS

Of 1002 subjects, female were more predominant (58%), with mean age of 41.5 years. The overall time point rate of depressive disorders was 5.9% (95% CI=4.3-7.1%). Major depressive disorder 3.7% (95% CI=2.5-4.9%) and dysthymia 2.4% (95% CI=1.5-3.3%) occupied the preceding position. The first question of screening test was more positive 3 times than the second one. It showed a high sensitivity of 96.5% (95% CI=95.4-97.6%) but low specificity of 45.6% (95% CI=42.5-48.7%). The second question showed a low sensitivity of 71.9% (95% CI=69.2-74.7%) but high specificity of 84.1% (95% CI=81.9-86.4%). When either one of two questions was positive, this test showed high sensitivity of 96.5% (95% CI=95.4-97.6%) and the positive likelihood ratio was 1.74 (95% CI=1.61-1.88). If both of two questions were positive, it showed high specificity of 85.1% (95% CI=82.9-87.3%) and the positive likelihood ratio was 4.82 (95% CI=3.86-6.02).

CONCLUSION

Two questions for screening of depression would detect most cases of depressive disorders in the Thai community which has the advantage of brevity, high sensitivity and specificity.