Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Protocol for a randomised controlled trial investigating self-help email messages for sub-threshold depression: the Mood Memos study

BACKGROUND

Sub-threshold depression is common, impairs functioning, and increases the risk of developing major depression. Although psychological treatments have been investigated for sub-threshold depression, they are costly. A less costly alternative could be an educational health promotion campaign about effective self-help for depression symptoms. The aim of the study is to test the efficacy of a low-cost email-based mental health promotion campaign in changing self-help behaviour and preventing more severe depression in adults with sub-threshold depression.

METHODS/DESIGN

The project is a randomised controlled trial of an automated preventive email-intervention aimed at people with sub-threshold depression. Adults aged 18+ with sub-threshold depression (as measured with the Patient Health Questionnaire-9), who are not already receiving professional treatment for depression, are eligible for admission to the study. Internet users will sign up via the study website http://www.moodmemos.com and be randomly allocated to receive emails twice weekly for six weeks containing either self-help coping advice or general information about depression as a control. Outcomes will be assessed at the start, midpoint, and end of the intervention, as well as six months later. Outcomes assessed include symptoms, incidence of major depression, psychological distress, social and occupational functioning, coping strategies, and coping self-efficacy. The primary hypothesis is that the Mood Memo emails containing coping strategies will reduce depression symptoms and be better at preventing major depression than the control emails that contain general information about depression.

DISCUSSION

Promotion of actions an individual can take to prevent physical disease is a technique often used in public health. This study applies this approach to mental health, and explores whether a low-cost, easily disseminated email-based campaign can improve self-help coping behaviour and prevent depression in adults with sub-threshold depression.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000925246.

Pilot testing of a multicomponent home care intervention for older adults with heart failure: an academic clinical partnership

BACKGROUND

Heart failure (HF) has clinically significant psychological and physical consequences for older persons, and hospitalization for HF is frequent and costly to the Medicare program. As HF is the most common primary Medicare home care diagnosis, there is a critical need to develop home care services that improve heath-related outcomes for this population. The primary aim of this pilot study was to develop, implement, and test the initial feasibility and potential efficacy of the Home-Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities (HEART) trial, a nurse-directed multicomponent home care intervention. Observed outcomes were quality of life (QOL), depressive symptoms, and 90-day hospitalization.

METHODS

Twenty-four patients with a primary diagnosis of HF were assigned to the intervention (n = 12) or control group (n = 12) according to geographical location in a large multibranch Medicare-certified home health agency. Intervention group patients received 8 structured nurse education visits using evidence-based protocols designed in previous trials to teach HF self-management and to prevent/reduce depression, as well as a telemonitoring system. Control group patients received usual care and telemonitoring. Quality of life was assessed using the Minnesota Living With Heart Failure questionnaire. Depressive symptoms were assed using the Patient Health Questionnaire 9 at baseline and 90-day study end point.

RESULTS

Study protocols and instrumentation were found to be feasible and effective. Examination of enrollment data led to a reevaluation of eligibility criteria. Patients participating in the HEART intervention demonstrated significantly improved QOL (F = 8.99, P = .007) and significantly reduced depressive symptoms (F = 35.10, P = .001) in comparison to control group patients at the study end point. There was a trend toward lower hospital readmission rates in the intervention group (16% vs 25%), but this was not statistically significant.

CONCLUSION

This pilot study suggests that a full-scale trial of the HEART intervention is feasible.

Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods

BACKGROUND

Although the PHQ-9 is widely used in primary care, little is known about its performance in quantifying improvement. The original validation study of the PHQ-9 defined clinically significant change as a post-treatment score of ≤9 combined with improvement of 50%, but it is unclear how this relates to other theoretically informed methods of defining successful outcome. We compared a range of definitions of clinically significant change (original definition, asymptomatic criterion, reliable and clinically significant change criteria a, b and c) in a clinical trial of a community-level depression intervention.

METHOD

Randomised Control Trial of collaborative care for depression. Levels of agreement were calculated between the standard definition, other definitions, and gold-standard diagnostic interview.

RESULTS

The standard definition showed good agreement (kappa>0.60) with the other definitions and had moderate, though acceptable, agreement with the diagnostic interview (kappa=0.58). The standard definition corresponded closely to reliable and clinically significant change criterion c, the recommended method of quantifying improvement when clinical and non-clinical distributions overlap.

LIMITATIONS

The absence of follow-up data meant that an asymptomatic criterion rather than remission or recovery criteria were used.

CONCLUSION

The close agreement between the standard definition and reliable and clinically significant change criterion c provides some support for the standard definition of improvement. However, it may be preferable to use a reliable change index rather than 50% improvement. Remission status, based on the asymptomatic range and a lower PHQ-9 score, may provide a useful additional category of clinical change.

Screening depression aging services clients

OBJECTIVES

To establish the psychometric characteristics of the Patient Heath Questionnaire (PHQ) (PHQ-2, -9, and their sequential administration) in older adults who use community-based, social service care management.

DESIGN

Comparison of screening tools with criterion standard diagnostic interview.

SETTING

A community-based aging services agency.

PARTICIPANTS

Three hundred seventy-eight adults aged 60 years or older undergoing in-home aging services care management assessments.

MEASUREMENTS

Subjects were administered the PHQ-9 and Structured Clinical Interview for DSM-IV-TR- fourth edition. The authors examined the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and receiver operating characteristic (ROC) curve for the PHQ-2 and PHQ-9 separately, and for a two-stage screening process that used each in sequence (the PHQ-2/9).

RESULTS

Using a cut score of 3, the sensitivity of the PHQ-2 was 0.80 and the specificity was 0.78. The area under the ROC curve (AUC) for the PHQ-2 was 0.87. Using a cut score of 10, the sensitivity and specificity of the PHQ-9 were 0.82 and 0.87. The AUC was 0.91. The sensitivity and specificity of the two-stage PHQ-2/9 were 0.81 and 0.89, respectively, and the AUC was 0.91.

CONCLUSIONS

The greater specificity of the PHQ-9 is an advantage over the PHQ-2 in aging service settings in which false-positive tests have potentially high cost. The PHQ-2/9 performed equally well as the PHQ-9, but would be more efficient for the agency to administer. Combined with an appropriate referral system to healthcare providers, use of the PHQ-2/9 sequence by aging services personnel can efficiently assist in reducing the burden of late-life depression.

Comparative responsiveness of pain outcome measures among primary care patients with musculoskeletal pain

BACKGROUND

Comparative responsiveness data are needed to inform choices about pain outcome measures.

OBJECTIVES

To compare responsiveness of pain intensity, pain-related function, and composite measures, using data from a randomized trial and observational study.

RESEARCH DESIGN

Analysis of responsiveness.

SUBJECTS

A total of 427 adults with persistent back, hip, or knee pain were recruited from primary care.

METHODS

Participants completed Brief Pain Inventory, Chronic Pain Grade (CPG), Roland disability, SF-36 bodily pain, and pain global rating of change measures. We used the global rating as the anchor for standardized response mean and receiver operating characteristic curve analyses. We used the distribution-based standard error of measurement to estimate minimally important change. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm.

RESULTS

All measures were responsive to global improvement and all had fair-to-good accuracy in discriminating between participants with and without improvement. SF bodily pain was less responsive than other measures in several analyses. The 3-item PEG was similarly responsive to full Brief Pain Inventory scales. CPG and SF bodily pain were less responsive to the trial intervention and did not perform well among participants with hip/knee pain. Agreement between anchor and distribution-based methods was modest.

CONCLUSIONS

If a brief measure is desired, the 3-item PEG is more responsive than the SF bodily pain scale. CPG and SF bodily pain scales may be relatively poor choices for trial outcome assessment. Both anchor and distribution-based methods should be considered when determining clinically important change.

Somatic symptoms in patients with cancer experiencing pain or depression: prevalence, disability, and health care use

BACKGROUND

The adverse impact of a high somatic symptom burden is well established for primary care and other noncancer populations with chronic medical disorders.

METHODS

This study examines the impact of somatic symptom burden on disability and health care use in patients with cancer experiencing pain, depression, or both. We performed secondary analyses of baseline data from 405 patients with cancer enrolled in a telecare management trial for pain or depression. Somatic symptom burden was measured using a 22-item scale. Multivariable models were conducted to determine the association of somatic symptom burden with the Sheehan Disability Scale (SDS) score, the number of self-reported disability days in the past 3 months, and health care use. Models were adjusted for sociodemographic characteristics, medical comorbidity, and depression and pain severity.

RESULTS

Somatic symptoms were highly prevalent, with 15 of the 22 symptoms reported by more than 50% of patients. The somatic symptom burden was similar across different types and phases of cancer. The mean SDS score (scored 0-10 [not at all disabled to unable to carry out any activities]) was 5.4, and the mean number of self-reported disability days in the past 4 weeks was 16.9. In multivariable models, somatic symptom burden was associated with SDS score (P < .001) and the likelihood of at least 14 disability days in the past 4 weeks (odds ratio, 1.51; 95% confidence interval, 1.19-1.92) but not with increased health care use.

CONCLUSIONS

The somatic symptom burden is high in patients with cancer who experience pain or depression. Given the strong association with disability and the high prevalence of many types of symptoms, recognizing and managing somatic symptoms may be important in improving quality of life and functional status regardless of type or phase of cancer. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

Summary of the National Institute on Aging-sponsored conference on depressive symptoms and cognitive complaints in the menopausal transition

OBJECTIVE

The National Institutes of Health and The North American Menopause Society sponsored a symposium to understand the impact of the menopausal transition on mood symptoms and cognitive disorders and to identify research priorities for further investigation.

METHODS

The symposium was divided into a morning session on depressive symptoms and an afternoon session on cognitive function. There were four speakers per session, and each session covered four methodological approaches, including longitudinal cohort studies, randomized intervention trials, pharmacological challenge studies, and clinical diagnosis. Interactive panel discussions focused on translating research findings to clinical practice.

RESULTS

Most women do not experience serious depressive symptoms during the menopausal transition, but a subgroup of women is at increased risk. Slight changes in memory function and processing speed are evident during the menopausal transition, and physiological factors associated with hot flashes may contribute to memory problems. Clinical trial evidence indicates that estradiol therapy can be effective in treating perimenopausal depression. There is some limited evidence of a cognitive benefit with estrogen-alone therapy in younger postmenopausal women and stronger evidence that certain forms of combination hormone therapy produce modest deficits in verbal memory in younger postmenopausal women.

CONCLUSIONS

Routine evaluation of depressive symptoms in perimenopausal women is warranted by the literature. Quick and valid screening tools for assessing depression in the clinic are available online and free of charge. Identifying a cognitively neutral or beneficial combination therapy for the treatment of menopausal symptoms in naturally postmenopausal women is an important goal for future research.

Reliability and validity of the PHQ-9 for screening late-life depression in Chinese primary care

OBJECTIVE

The aim of this study was to examine the reliability and validation of the 9-item Patient Health Questionnaire (PHQ-9) for late-life depression in Chinese primary care.

METHODS

In the primary care clinics (PCCs) of Hangzhou city, we recruited 364 older patients (aged ≥ 60) for the PHQ-9 screening. Then 77 of them were further interviewed with Structured Clinical Interview for DSM Disorders (SCID) for the diagnosis of major depression in late life. Statistic strategies for the feasibility, reliability, validity, and receiver operating characteristic curve were performed.

RESULTS

The mean administration time was 7.5 min, and the Cronbach's α was 0.91. The optimal cut-off score of PHQ-9 ≥ 9 revealed a sensitivity of 0.86, specificity of 0.77, and positive likelihood ratio of 5.73. The area under the curve (AUC) in this study was 0.92 (SD = 0.02, 95% CI 0.88-0.96). The PHQ-2 also revealed good sensitivity (0.84) and specificity (0.90) at the cut-off point ≥ 3.

CONCLUSIONS

The PHQ-9 performs well and has acceptable psychometric properties for screening of patients with late-life depression in Chinese primary care settings.

Patient- and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: a cross-sectional study

Background

Identifying the determinants of health-related quality of life (HRQOL) in patients with systolic heart failure (CHF) is rare in primary care; studies often lack a defined sample, a comprehensive set of variables and clear HRQOL outcomes. Our aim was to explore the impact of such a set of variables on generic and disease-specific HRQOL.

Methods

In a cross-sectional study, we evaluated data from 318 eligible patients. HRQOL measures used were the SF-36 (Physical/Mental Component Summary, PCS/MCS) and four domains of the KCCQ (Functional status, Quality of life, Self efficacy, Social limitation). Potential determinants (instruments) included socio-demographical variables (age, sex, socio-economic status: SES), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, multimorbidity (CIRS-G)), depression (PHQ-9), behavioural (EHFScBs and prescribing) and provider (e.g. list size of and number. of GPs in practice) variables. We performed linear (mixed) regression modelling accounting for clustering.

Results

Patients were predominantly male (71.4%), had a mean age of 69.0 (SD: 10.4) years, 12.9% had major depression, according to PHQ-9. Across the final regression models, eleven determinants explained 27% to 55% of variance (frequency across models, lowest/highest β): Depression (6×, -0.3/-0.7); age (4×, -0.1/-0.2); multimorbidity (4×, 0.1); list size (2×, -0.2); SES (2×, 0.1/0.2); and each of the following once: no. of GPs per practice, NYHA class, COPD, history of CABG surgery, aldosterone antagonist medication and Self-care (0.1/-0.2/-0.2/0.1/-0.1/-0.2).

Conclusions

HRQOL was determined by a variety of established individual variables. Additionally the presence of multimorbidity burden, behavioural (self-care) and provider determinants may influence clinicians in tailoring care to individual patients and highlight future research priorities.

Research to Encourage Exercise for Fibromyalgia (REEF): use of motivational interviewing design and method

Fibromyalgia (FM), defined as the presence of both chronic widespread pain and the finding of 11/18 tender points on examination, is an illness associated with major personal and societal burden. Supervised aerobic exercise is an important treatment modality to improve patient symptoms. Unfortunately, adherence to an exercise regimen after a structured supervised program is disappointingly low. Since FM is a chronic illness, studies are needed to test strategies that would enhance exercise adherence in these individuals. Individuals who are able to adhere to exercise almost always maintain the symptomatic benefits of exercise. The objective of this paper was to describe the protocol of the Research to Encourage Exercise for Fibromyalgia (REEF). REEF is a randomized attention-controlled trial that seeks to test the efficacy of 6 sessions of telephone delivered motivational interviewing (MI) that targets exercise adherence to improve FM-relevant clinical outcomes (i.e., physical function and pain severity). The trial has recently completed enrolling 216 subjects, and randomization has resulted in well-balanced groups. Details on the study design, MI program, and treatment fidelity are provided in the paper. Outcome assessments at week 12, week 24 and week 36 will test the immediate, intermediate and long-term effects of exercise-based MI on adherence (as measured by the Community Health Activities Model Program for Seniors/CHAMPS and accelerometer) and clinical outcomes. When completed, REEF will determine whether exercise-based MI could be utilized as a management strategy to sustain the clinical benefits of exercise for FM.

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.

Long-term clinical outcomes of care management for chronically depressed primary care patients: a report from the depression in primary care project

PURPOSE

Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.

METHODS

The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.

RESULTS

DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P = .012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.

CONCLUSIONS

The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.

Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics

Background

For the treatment of depression in diabetes patients, it is important that depression is recognized at an early stage. A screening method for depression is the patient health questionnaire (PHQ-9). The aim of this study is to validate the 9-item Patient Health Questionnaire (PHQ-9) as a screening instrument for depression in diabetes patients in outpatient clinics.

Methods

197 diabetes patients from outpatient clinics in the Netherlands filled in the PHQ-9. Within 2 weeks they were approached for an interview with the Mini Neuropsychiatric Interview. DSM-IV diagnoses of Major Depressive Disorder (MDD) were the criterion for which the sensitivity, specificity, positive- and negative predictive values and Receiver Operator Curves (ROC) for the PHQ-9 were calculated.

Results

The cut-off point of a summed score of 12 on the PHQ-9 resulted in a sensitivity of 75.7% and a specificity of 80.0%. Predictive values for negative and positive test results were respectively 93.4% and 46.7%. The ROC showed an area under the curve of 0.77.

Conclusions

The PHQ-9 proved to be an efficient and well-received screening instrument for MDD in this sample of diabetes patients in a specialized outpatient clinic. The higher cut-off point of 12 that was needed and somewhat lower sensitivity than had been reported elsewhere may be due to the fact that the patients from a specialized diabetes clinic have more severe pathology and more complications, which could be recognized by the PHQ-9 as depression symptoms, while instead being diabetes symptoms.

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.

Study protocol: home-based telehealth stroke care: a randomized trial for veterans

Background

Stroke is one of the most disabling and costly impairments of adulthood in the United States. Stroke patients clearly benefit from intensive inpatient care, but due to the high cost, there is considerable interest in implementing interventions to reduce hospital lengths of stay. Early discharge rehabilitation programs require coordinated, well-organized home-based rehabilitation, yet lack of sufficient information about the home setting impedes successful rehabilitation. This trial examines a multifaceted telerehabilitation (TR) intervention that uses telehealth technology to simultaneously evaluate the home environment, assess the patient's mobility skills, initiate rehabilitative treatment, prescribe exercises tailored for stroke patients and provide periodic goal oriented reassessment, feedback and encouragement.

Methods

We describe an ongoing Phase II, 2-arm, 3-site randomized controlled trial (RCT) that determines primarily the effect of TR on physical function and secondarily the effect on disability, falls-related self-efficacy, and patient satisfaction. Fifty participants with a diagnosis of ischemic or hemorrhagic stroke will be randomly assigned to one of two groups: (a) TR; or (b) Usual Care. The TR intervention uses a combination of three videotaped visits and five telephone calls, an in-home messaging device, and additional telephonic contact as needed over a 3-month study period, to provide a progressive rehabilitative intervention with a treatment goal of safe functional mobility of the individual within an accessible home environment. Dependent variables will be measured at baseline, 3-, and 6-months and analyzed with a linear mixed-effects model across all time points.

Discussion

For patients recovering from stroke, the use of TR to provide home assessments and follow-up training in prescribed equipment has the potential to effectively supplement existing home health services, assist transition to home and increase efficiency. This may be particularly relevant when patients live in remote locations, as is the case for many veterans.

Trial Registration

Clinical Trials.gov Identifier: NCT00384748

Patient-physician discordance in assessments of global disease severity in rheumatoid arthritis

OBJECTIVE

To determine the degree of discordance between patient and physician assessment of disease severity in a multiethnic cohort of adults with rheumatoid arthritis (RA), to explore predictors of discordance, and to examine the impact of discordance on the Disease Activity Score in 28 joints (DAS28).

METHODS

Adults with RA (n = 223) and their rheumatologists completed a visual analog scale (VAS) for global disease severity independently. Patient demographics, the 9-item Patient Health Questionnaire (PHQ-9) depression scale score, the Health Assessment Questionnaire score, and the DAS28 were also collected. Logistic regression analyses were used to identify predictors of positive discordance, defined as a patient rating minus physician rating of >25 mm on a 100-mm VAS (considered clinically relevant). DAS28 scores stratified by level of discordance were compared using a paired t-test.

RESULTS

Positive discordance was found in 30% of cases, with a mean +/- SD difference of 46 +/- 15. The strongest independent predictor of discordance was a 5-point increase in PHQ-9 score (adjusted odds ratio 1.61, 95% confidence interval 1.02-2.55). Higher swollen joint count and Cantonese/Mandarin language were associated with lower odds of discordance. DAS28 scores were most divergent among subjects with discordance.

CONCLUSION

Nearly one-third of RA patients differed from their physicians to a meaningful degree in assessment of global disease severity. Higher depressive symptoms were associated with discordance. Further investigation of the relationships between mood, disease activity, and discordance may guide interventions to improve care for adults with RA.

[Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor]

The aim of this study was to examine whether depression is a strong predictor of elevated postoperative pain levels following orthopedic surgery and whether the implementation of standardized pain management is more beneficial for patients with depression. We performed a non-randomized, prospective study with two different groups of patients who underwent orthopedic surgery. Group 1 (n=249) received non-standardized pain therapy whereas group 2 (n = 243) was treated with a standardized pain management concept. Effects of the treatment were monitored with a VAS-based pain assessment protocol. Depression was measured preoperatively with the self-reported Patient Health Questionnaire (PHQ-9). Patients with the probable diagnosis of a current episode of major depression showed significantly higher postoperative pain than patients without a depressive episode. On the other hand, patients with depression benefited from the implementation of standardized pain management. Our data suggest a predictive value of depression for severe postoperative pain. Patients with depression benefited from standardized postoperative pain therapy, but were still suffering from significantly higher postoperative pain.

Internet treatment for depression: a randomized controlled trial comparing clinician vs. technician assistance

BACKGROUND

Internet-based cognitive behavioural therapy (iCBT) for depression is effective when guided by a clinician, less so if unguided.

QUESTION

Would guidance from a technician be as effective as guidance from a clinician?

METHOD

Randomized controlled non-inferiority trial comparing three groups: Clinician-assisted vs. technician-assisted vs. delayed treatment. Community-based volunteers applied to the VirtualClinic (www.virtualclinic.org.au) research program, and 141 participants with major depressive disorder were randomized. Participants in the clinician- and technician-assisted groups received access to an iCBT program for depression comprising 6 online lessons, weekly homework assignments, and weekly supportive contact over a treatment period of 8 weeks. Participants in the clinician-assisted group also received access to a moderated online discussion forum. The main outcome measures were the Beck Depression Inventory (BDI-II) and the Patient Health QUESTIONnaire-9 Item (PHQ-9). Completion rates were high, and at post-treatment, both treatment groups reduced scores on the BDI-II (p<0.001) and PHQ-9 (p<0.001) compared to the delayed treatment group but did not differ from each other. Within group effect sizes on the BDI-II were 1.27 and 1.20 for the clinician- and technician-assisted groups respectively, and on the PHQ-9, were 1.54 and 1.60 respectively. At 4-month follow-up participants in the technician group had made further improvements and had significantly lower scores on the PHQ-9 than those in the clinician group. A total of approximately 60 minutes of clinician or technician time was required per participant during the 8-week treatment program.

CONCLUSIONS

Both clinician- and technician-assisted treatment resulted in large effect sizes and clinically significant improvements comparable to those associated with face-to-face treatment, while a delayed treatment control group did not improve. These results provide support for large scale trials to determine the clinical effectiveness and acceptability of technician-assisted iCBT programs for depression. This form of treatment has potential to increase the capacity of existing mental health services.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000559213.

Assessment of mood: guides for clinicians

OBJECTIVE

This article is one of the series of review articles aiming to present a convenient guideline for practicing clinicians in their selection of scales for clinical and research purposes. This article focuses on assessment scales for mood (depression, mania).

METHODS

After reviewing the basic principles of clinical psychometrics, we present a selective review of representative scales measuring depressed or manic mood.

RESULTS

We reviewed and reported on reliability, validity, interpretability, and feasibility of the following rating scales: Patient Health Questionnaire-9 (PHQ-9), K6, Beck Depression Inventory II (BDI-II), and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR) as self-report scales for depressed mood; Hamilton Rating Scale for Depression (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS) as clinician-administered measure for depression; and Young Mania Rating Scale (YMRS) as a clinician-administered instrument for mania.

CONCLUSION

Although the rating scales for mood represent a well-trodden terrain, this brief review of the most frequently used scales in the literature revealed there is still some room for improvement and for further research, especially with regard to their clinical interpretability.

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.

Advantages of using estimated depression-free days for evaluating treatment efficacy

OBJECTIVE

Several common methods for measuring treatment response present a snapshot of depression symptoms. The construct of estimated depression-free days (DFDs) simultaneously captures treatment outcome and estimates the patient's experience of depression over time. The study compared this measure with traditional measures used in depression treatment research.

METHODS

This secondary data analysis was based on data from the Improving Mood-Promoting Access to Collaborative Treatment trial, a multisite depression treatment study conducted in 18 primary care clinics in five states and representing eight health care systems. The sample of older adults (N=906) had been randomly assigned to receive collaborative care for depression. Participants were aged 60 or older and met criteria for major depressive disorder, dysthymia, or both. Exclusion criteria included severe cognitive impairment, active substance abuse, active suicidal behavior, severe mental illness, and active treatment from a psychiatrist. The Patient Health Questionnaire (PHQ-9) and the Hopkins Symptom Checklist (HSCL-20) were used as outcome measures at four assessment points (baseline, three months, six months, and 12 months). Outcomes were computed for relative change, standardized differences, the proportion of improvement in depression, and DFDs.

RESULTS

Using four assessment points improved the agreement between DFDs and the course of symptom change between pre- and posttest measures.

CONCLUSIONS

The DFD is a valid measure for estimating treatment outcomes that reflects the course of symptom change over time. When multiple assessments were conducted between the pre- and posttest periods, DFDs incorporated additional data yet remained easily interpreted. The DFD should be considered for reporting outcomes in depression research.

Reinvention of depression instruments by primary care clinicians

PURPOSE

Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use.

METHODS

Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators' field notes on office practice environments complemented individual interviews.

RESULTS

The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions.

CONCLUSIONS

Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression.

Correlates of sexual risk behavior in sexually active male military personnel stationed along border-crossing zones in the Dominican Republic

CONTEXT

A survey was conducted of sexually active male military personnel stationed along major border-crossing zones between the Dominican Republic (DR) and Haiti, taking an applied scientific approach, to better inform prevention programming with military personnel in the region.

DESIGN AND METHOD

A subsample of 470 sexually active male military personnel was drawn from a stratified systematic sample of military personnel stationed along the three largest border-crossing zones on the western border of the Dominican Republic. Using a verbally administered questionnaire, an examination of how foci of current HIV prevention programming with military personnel correlated with key sexual risk behavioral outcomes was conducted.

RESULTS

Mental health factors such as probable alcohol abuse and posttraumatic stress disorder showed consistent associations with sexual risk behaviors. Participants showed a relatively high level of HIV/AIDS-related knowledge, a moderate level of negative attitudes toward condoms, and a moderate level of stigma toward people living with HIV/AIDS. Psychosocial factors, which are typically preventive in nature, were not associated with decreased sexual risk behaviors.

CONCLUSION

Gaps were identified in HIV prevention programming that need to be addressed in this population of sexually active male military personnel. Although knowledge, attitudes, and psychosocial factors are important foci of HIV prevention programming, they were not associated with sexual risk behaviors, particularly after controlling for mental health factors. The authors suggest that prevalent psychiatric disorders in military personnel, such as posttraumatic stress disorder, should be factored in to the development of HIV prevention programs for military personnel.

Depression symptoms and treatment among HIV infected and uninfected veterans

Depression is one of the most common comorbid conditions affecting persons with HIV. We compared depressive symptoms and depression treatment using data from the Veterans Aging Cohort Study (VACS), a prospective cohort of HIV-infected and uninfected subjects. We identified subjects with a Patient Health Questionnaire score of 10 or greater. Treatment was defined as prescription of a selective serotonin reuptake inhibitor (SSRI) or mental health counseling. Overall, 16% of 4,480 subjects had depressive symptoms, and HIV-infected patients were more likely to have had depressive symptoms (OR = 1.38, 95% CI = 1.18, 1.62). Geographic site of care and having a mental health provider at the clinic was associated with treatment. In multivariable models restricted to 732 patients with depressive symptoms, receipt of depression treatment did not differ by HIV status (Adjusted OR = 1.11, 95% CI = 0.80, 1.54). Non-Hispanic whites were more likely to receive treatment (Adjusted OR = 2.09, 95% CI 1.04, 4.24). Primary care and HIV providers were equally unlikely to treat active depressive symptoms. Treatment variation by race, site, and availability of a mental health provider, suggests targets for intervention.

Sleep quality, mood, alertness and their variability in CKD and ESRD

BACKGROUND/AIMS

Little is known about the association of chronic kidney disease (CKD) with sleep quality, mood, and alertness. In this report, we assessed these symptoms among patients with advanced CKD (stages 4-5) and those with end-stage renal disease (ESRD) and compared them to healthy controls without known kidney disease.

METHODS

Patients were recruited from local dialysis units, outpatient nephrology clinics and the Thomas E. Starzl Transplant Institute. Healthy control subjects matched for age, gender and race were drawn from an archival database. Daily symptoms of sleep quality, mood, and alertness were assessed by visual analogue scales of the Pittsburgh Sleep Diary. Health-related quality of life was assessed by the Short Form-36 instrument.

RESULTS

Sixty-nine dialysis patients and 23patients with advanced CKD demonstrated worse scores in sleep quality, mood, and alertness (p < 0.001) than controls. In adjusted analyses, European-American race, dialysis dependency, younger age, and physical performance SF-36 components were significantly associated with poor sleep quality, mood and alertness (p < 0.05). The dialysis population demonstrated higher day-to-day variability in scores than either the advanced CKD patients or the controls.

CONCLUSION

Advanced CKD and dialysis dependency are associated with impaired and highly variable sleep quality, mood, and alertness.

Olfactory and gustatory function in irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common, functional disorder diagnosed by gastroenterologists. It is still unclear whether IBS has a central etiology, e.g., hyperreactivity of the brain, or a peripheral etiology, e.g., stimulation of olfactory/gustatory receptors on enterochromaffin cells, followed by serotonin release and changed gut motility. Testing the odor identification (ID), odor discrimination (DIS) and odor threshold (THR) as well as the total taste and the taste qualities "sweet", "sour", "salty" and "bitter" should be of help for determining the etiology. To our knowledge, this is the first study investigating the olfactory/gustatory function in IBS patients. The olfactory/gustatory function of 43 patients (32 women, 11 men) suffering from IBS as defined by the ROME III criteria was investigated by means of validated tests (Sniffin' Sticks and taste strips). Compared to normative data, scores of THR were decreased and scores of ID and DIS were increased in IBS patients. Additionally, when compared to normative data, there was no difference in the taste function of IBS patients. Assuming that THR reflects more the peripheral olfactory function, whereas ID and DIS are influenced by central activity, and that taste did not differ in IBS patients compared to normative data, this supports the idea of a central etiology of IBS.

Changes in resting state effective connectivity in the motor network following rehabilitation of upper extremity poststroke paresis

BACKGROUND

A promising paradigm in human neuroimaging is the study of slow (<0.1 Hz) spontaneous fluctuations in the hemodynamic response measured by functional magnetic resonance imaging (fMRI). Spontaneous activity (i.e., resting state) refers to activity that cannot be attributed to specific inputs or outputs, that is, activity intrinsically generated by the brain.

METHOD

This article presents pilot data examining neural connectivity in patients with poststroke hemiparesis before and after 3 weeks of upper extremity rehabilitation in the Accelerated Skill Acquisition Program (ASAP). Resting-state fMRI data acquired pre and post therapy were analyzed using an exploratory adaptation of structural equation modeling (SEM) to evaluate therapy-related changes in motor network effective connectivity.

RESULTS

Each ASAP patient showed behavioral improvement. ASAP patients also showed increased influence of the affected hemisphere premotor cortex (a-PM) upon the unaffected hemisphere premotor cortex (u-PM) following therapy. The influence of a-PM on affected hemisphere primary motor cortex (a-M1) also increased with therapy for 3 of 5 patients, including those with greatest behavioral improvement.

CONCLUSIONS

Our findings suggest that network analyses of resting-state fMRI constitute promising tools for functional characterization of functional brain disorders, for intergroup comparisons, and potentially for assessing effective connectivity within single subjects; all of which have important implications for stroke rehabilitation.

[Outcome of simultaneous psychosomatic/internal-medicine inpatient care--a naturalistic follow-up study]

OBJECTIVES

The effectiveness of simultaneous psychosomatic and internal-medicine inpatient care has not yet been satisfyingly investigated. What outcome is found in patients treated in a psychosomatic/internal medicine setting? Can we predict a reduction in depression and symptom severity?

METHODS

The study design is prospective and naturalistic. Patients from a psychosomatic/internal-medicine setting and a solely internal-medicine ward filled in self-report questionnaires on the day of admission, five days thereafter, and three months after discharge.

RESULTS

A total of 221 patients from a psychosomatic/internal-medicine setting and 418 patients from a solely internal-medicine ward were included. Patient characteristics differed significantly between the two wards. Treatment was associated with a reduction of depression and somatic symptom severity over time. Depression severity improved more in the psychosomatic/internal-medicine setting than in the internal-medicine ward (ES = 0.37 vs. ES = 0.65). The strongest predictor of improvement of depression and somatic symptom severity was the patients' belief that their physical well-being was influenced by psychological factors (B = 1.44 and 1 = 0.65).

CONCLUSIONS

The results document a differential approach to admission in an integrated psychosomatic/internal medicine setting and underline the favourable course for psychological and somatic symptoms.

Comparison of two self-rating scales to detect depression: HADS and PHQ-9

BACKGROUND

More than half of patients with depression go undetected. Self-rating scales can be useful in screening for depression, and measuring severity and treatment outcome.

AIM

This study compares the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) with regard to their psychometric properties, and investigates their agreement at different cut-off scores.

METHOD

Swedish primary care patients and psychiatric outpatients (n = 737) who reported symptoms of depression completed the self-rating scales. Data were collected from 2006 to 2007. Analyses with respect to internal consistency, factor analysis, and agreement (Cohen's kappa) at recommended cut-offs were performed.

RESULTS

Both scales had high internal consistency (alpha = 0.9) and stable factor structures. Using severity cut-offs, the PHQ-9 (> or =5) diagnosed about 30% more patients than the HADS depression subscale (HADS-D; > or =8). They recognised the same prevalence of mild and moderate depression, but differed in relation to severe depression. When comparing recommended screening cut-offs, HADS-D > or =11 (33.5% of participants) and PHQ-9 > or =10 (65.9%) agreement was low (kappa = 0.35). Using the lower recommended cut-off in the HADS-D (> or =8), agreement with PHQ-9 > or =10 was moderate (kappa = 0.52). The highest agreement (kappa = 0.56) was found comparing HADS-D > or =8 with PHQ-9 > or =12. This also equalised the prevalence of depression found by the scales.

CONCLUSION

The HADS and PHQ-9 are both quick and reliable. The HADS has the advantage of evaluating both depression and anxiety, and the PHQ-9 of being strictly based upon the Diagnostic and Statistical Manual of Mental Disorders. The agreement between the scales at the best suitable cut-off is moderate, although the identified prevalence was similar. This indicates that the scales do not fully identify the same cases. This difference needs to be further explored.

SF-36 includes less Parkinson Disease (PD)-targeted content but is more responsive to change than two PD-targeted health-related quality of life measures

Objective

To compare validity including responsiveness, and internal consistency reliability and scaling assumptions of a generic (SF-36) and Parkinson Disease (PD)-targeted (PDQ-39; PDQUALIF) health-related quality of life (HRQOL) measures.

Methods

Ninety-six PD patients were administered for all HRQOL measures by telephonic interview at baseline and 18 months. Relative efficiency and responsiveness were compared relative to four external criteria (self-ratings of PD’s daily effects, global Quality of Life, PD symptom severity, and a depression screener). We examined whether PD-targeted measures explained unique variance beyond the SF-36 by regressing criterion variables on HRQOL scales/items. Adequacy of PD-targeted measures’ original scaling was explored by item-scale correlations.

Results

Relative efficiency estimates were similar for generic and PD-targeted measures across all criteria. Responsiveness analyses showed that the SF-36 yielded large (>0.8) effect sizes (ES) for three of eight scales for each of two criterion variables, compared to only one large ES for any scale in either PD-targeted measure. Adjusted R² increased from 14 to 27% in regression models that included PD-targeted items compared to models with only SF-36 scales. Item-scale correlations showed significant cross-loading of items across scales of the PD-targeted measures.

Conclusions

SF-36 responsiveness was better than that of two PD-targeted measures, yet those measures had content that significantly explains PD patients’ HRQOL.

Effectiveness of a depression disease management program in improving depression and work function--a pilot study

OBJECTIVE

We examined whether there were differences in depression and work function outcomes among primary care and specialty mental health patients treated by the Michigan Depression Outreach and Collaborative Care (M-DOCC), a depression care management program, developed by the University of Michigan Depression Center. In addition, we examined the relationship between depressive symptoms and workplace functioning among M-DOCC enrollees over time.

METHOD

We used mixed model and logistic regression analyses.

RESULTS

Despite baseline differences in patient characteristics between primary care and specialty care patients, the location of treatment setting was not a significant predictor of depression or work function outcomes over time among patients enrolled in a depression care management program. Patients in both treatment settings showed significant decreases in depressive and functional impairment over time, with improvements in these symptoms occurring concurrently. Patients with greater case severity were less likely to demonstrate depression and work function improvements over time, and more severe side effects were associated with fewer depression symptom improvements over time.

CONCLUSIONS

Both depression and work function outcomes improved over time among patients enrolled in a depression care management program, and this improvement did not differ based on whether a patient was treated in a primary or specialty care setting.

Internet treatment for social phobia reduces comorbidity

OBJECTIVE

Social phobia can be treated by brief Internet-based cognitive behaviour therapy (CBT). Most people with social phobia, however, meet criteria for another mental disorder; this comorbidity is associated with significant disability, and cases of comorbidity may be more difficult to treat. The present study examined the impact of the Shyness programme, an Internet-based treatment programme for social phobia, on comorbid symptoms of depression and generalized anxiety disorder.

METHOD

Data from three randomized controlled trials using the Shyness programme to treat social phobia were reanalysed. The 211 subjects, all of whom met DSM-IV criteria for social phobia, were divided into four groups: (i) social phobia only; (ii) social phobia with elevated symptoms of depression; (iii) social phobia with elevated symptoms of generalized anxiety; and (iv) social phobia with elevated symptoms of both generalized anxiety and depression. The improvement in social phobia, depression and anxiety following Internet-based treatment for social phobia was measured.

RESULTS

Improvement in social phobia was seen in all groups, whether comorbid or not. Significant improvements in comorbid symptoms of depression and generalized anxiety occurred even though the treatment was focused on the social phobia.

CONCLUSIONS

Brief Internet-based CBT can reduce both the target disorder as well as comorbid symptoms. These findings are consistent with evidence that unified or transdiagnostic programmes may reduce the severity of comorbid disorders and symptoms, indicating an important direction for future research.

A cross-sectional cohort survey in 2100 patients with painful diabetic neuropathy and postherpetic neuralgia: Differences in demographic data and sensory symptoms

Patients with neuropathic pain syndromes are heterogeneous. They present with a variety of sensory symptoms and pain qualities. The knowledge of these data and etiology-specific differences is important to optimize clinical trial design and to develop more effective drugs. This investigation uses epidemiological and clinical data on the symptomatology of 2100 patients with painful diabetic neuropathy (DPN) and postherpetic neuralgia (PHN) from a cross-sectional survey (painDETECT) to (1) describe characteristic epidemiological differences, (2) analyse typical patterns of sensory symptoms in both cohorts and (3) determine whether questionnaires can capture these characteristics. PHN patients suffer more often from clinically relevant sensory disturbances although the average pain intensity is only marginally higher. This difference is particularly obvious with dynamic mechanical allodynia which is present in half of the PHN patients and in 18% of the DPN patients. Thermal hyperalgesia occurs twice as often in PHN. Numbness is described more often in DPN. Age has no influence on sensory symptoms in both entities. A hierarchical cluster analysis revealed five distinct subgroups of patients showing a characteristic sensory profile, a typical constellation and combination of neuropathic symptoms. All subgroups occur in relevant numbers in both entities but the frequencies differ between PHN and DPN. Since sensory symptoms likely translate into pain-generating mechanisms enrichment for potential treatment responders might be possible in clinical trials by assessing the sensory profiles. Patient-Reported Outcomes can be used to obtain a precise sensory characterization of each patient.

Determination of prevalence of depression in an epilepsy clinic using a brief DSM-IV-based self-report questionnaire

Depression in epilepsy is common, underrecognized, and an indicator of quality of life. The Patient Health Questionnaire nine-item depression scale (PHQ-9) is a self-administered questionnaire based on Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria with high sensitivity and specificity for diagnosing depression. Using the PHQ-9, we determined that one-third of 263 patients seen in an epilepsy clinic had scores consistent with major depression. Seizure-free patients had lower depression scores than those with persistent seizures. Depression scores were not related to the number or type of antiepileptic drugs used. One-half of patients with scores consistent with major depression were not on antidepressant medication. The brevity of the PHQ-9 is conducive to routine screening of patients with epilepsy.

Clinician-assisted Internet-based treatment is effective for depression: randomized controlled trial

OBJECTIVE

The aim of the present study was to determine the efficacy of an Internet-based clinician-assisted computerized cognitive behavioural treatment (CaCCBT) programme for depression.

METHOD

Forty-five individuals meeting diagnostic criteria for depression were randomly assigned to the Sadness programme or to a waitlist control group. In the clinician-assisted Sadness programme, participants complete six online lessons, weekly homework assignments, receive weekly email contact from a clinical psychologist, and contribute to a moderated online discussion forum with other participants. An intention-to-treat model was used for data analyses.

RESULTS

A total of 20 (74%) treatment group participants completed all lessons within the 8 week programme, and post-treatment data were collected from 18/27 treatment group and 17/18 waitlist group participants. Treatment group participants reported significantly reduced symptoms of depression as measured by the Beck Depression Inventory-second edition and the Patient Health Questionnaire-Nine Item. Treatment group participants each received an average of eight email contacts (111 min of therapist time]. Mean within- and between-group effect sizes (Cohen's d) across the two measures of depressive symptoms were 0.98 and 0.75, respectively. Participants found the treatment programme acceptable and satisfactory.

CONCLUSIONS

These results replicate those from the pilot trial reported by Perini et al. and are consistent with literature indicating that Internet-based programmes for depression and other mental disorders combined with clinical guidance can result in clinically significant improvements. These data provide further support for the development of Internet-based treatment for common mental disorders.

Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial

CONTEXT

Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs.

OBJECTIVE

To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score > or = 10).

INTERVENTION

Patients were randomly assigned to the intervention (n = 123) or to usual care (n = 127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3).

MAIN OUTCOME MEASURES

Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months.

RESULTS

At 12 months, 46 of the 123 intervention patients (37.4%) had a 50% or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (> or = 30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]).

CONCLUSION

Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118430.

Community-based peer-led diabetes self-management: a randomized trial

PURPOSE

The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a randomized usual-care control group at 6 months.

METHODS

A total of 345 adults with type 2 diabetes but no criteria for high A1C were randomized to a usual-care control group or 6-week community-based, peer-led diabetes self-management program (DSMP). Randomized participants were compared at 6 months. The DSMP intervention participants were followed for an additional 6 months (12 months total). A1C and body mass index were measured at baseline, 6 months, and 12 months. All other data were collected by self-administered questionnaires.

RESULTS

At 6 months, DSMP participants did not demonstrate improvements in A1C as compared with controls. Baseline A1C was much lower than in similar trials. Participants did have significant improvements in depression, symptoms of hypoglycemia, communication with physicians, healthy eating, and reading food labels (P < .01). They also had significant improvements in patient activation and self-efficacy. At 12 months, DSMP intervention participants continued to demonstrate improvements in depression, communication with physicians, healthy eating, patient activation, and self-efficacy (P < .01). There were no significant changes in utilization measures.

CONCLUSIONS

These findings suggest that people with diabetes without elevated A1C can benefit from a community-based, peer-led diabetes program. Given the large number of people with diabetes and lack of low-cost diabetes education, the DSMP deserves consideration for implementation.

Depression screening using the Patient Health Questionnaire-9 administered on a touch screen computer

OBJECTIVE

To (1) evaluate the feasibility of touch screen depression screening in cancer patients using the Patient Health Questionnaire-9 (PHQ-9), (2) evaluate the construct validity of the PHQ-9 using the touch screen modality, and (3) examine the prevalence and severity of depression using this screening modality.

METHODS

The PHQ-9 was placed in a web-based survey within a study of the clinical impact of computerized symptom and quality of life screening. Patients in medical oncology, radiation oncology, and hematopoietic stem cell transplantation (HSCT) clinics used the program on a touch screen computer in waiting rooms prior to therapy (T1) and during therapy (T2). Responses of depressed mood or anhedonia (PHQ-2 cardinal depression symptoms) triggered additional items. PHQ-9 scores were provided to the oncology team in real time.

RESULTS

Among 342 patients enrolled, 33 (9.6%) at T1 and 69 (20.2%) at T2 triggered the full PHQ-9 by endorsing at least one cardinal symptom. Feasibility was high, with at least 97% completing the PHQ-2 and at least 96% completing the PHQ-9 when triggered and a mean completion time of about 2 min. The PHQ-9 had good construct validity. Medical oncology patients had the highest percent of positive screens (12.9%) at T1, while HSCT patients had the highest percent (30.5%) at T2. Using this method, 21 (6.1%) at T1 and 54 (15.8%) at T2 of the total sample had moderate to severe depression.

CONCLUSIONS

The PHQ-9 administered on a touch screen computer is feasible and provides valid depression data in a diverse cancer population.

The PHQ-8 as a measure of current depression in the general population

BACKGROUND

The eight-item Patient Health Questionnaire depression scale (PHQ-8) is established as a valid diagnostic and severity measure for depressive disorders in large clinical studies. Our objectives were to assess the PHQ-8 as a depression measure in a large, epidemiological population-based study, and to determine the comparability of depression as defined by the PHQ-8 diagnostic algorithm vs. a PHQ-8 cutpoint > or = 10.

METHODS

Random-digit-dialed telephone survey of 198,678 participants in the 2006 Behavioral Risk Factor Surveillance Survey (BRFSS), a population-based survey in the United States. Current depression as defined by either the DSM-IV based diagnostic algorithm (i.e., major depressive or other depressive disorder) of the PHQ-8 or a PHQ-8 score > or = 10; respondent sociodemographic characteristics; number of days of impairment in the past 30 days in multiple domains of health-related quality of life (HRQoL).

RESULTS

The prevalence of current depression was similar whether defined by the diagnostic algorithm or a PHQ-8 score > or = 10 (9.1% vs. 8.6%). Depressed patients had substantially more days of impairment across multiple domains of HRQoL, and the impairment was nearly identical in depressed groups defined by either method. Of the 17,040 respondents with a PHQ-8 score > or = 10, major depressive disorder was present in 49.7%, other depressive disorder in 23.9%, depressed mood or anhedonia in another 22.8%, and no evidence of depressive disorder or depressive symptoms in only 3.5%.

LIMITATIONS

The PHQ-8 diagnostic algorithm rather than an independent structured psychiatric interview was used as the criterion standard.

CONCLUSIONS

The PHQ-8 is a useful depression measure for population-based studies, and either its diagnostic algorithm or a cutpoint > or = 10 can be used for defining current depression.

General health and quality-of-life measures in active, recent, and comorbid mental disorders: a population-based health 2000 study

AIMS

We studied the impact of comorbidity and recency in psychiatric disorders on psychological well-being, perceived health, and quality of life and compared their effect with the effect of a chronic medical condition, type 2 diabetes mellitus.

METHODS

Established instruments for psychological distress (12-item General Health Questionnaire [GHQ-12]), self-rated general health, and health-related quality of life (EQ-5D and 15D) were administered for the participants of the nationwide Finnish Health 2000 survey. The diagnoses of depressive, anxiety, and alcohol use disorders and their unique comorbid combinations were based on the Munich version of the Composite International Diagnostic Interview (M-CIDI).

RESULTS

People with comorbid anxiety and depressive disorders had the highest distress and lowest health and quality-of-life ratings on all scales. The effects of mental disorders on health-related quality of life and self-rated health were comparable to the effects of diabetes. Type 2 diabetes mellitus and alcohol use disorder were associated with minimal, although statistically significant, increase of psychological distress. Symptom recovery from an active depressive disorder associated with improved well-being on all measures, but residual ill-being was also remarkably common among the partly or fully recovered in all disorder categories.

CONCLUSIONS

Even in comparison with a chronic physical illness such as diabetes, comorbid psychiatric disorders have a high impact on psychological well-being, perceived health, and quality of life, when evaluated by simple, useful, and feasible self-rating scales. The scales used may be useful in monitoring the severity and course of psychiatric conditions. Recognizing and treating psychiatric comorbidity is important in improving the quality of life of psychiatric patients.

Electronic screening for mental health in rural primary care: implementation

The goals of this study were to develop a computer-based electronic screening tool (eScreening) and determine the feasibility of implementing eScreening for rural users of primary care. This descriptive pilot adapted existing screening measures for depression and alcohol abuse to a portable computer-based format and examined the feasibility of its adoption and use. This was a three-step design using convenience samples for (1) a focus group with providers, (2) usability testing with selected rural patients using the computerized touch screen, and (3) implementing the touch screen platform with a small sample in primary care to determine feasibility. This paper reports on Phase III, which assessed consumer response to eScreening.

Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya

BACKGROUND

Depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained settings.

OBJECTIVE

To assess the validity/reliability of PHQ-9 and PHQ-2.

DESIGN

Observational, two occasions 7 days apart.

PARTICIPANTS

A total of 347 patients attending psychosocial support groups.

MEASUREMENTS

Demographics, PHQ-9, PHQ-2, general health perception rating and CD4 count.

RESULTS

Rates for PHQ-9 DSM-IV major depressive disorder (MDD), other depressive disorder (ODD) and any depressive disorder were 13%, 21% and 34%. Depression was associated with female gender, but not CD4. Construct validity was supported by: (1) a strong association between PHQ-9 and general health rating, (2) a single major factor with loadings exceeding 0.50, (3) item-total correlations exceeding 0.37 and (4) a pattern of item means similar to US validation studies. Four focus groups indicated culturally relevant content validity and minor modifications to the PHQ-9 instructions. Coefficient alpha was 0.78. Test-retest reliability was acceptable: (1) intraclass correlation 0.59 for PHQ-9 total score, (2) kappas 0.24, 0.25 and 0.38 for PHQ-9 MDD, ODD and any depressive disorder and (3) weighted kappa 0.53 for PHQ-9 depression severity categories. PHQ-2 > or =3 demonstrated high sensitivity (85%) and specificity (95%) for diagnosing any PHQ-9 depressive disorder (AUC, 0.97), and 91% and 77%, respectively, for diagnosing PHQ-9 MDD (AUC, 0.91). Psychometrics were also good within four gender/age (18-35, 36-61) subgroups.

CONCLUSIONS

PHQ-9 and PHQ-2 appear valid/reliable for assessing DSM-IV depressive disorders and depression severity among adults living with HIV/AIDS in western Kenya.

Depression revealed: the need for screening, treatment, and monitoring

Depression is common among both the elderly and those with chronic conditions. Unidentified and inadequately treated depression in home health patients has serious and costly consequences. The authors argue that many negative consequences can be avoided by careful management. They discuss the importance of adding a structured depression tool to routine assessments when indicated, present a 3-step approach for depression screening and monitoring, and describe 1 method for tool selection based on measurement soundness and utility.

Psychological aggression, physical aggression, and injury in nonpartner relationships among men and women in treatment for substance-use disorders

OBJECTIVE

This study focused on the prevalence and predictors of psychological aggression, physical aggression, and injury rates in nonintimate partner relationships in a substance-use disorder treatment sample.

METHOD

The sample included 489 (76% men, 24% women) participants who completed screening measures for inclusion in a randomized control trial for an aggression-prevention treatment. Primary outcome measures included rates of past-year psychological aggression, physical aggression, and injury (both from the participant to nonpartners and from nonpartners to the participant). Potential predictors included individual factors (e.g., age, gender), developmental factors (e.g., family history of drug use, childhood physical abuse), and recent factors (e.g., depression, cocaine use).

RESULTS

Rates of participant-to nonpartner psychological aggression (83%), physical aggression (61%), and injury (47%) were high, as were rates of nonpartner-to-participant aggression. Bivariate analyses revealed significant relationships between the aggression outcomes and most of the individual, developmental, and recent factors. However, multivariate analyses (zero-inflated Poisson regression) revealed that age, treatment status, current symptoms of depression, heavy periods of drinking, and cocaine use were related most frequently to the occurrence of aggression to and from nonpartners.

CONCLUSIONS

Nonpartner aggression may be as common within a substance-use disorder sample as partner aggression, and it is associated with heavy drinking episodes, cocaine use, and depressive symptoms. The findings highlight the need for the development of effective violence interventions addressing violence in nonpartner relationship types.

Treatment needs of men and women with violence problems in substance use disorder treatment

This study examined treatment needs of men and women in substance use disorder (SUD) treatment. The sample (n = 489) was recruited between 2006 and 2007 from a Midwestern state in the United States, and participants were grouped based on injury occurring in partner and nonpartner relationships in the past year. Rates of injury across relationship types were alarming with over 54.8% reporting injuring another person and 55.4% reporting being injured. Overall, those injuring nonpartners or both partners/nonpartners had more severe problems. Implications of the findings for SUD treatment settings and a model for integrated violence prevention are discussed.

Collaborative care for adolescent depression: a pilot study

OBJECTIVE

The main objectives of this study were to explore the preliminary outcomes and assess the feasibility and acceptability of a collaborative care intervention designed to improve treatment and outcomes of depression among youth seen in primary care settings.

METHODS

We conducted a pilot intervention study at three clinics in a university affiliated primary care clinic network. The intervention model was designed to support the provision of depression treatment by primary care providers using methods adapted from the IMPACT study developed for the improvement of depression among older adults. Specific components include the provision of regular case management by a nurse depression care manager (DCM), enhanced patient and parent education about depression and its treatment, encouragement of patient self-management with a choice of starting medications or therapy or both, and oversight of the DCM by a mental health specialist. Study participants were assessed regularly by the DCM for 6 months and completed written self-report assessments at baseline, 3, and 6 months after starting the intervention.

RESULTS

40 youth (12-18 years) with major and minor depression enrolled in the intervention. Study participants were predominantly female (90%). The baseline Patient Health Questionnaire (PHQ-9) score was 14.2 (SD=4.5). Patients were similarly divided among initiating medications (n=12), therapy (n=15), or combination therapy (n=8). Five patients withdrew prior to initiating treatment. The mean number of in person and telephone contacts with the DCM was 9 (range=5 to 17). Eighty-seven percent of youth completed the 6-month intervention. At 6 month follow-up, 74% of youth had a 50% or more reduction in depressive symptoms as measured by the PHQ-9. Parents, youth and physicians indicated high levels of satisfaction with the intervention on written surveys and in qualitative exit interviews.

CONCLUSION

The collaborative care model is feasible and highly acceptable to adolescents and parents as demonstrated both by self-report and by engagement in the intervention. It is also associated with improved depressive outcomes at similar levels to adult interventions. Future studies should evaluate these models in a randomized controlled trial.

Depressive symptoms and suicidal ideation among older adults receiving home delivered meals

OBJECTIVE

Homebound older adults may be vulnerable to the deleterious impact of untreated depression. Yet because these elders are difficult to reach, there is little data on the rates of depressive symptoms and suicidal ideation among this group. The objective of this study is to document the rates of depression and correlates among a population of homebound elders.

METHODS

Using a community based participatory research partnership, we implemented a routine screening for depressive symptoms and suicidal ideation among older recipients of Westchester County's home meal program. Older adults enrolled in the home delivered meal program were administered the Physician Health Questionnaire-9 (PHQ-9), and questions to assess pain, falls, alcohol abuse and perceived emotional distress.

RESULTS

In our sample of 403 meal recipients, 12.2% of older adults reported clinically significant depression (PHQ-9 > 9) and 13.4% reported suicidal thoughts. One-third of recipients with significant depressive symptoms were currently taking an antidepressant. Almost one-third of older adults who endorsed suicide ideation did not report clinically significant depressive symptoms. Among men, suicidal thoughts were associated with chronic pain and greater depression severity, whereas pain was not a predictor of suicidal thoughts among women.

CONCLUSION

More than one in nine elders suffer from depression; most are untreated with one-third undertreated. Through partnerships between public agencies that provide age related services and academic investigators there is an opportunity for improved detection of unmet mental health needs. Future research should explore innovative models to improve access to mental health services once unmet need is detected.