Monitoring Depression Treatment Outcomes With the Patient Health Questionnaire-9

Partner aggression among men and women in substance use disorder treatment: correlates of psychological and physical aggression and injury

This study examined intimate partner aggression in a sample of 489 participants enrolled in substance use disorder treatment, and expands on prior research by including measures of various forms of aggression, a mixed gender sample (76% men, 24% women), and measurement of several potential risk domains. Aggression measures included both participant-partner and partner-to-participant psychological aggression, physical aggression and injury. Analyses focused on the role of distal and proximal risk factors, including demographics, history of childhood physical and sexual abuse, and family history of problems with alcohol, drugs and depression, as well as recent substance use and symptoms of depression. Overall rates of participant-partner psychological aggression (77%), physical aggression (54%) and injuring partners (33%) were high, as were rates of partner-to-participant psychological aggression (73%), physical aggression (51%), and injury (33%). Several distal (family history variables, physical abuse) and proximal factors (binge drinking, several different drugs, depressive symptoms) were bivariately related to most of the aggression measures. However, according to multivariate analyses predicting aggression and injury measures, binge drinking and cocaine use were the drugs significantly associated with most measures, depression symptoms also were related to most aggression and injury measures, and a history of reported childhood physical abuse was related to all frequency of aggression and injury measures among those reporting such behaviors. Overall, the high rates of aggression among both men and women observed in this study further illustrate the need for interventions targeting substance use and aggression, and for further research regarding the inter-relationships among substance, aggression and depressive symptoms.

Randomized controlled trial of collaborative care management of depression among low-income patients with cancer

PURPOSE

To determine the effectiveness of the Alleviating Depression Among Patients With Cancer (ADAPt-C) collaborative care management for major depression or dysthymia.

PATIENTS AND METHODS

Study patients included 472 low-income, predominantly female Hispanic patients with cancer age >or= 18 years with major depression (49%), dysthymia (5%), or both (46%). Patients were randomly assigned to intervention (n = 242) or enhanced usual care (EUC; n = 230). Intervention patients had access for up to 12 months to a depression clinical specialist (supervised by a psychiatrist) who offered education, structured psychotherapy, and maintenance/relapse prevention support. The psychiatrist prescribed antidepressant medications for patients preferring or assessed to require medication.

RESULTS

At 12 months, 63% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline as assessed by the Patient Health Questionnaire-9 (PHQ-9) depression scale compared with 50% of EUC patients (odds ratio [OR] = 1.98; 95% CI, 1.16 to 3.38; P = .01). Improvement was also found for 5-point decrease in PHQ-9 score among 72.2% of intervention patients compared with 59.7% of EUC patients (OR = 1.99; 95% CI, 1.14 to 3.50; P = .02). Intervention patients also experienced greater rates of depression treatment (72.3% v 10.4% of EUC patients; P < .0001) and significantly better quality-of-life outcomes, including social/family (adjusted mean difference between groups, 2.7; 95% CI, 1.22 to 4.17; P < .001), emotional (adjusted mean difference, 1.29; 95% CI, 0.26 to 2.22; P = .01), functional (adjusted mean difference, 1.34; 95% CI, 0.08 to 2.59; P = .04), and physical well-being (adjusted mean difference, 2.79; 95% CI, 0.49 to 5.1; P = .02).

CONCLUSION

ADAPt-C collaborative care is feasible and results in significant reduction in depressive symptoms, improvement in quality of life, and lower pain levels compared with EUC for patients with depressive disorders in a low-income, predominantly Hispanic population in public sector oncology clinics.

Perceptions about competing psychosocial problems and treatment priorities among older adults with depression

OBJECTIVE

Depression often co-occurs with other conditions that may pose competing demands to depression care, particularly in later life. This study examined older adults' perceptions of depression among co-occurring social, medical, and functional problems and compared the priority of depression with that of other problems.

METHODS

The study's purposeful sample comprised 49 adults age 60 or older with a history of depression and in publicly funded community long-term care. Four-part, mixed-methods interviews sought to capture participants' perceptions of life problems as well as the priority they placed on depression. Methods included standardized depression screening, semistructured qualitative interviews, listing of problems, and qualitative and quantitative analysis of problem rankings.

RESULTS

Most participants identified health, functional, and psychosocial problems co-occurring with depressive symptoms. Depression was ranked low among the co-occurring conditions; 6% ranked depression as the most important of their problems, whereas 45% ranked it last. Relative rank scores for problems were remarkably similar, with the notable exception of depression, which was ranked lowest of all problems. Participants did not see depression as a high priority compared with co-occurring problems, particularly psychosocial ones.

CONCLUSIONS

Effective and durable improvements to mental health care must be shaped by an understanding of client perceptions and priorities. Motivational interviewing, health education, and assessment of treatment priorities may be necessary in helping older adults value and accept depression care. Nonspecialty settings of care may effectively link depression treatment to other services, thereby increasing receptivity to mental health services.

Assessing the prevalence of depression among individuals with diabetes in a Medicaid managed-care program

OBJECTIVES

To determine the prevalence of self-reported depression symptoms among diabetic individuals enrolled in Gold Choice, a Medicaid managed care organization specifically for people with mental health and/or substance abuse diagnoses; and to assess the sensitivity and specificity of individuals' self-report with encounter data.

METHODS

The 9-item depression scale of the Patient Health Questionnaire (PHQ-9) was mailed to 454 Gold Choice members in Western New York diagnosed with diabetes; and 249 completed PHQ-9 forms were returned (55% response rate). The PHQ-9 forms were compared to primary care encounter data to determine whether the respondents had been diagnosed with depression. Descriptive and inferential statistical analysis was undertaken.

RESULTS

The majority (56%) of individuals in the sample screened positive for depression (PHQ-9 > or = 10), and half (49%) did not have evidence of a diagnosis in their encounter data. The percentage of those diagnosed with depression rose with increasing PHQ-9 severity levels, with 63% of individuals with the most severe depression (PHQ-9 > or = 20) having a diagnosis. This trend was statistically significant, confirmed by independent sample t-tests and chi-square tests. The sensitivity of the PHQ-9 was moderate (66%), as was the specificity (52%).

CONCLUSIONS

The results of this study suggest that depressive disorders may be under-recognized and under-treated amongst individuals with diabetes in the primary care setting. Half (51%) of those with PHQ-9 scores > or = 10 had depression diagnoses, suggesting poor compliance rates and/or a need for therapy reassessment.

Lipoatrophy among HIV-infected patients is associated with higher levels of depression than lipohypertrophy

OBJECTIVES

We sought to determine the association between body morphology abnormalities and depression, examining lipoatrophy and lipohypertrophy separately.

METHODS

An observational cross-sectional study of 250 patients from the University of Washington HIV Cohort was carried out. Patients completed an assessment including measures of depression and body morphology. We used linear regression analysis to examine the association between lipoatrophy or lipohypertrophy and depression. Analysis of variance was used to examine the relationship between mean depression scores and lipoatrophy and lipohypertrophy in 10 body regions.

RESULTS

Of 250 patients, 76 had lipoatrophy and 128 had lipohypertrophy. Mean depression scores were highest among patients with moderate-to-severe lipoatrophy (16.4), intermediate among those with moderate-to-severe lipohypertrophy (11.7), mild lipohypertrophy (9.9) and mild lipoatrophy (8.5), and lowest among those without body morphology abnormalities (7.7) (P=0.002). After adjustment, mean depression scores for subjects reporting moderate-to-severe lipoatrophy were 9.2 points higher (P<0.001), scores for subjects with moderate-to-severe lipohypertrophy were 4.8 points higher (P=0.02), and scores for subjects with mild lipohypertrophy were 2.8 points higher (P=0.03) than those for patients without body morphology abnormalities. Facial lipoatrophy was the body region associated with the most severe depression scores (15.5 vs. 8.9 for controls; P=0.03).

CONCLUSIONS

In addition to long-term cardiovascular implications, body morphology has a more immediate effect on depression severity.

Health beliefs about depression among African American women

PURPOSE

A qualitative descriptive research study was conducted to explore the health beliefs of African American women and depression to improve insight regarding treatment decisions.

DESIGN AND METHODS

Focus group interviews were performed with purposeful sampling of 14 self-identified African American women.

FINDINGS

Responses and comments were sorted into five major content areas that represent the core constructs of the Health Belief Model.

PRACTICE IMPLICATIONS

Practitioners must seek to understand clients' understanding and explanations of depression to gain insight about ways to build an effective treatment alliance with clients and other practitioners.

Quality of life is impaired in patients with peristomal bulging of a sigmoid colostomy

OBJECTIVE

Peristomal bulging caused by hernia or prolapse is common in patients with a sigmoidostomy. It is not known whether and to what extent peristomal bulging influences various daily activities. The purpose of this study was to evaluate the effects of bulging by using a general and disease-specific health scale (Short Health Scale, SHS) and a stoma-specific quality of life (Stoma-QoL) questionnaire in patients with and without peristomal bulging.

MATERIAL AND METHODS

Seventy patients with sigmoidostomies were examined to identify peristomal bulging. The mean (SD) age was 71.7 (13.7) years and the patients had had their sigmoidostomies for a mean of 8.1 (7.9) years. Bulging was noticed in 46 patients (66%) while 24 had no bulging.

RESULTS

It was found that patients with bulging were at a disadvantage. In the SHS, patients with bulging reported significantly impaired QoL in 3 out of 4 scales regarding symptom load, worry and general sense of well-being. Also, in the Stoma-QoL questionnaire there was a significant difference between patients with and those without bulging.

CONCLUSIONS

QoL evaluated with a general and disease-specific instrument (SHS) was significantly impaired in patients with bulging around a sigmoidostomy. The Stoma-QoL questionnaire showed a small but statistically significant difference between patients with and those without bulging but the clinical significance is uncertain. Further studies are required to evaluate the role of some of the individual items in the Stoma-QoL questionnaire.

Multidisciplinary collaborative care for depressive disorder in the occupational health setting: design of a randomised controlled trial and cost-effectiveness study

BACKGROUND

Major depressive disorder (MDD) has major consequences for both patients and society, particularly in terms of needlessly long sick leave and reduced functioning. Although evidence-based treatments for MDD are available, they show disappointing results when implemented in daily practice. A focus on work is also lacking in the treatment of depressive disorder as well as communication of general practitioners (GPs) and other health care professionals with occupational physicians (OPs). The OP may play a more important role in the recovery of patients with MDD. Purpose of the present study is to tackle these obstacles by applying a collaborative care model, which has proven to be effective in the USA, with a focus on return to work (RTW). From a societal perspective, the (cost)effectiveness of this collaborative care treatment, as a way of transmural care, will be evaluated in depressed patients on sick leave in the occupational health setting.

METHODS/DESIGN

A randomised controlled trial in which the treatment of MDD in the occupational health setting will be evaluated in the Netherlands. A transmural collaborative care model, including Problem Solving Treatment (PST), a workplace intervention, antidepressant medication and manual guided self-help will be compared with care as usual (CAU). 126 Patients with MDD on sick leave between 4 and 12 weeks will be included in the study. Care in the intervention group will be provided by a multidisciplinary team of a trained OP-care manager and a consultant psychiatrist. The treatment is separated from the sickness certification. Data will be collected by means of questionnaires at baseline and at 3, 6, 9 and 12 months after baseline. Primary outcome measure is reduction of depressive symptoms, secondary outcome measure is time to RTW, tertiary outcome measure is the cost effectiveness.

DISCUSSION

The high burden of MDD and the high level of sickness absence among people with MDD contribute to the relevance of this study. The intervention is an innovative approach, with trained OPs in a new role as care managers in the treatment of MDD. If this intervention proves to be cost-effective, implementation will be very relevant for individual patients as well as for society.

TRIAL REGISTRATION

ISRCTN78462860.

Risk factors of symptom underestimation by physicians

OBJECTIVE

The aims of this study were to characterize patient-physician agreement on various psychological and somatic symptoms in internal medicine inpatients and to identify predictors of symptom severity underestimation by physicians.

METHODS

Consecutive adult inpatients of two internal medicine wards of a university hospital completed visual analogue scales (VASs) for severity of disability, anxiety, depression, somatic symptoms, and pain at the time of admission (n=639, participation rate=70%) and 5 days thereafter (n=401, participation rate=82%). In addition, the Patient Health Questionnaire 9 (PHQ-9) depression scale and the Clinical Global Impression Scale--Revised were used. At the same time, the six treating physicians independently rated the complaints of their patients using the same VAS. Rates of overestimation, concordance, and underestimation of symptom severity were analyzed. Logistic regression analyses were used to identify predictors of symptom underestimation by physicians.

RESULTS

Concordance between patients and physicians regarding disability, anxiety, depression, somatic symptom severity, and pain reached 50-60%. Symptom severity of patients suffering from major depressive episode was significantly more often underestimated than that of nondepressed patients (all P<.01). Of all the variables, greater depression on the PHQ depression score was the most important risk factor for symptom underestimation by physicians (OR ranging from 1.29 to 1.57; all P<.05, except underestimation of disability). Symptom underestimation of pain severity was also associated with panic disorder symptoms (odds ratio, 2.44; P=.01).

CONCLUSION

Depressed patients seem to be at greater risk of symptom underestimation by their physicians--a finding bearing implications for avoidance of underdiagnosis and insufficient treatment. Mutual understanding could be improved by better doctor-patient communication skills. Brief self-report depression screeners might help to reliably identify patients at risk for symptom underestimation by physicians.

Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population

BACKGROUND

The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a practical self-report anxiety questionnaire that proved valid in primary care. However, the GAD-7 was not yet validated in the general population and thus far, normative data are not available.

OBJECTIVES

To investigate reliability, construct validity, and factorial validity of the GAD-7 in the general population and to generate normative data.

RESEARCH DESIGN

Nationally representative face-to-face household survey conducted in Germany between May 5 and June 8, 2006.

SUBJECTS

Five thousand thirty subjects (53.6% female) with a mean age (SD) of 48.4 (18.0) years.

MEASURES

The survey questionnaire included the GAD-7, the 2-item depression module from the Patient Health Questionnaire (PHQ-2), the Rosenberg Self-Esteem Scale, and demographic characteristics.

RESULTS

Confirmatory factor analyses substantiated the 1-dimensional structure of the GAD-7 and its factorial invariance for gender and age. Internal consistency was identical across all subgroups (alpha = 0.89). Intercorrelations with the PHQ-2 and the Rosenberg Self-Esteem Scale were r = 0.64 (P < 0.001) and r = -0.43 (P < 0.001), respectively. As expected, women had significantly higher mean (SD) GAD-7 anxiety scores compared with men [3.2 (3.5) vs. 2.7 (3.2); P < 0.001]. Normative data for the GAD-7 were generated for both genders and different age levels. Approximately 5% of subjects had GAD-7 scores of 10 or greater, and 1% had GAD-7 scores of 15 or greater.

CONCLUSIONS

Evidence supports reliability and validity of the GAD-7 as a measure of anxiety in the general population. The normative data provided in this study can be used to compare a subject's GAD-7 score with those determined from a general population reference group.

Summed score of the Patient Health Questionnaire-9 was a reliable and valid method for depression screening in chronically ill elderly patients

OBJECTIVE

To assess the psychometric properties of the Patient Health Questionnaire-9 (PHQ-9) as a screening instrument for depression in elderly patients with diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) without known depression.

STUDY DESIGN AND SETTING

DM and COPD patients aged >59 years were selected from general practices. A test-retest was conducted in 105 patients. Criterion validity, using the Mini International Neuropsychiatric Interview psychiatric interview to diagnose major depressive disorder (MDD) and any depressive disorder (ADD) as diagnostic standard, was evaluated for both summed and algorithm-based PHQ-9 score in 713 patients. Correlations with quality of life and severity of illness were calculated to assess construct validity.

RESULTS

Cohen's kappa for the algorithm-based score was 0.71 for MDD and 0.69 for ADD. Correlation for test-retest assessment of the summed score was 0.91. The algorithm-based score had low sensitivity and high specificity, but both sensitivity and specificity were high for the optimal cut-off point of 6 on the summed score for ADD (Se 95.6%, Sp 81.0%). Correlations between summed score and quality of life and severity of illness were acceptable.

CONCLUSION

The summed PHQ-9 score seems a valid and reliable screening instrument for depression in elderly primary care patients with DM and COPD.

Depression is a major determinant of quality of life in patients with chronic systolic heart failure in general practice

BACKGROUND

Quality of life (QoL) is severely restricted in patients with chronic heart failure (CHF). Patients frequently suffer from depressive comorbidity. It is not clear, to what extent sociodemographic variables, heart failure severity, somatic comorbidities and depression determine QoL of patients with CHF in primary care.

METHODS AND RESULTS

In a cross-sectional analysis, 167 patients, 68.2 +/- 10.1 years old, 68.9% male, New York Heart Association (NYHA) functional class II-IV, Left ventricular ejection fraction (LVEF) < or = 40%, were recruited in their general practitioner's practices. Heart failure severity was assessed with echocardiography and N-terminal brain natriuretic peptide (NT-proBNP); multimorbidity was assessed with the Cumulative Illness Rating Scale (CIRS-G). QoL was measured with the Short Form 36 Health Survey (SF-36) and depression with the depression module of the Patient Health Questionnaire (PHQ-9). Significant correlations with all SF-36 subscales were only found for the CIRS-G (r = -0.18 to -0.36; P < .05) and the PHQ-9 (r = -0.26 to -0.75; P < .01). In multivariate forward regression analyses, the PHQ-9 summary score explained the most part of QoL variance in all of the SF-36 subscales (r2 = 0.17-0.56). LVEF and NT-proBNP did not have significant influence on QoL.

CONCLUSIONS

Depression is a major determinant of quality of life in patients with chronic systolic heart failure, whereas somatic measures of heart failure severity such as NT-proBNP and LVEF do not contribute to quality of life. Correct diagnosis and treatment of depressive comorbidity in heart failure patients is essential.

Depression profile in patients with and without chronic heart failure

OBJECTIVE

Depression often goes undetected and untreated in patients with chronic heart failure (CHF). To investigate whether patients with CHF show a specific profile of depression symptoms, we compared depression symptoms in depressed patients with and without CHF.

METHODS

Of a total of 921 patients from a CHF and a psychosomatic outpatient clinic, 137 met DSM-IV diagnostic criteria for major depressive disorder and 113 for other depressive disorders. Depressed patients with CHF (n=113) and without CHF (n=137) were compared with respect to severity of individual DSM-IV depressive symptoms, as measured with the PHQ-9. To stratify for depression severity, ANCOVAs with sociodemographic characteristics as covariates were performed separately for patients with major depressive disorder and other depressive disorders.

RESULTS

Among the patients meeting the criteria for major depressive disorder, patients with CHF reported significantly lower levels of depressed mood (p=.006) and worthlessness/guilt (p=.019) than patients without CHF. In contrast, no significant group differences were found for any of the other depression symptoms. Group comparisons among the patients with other depressive disorders completely replicated these results (p< or =.001, and p=.04, respectively).

LIMITATIONS

Our study population of CHF patients may not be representative for CHF patients recruited in the general population.

CONCLUSIONS

The diagnostic features discriminating between depressed patients with and without CHF are the cognitive-emotional symptoms of depression, not the somatic symptoms. This finding may partially explain the low recognition rate of depression in patients with CHF. The different profile of depression symptoms in patients with and without CHF should be considered in diagnosis, treatment and medical education.

Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: design and practical implications of an intervention for comorbid pain and depression

OBJECTIVE

Depression and pain are common comorbid conditions that have reciprocal adverse effects on disability and treatment outcomes. The objective of this article is to describe a study that tests the effectiveness of a stepped-care approach using a combined medication-behavioral intervention.

METHOD

Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) is an NIMH-sponsored randomized clinical trial nested within a prospective cohort study. A total of 250 patients with clinically significant depression (PHQ-9 scores > or =10) and musculoskeletal pain of the lower back or legs (hip or knee) and 250 nondepressed patients with similar pain are enrolled, with baseline and serial follow-up assessments to be conducted over 12 months. The depressed patients are randomized to either a stepped-care intervention group or a usual-care control group. Stepped-care patients receive 12 weeks of optimized antidepressant management (Step 1) followed by six sessions of a pain self-management (PSM) program over the next 12 weeks (Step 2), all delivered by a nurse care manager who is supervised by a physician specialist. Approximately two thirds of the care manager contacts are by telephone.

RESULTS

The target sample of 500 subjects has been successfully enrolled, and randomization of the depressed patients has resulted in balanced groups of patients with moderately severe pain and depression. Mean SCL-20 depression severity in the clinical trial group is 1.9, with most meeting DSM-IV criteria for major depression (76.3%) and the rest having dysthymia only (18.4%) or minor depression (5.3%). Pain is about equally distributed between lower back (53%) and hip or knee (47%). A rational algorithmic approach to antidepressant selection and dosing, as well as an overview of the PSM program, is provided.

CONCLUSIONS

When completed, SCAMP will test whether optimized antidepressant management improves outcomes in patients with comorbid depression and pain and whether PSM produces additional benefits. The findings will be important for both primary care and mental health clinicians confronted by the prevalent depression-pain dyad.

A system-based approach to depression management in primary care using the Patient Health Questionnaire-9

Primary care physicians are more likely to see patients with depression than with any other disorder except hypertension, and its management poses a challenge to busy primary care practices. The Patient Health Questionnaire-9, a simple self-administered tool of proven validity and reliability, is a commonly used screening instrument for depression in primary care practice. This review article provides a system-based approach to depression management using the Patient Health Questionnaire-9 to guide clinicians in the identification and treatment of depression and its follow-up care.

Managing depression in home health care: a randomized clinical trial

A prospective randomized trial was conducted to examine the effectiveness, feasibility, and degree of implementation of home health care quality improvement interventions when implemented under usual conditions by usual care providers. A total of 311 older adults were randomized to enhanced usual care (EUC) that included routine depression screening and staff training in depression care management for older adults or to the intervention group (INT) that included antidepressants and/or psychotherapy treatment plus EUC. Implementing a routine screening protocol using the PHQ-9 and depression care management quality improvements is feasible in diverse home health care organizations and results in consistently better (but not statistically significant) depression outcomes in the INT group.

The acceptability of a depression screening tool in an urban, Aboriginal community-controlled health service

OBJECTIVE

To assess the acceptability and face validity of a psychological assessment instrument, the Patient Health Questionnaire 9 (PHQ-9), as a depression screening tool for use with Aboriginal and Torres Strait Islander patients.

METHODS

Four focus groups were held in an urban, Aboriginal community-controlled health service. Participants' attitudes to screening for depression and the specific components of PHQ-9 were explored.

RESULTS

Process-oriented and PHQ-9-specific themes were raised. They included the role of family in the screening process, the need for a trusting relationship between the tool administrator and patient, the risk of confounding by social disadvantage or physical co-morbidities, the absence of a question assessing the presence of anger as a symptom of depression, and the importance of culturally appropriate language within the tool.

CONCLUSION

Modification of the screening process and wording of the PHQ-9 in response to these concerns should render it acceptable for use with Aboriginal and Torres Strait Islander patients in this setting.

IMPLICATIONS

These results may apply to the use of other psychological screening tools in the Aboriginal and Torres Strait Islander population. This is particularly relevant given the policy emphasis on screening in Indigenous health.

Using the chronic care model to tackle depression among older adults who have long-term physical conditions

Effective psychological and pharmacological treatments are available, but for depressed older adults with long-term physical conditions, the outcome of routine care is generally poor. This paper introduces the chronic care model, a systemic approach to quality improvement and service redesign, which was developed by Ed Wagner and colleagues. The model highlights six key areas that need to be addressed, if depression is to be tackled more effectively in this neglected patient group: delivery system design, patient-provider relationships, decision support, clinical information systems, community resources and healthcare organization. Three influential programmes, the Improving Mood Promoting Access to Collaborative Treatment programme, the Prevention of Suicide in Primary Care Elderly Collaborative Trial, and the Program to Encourage Active, and Rewarding Lives for Seniors, have shown that when the model is adopted, significant improvements in outcomes can be achieved. The paper concludes with a case study, which illustrates the difference that adopting the chronic care model can make. Radical changes in working practices may be required, to implement the model in practice. However, Greg Simon, a leading researcher in the field of depression care, has suggested that there is already sufficient evidence to justify a shift in emphasis from research towards dissemination and implementation.

An association between negatively biased response to neutral stimuli and antidepressant nonadherence

OBJECTIVE

Our primary objective was to test whether negatively biased response to neutral physical or visual stimuli was associated with antidepressant nonadherence.

METHODS

We surveyed 22 primary care adults receiving pharmacological treatment for depression. Somatoform complaints, in addition to interpretation of and response to neutral facial expressions (NFEs), were assessed with surveys. Seven response anchors to NFE were classified as "negative" or "neutral/positive." Antidepressant adherence was ascertained after 3 months by self-report and pharmacy refill records.

RESULTS

Elevated somatoform complaints were associated with early antidepressant discontinuation (P=.01). Exclusively negative emotional response to NFE, reported by 55% (12/22) of subjects, was associated with clinically significant missed antidepressant doses (R=-.69, P=.0004). Two multivariate models adjusted for depressive symptoms demonstrated that exclusively positive or neutral emotional response to NFE was associated with improved adherence relative to an exclusively negative response (beta=34.0, t=3.7, P=.002); the somatoform complaints subscale "health concerns" adversely influenced depressive symptom improvement (beta=-.3, t=-3.0, P=.008).

CONCLUSION

Negatively biased responses to neutral stimuli in the physical and visual axes were associated with early antidepressant discontinuation and missed doses, respectively. If substantiated, these initial findings might contribute to improved understanding and treatment of antidepressant nonadherence.

Concordance between the PHQ-9 and the HSCL-20 in depressed primary care patients

BACKGROUND

Two instruments commonly used in primary care research to measure depressive severity are the Patient Health Questionnaire-9 (PHQ-9) and the Hopkins Symptom Checklist-20 (HSCL-20). However, there is little information regarding the relationship between clinical information derived from these scales. The present study investigates the psychometric properties of the PHQ-9 and HSCL-20, determines the degree of instrument concordance, and describes the factor structure of the HSCL-20.

METHODS

A secondary data analysis from a randomized controlled trial was performed. A total of 405 primary care patients with major depressive disorder and/or dysthymia were administered the PHQ-9 and the HSCL-20 when recruited for the study.

RESULTS

Good internal consistency reliability estimates were obtained for both scales (PHQ-9 alpha=0.803; HSCL-20 alpha=0.837). All PHQ-9 inter-item and corrected item-total correlations showed that no item detracted from overall scale functioning. HSCL-20 items assessing overeating, poor appetite, and sexual interest were poorly correlated with other items and with the total scale score. A positive, moderate strength relationship was found between the instruments (r=0.54, p<0.0001). Exploratory factor analysis of the HSCL-20 yielded a six-factor structure, which accounted for almost 63% of the variance in total score. The largest contribution to common variance in the scale was provided by an "anxiety and self-reproach" factor.

CONCLUSIONS

PHQ-9 and HSCL-20 total scores were moderately correlated. Although the HSCL-20 is utilized as a measure of depression severity, it may lack sufficient specificity to be an accurate reflection of depression status per se.

Swahili translation and validation of the Patient Health Questionnaire-9 depression scale in the Kenyan head and neck cancer patient population

BACKGROUND

Depression is an important predictor of post therapy quality of life (QOL) in head and neck (H&N) cancer patients. In addition, depression rates may vary among cultures.

OBJECTIVE

As part of a larger cross cultural study on post therapy QOL differences in H&N cancer patients, the goal of this project was to translate a well-validated English language depression scale into Swahili, and then validate this scale in Kenyan H&N cancer patients. METHODS, SETTINGS AND SUBJECTS: In Part 1 of the study, we translated the Patient Health Questionnaire-9 (PHQ-9) into Swahili, adhering to established International Quality of Life Association (IQOLA) guidelines. In Part 2, we psychometrically validated the newly translated scale using a prospective study of 48 patients at the Kenyatta National Hospital ENT clinic in Nairobi, Kenya.

RESULTS

The Swahili PHQ-9 had good test retest reliability (Intraclass correlation coefficient, 0.71) and internal consistency (Cronbach's alpha = 0.80). It also had good construct validity, as scores correlated strongly with TNM stage (Chi square = 123, p < 0.05), and with the compositeand global scores of an H&N cancer specific QOL scale (UW-QOL, r = -0.87, p < 0.05).

CONCLUSION

The Swahili version of the PHQ-9 is a reliable scale in Kenyan H&N cancer patients, and is a valuable tool in screening for and monitoring of depression as a function of QOL in this population.

Cost-effectiveness of collaborative care including PST and an antidepressant treatment algorithm for the treatment of major depressive disorder in primary care; a randomised clinical trial

BACKGROUND

Depressive disorder is currently one of the most burdensome disorders worldwide. Evidence-based treatments for depressive disorder are already available, but these are used insufficiently, and with less positive results than possible. Earlier research in the USA has shown good results in the treatment of depressive disorder based on a collaborative care approach with Problem Solving Treatment and an antidepressant treatment algorithm, and research in the UK has also shown good results with Problem Solving Treatment. These treatment strategies may also work very well in the Netherlands too, even though health care systems differ between countries.

METHODS/DESIGN

This study is a two-armed randomised clinical trial, with randomization on patient-level. The aim of the trial is to evaluate the treatment of depressive disorder in primary care in the Netherlands by means of an adapted collaborative care framework, including contracting and adherence-improving strategies, combined with Problem Solving Treatment and antidepressant medication according to a treatment algorithm. Forty general practices will be randomised to either the intervention group or the control group. Included will be patients who are diagnosed with moderate to severe depression, based on DSM-IV criteria, and stratified according to comorbid chronic physical illness. Patients in the intervention group will receive treatment based on the collaborative care approach, and patients in the control group will receive care as usual. Baseline measurements and follow up measures (3, 6, 9 and 12 months) are assessed using questionnaires and an interview. The primary outcome measure is severity of depressive symptoms, according to the PHQ9. Secondary outcome measures are remission as measured with the PHQ9 and the IDS-SR, and cost-effectiveness measured with the TiC-P, the EQ-5D and the SF-36.

DISCUSSION

In this study, an American model to enhance care for patients with a depressive disorder, the collaborative care model, will be evaluated for effectiveness in the primary care setting. If effective across the Atlantic and across different health care systems, it is also likely to be an effective strategy to implement in the treatment of major depressive disorder in the Netherlands.

Depression case finding in primary care: a method for the mandates

The current mandates for depression screening in primary care create a dilemma for clinicians. How should screening be implemented in the face of limited evidence for sustainable strategies for effective depression monitoring and management in primary care. In this article we review the issues surrounding primary care depression screening, and develop the argument for a case-finding strategy that includes careful choice of a single instrument, focused identification of high-risk patients, and systematic monitoring of outcomes. We believe this is a sustainable method that primary care clinicians can implement to address the spirit of current depression screening mandates.

Cost-effectiveness of collaborative care for chronically ill patients with comorbid depressive disorder in the general hospital setting, a randomised controlled trial

BACKGROUND

Depressive disorder is one of the most common disorders, and is highly prevalent in chronically ill patients. The presence of comorbid depression has a negative influence on quality of life, health care costs, self-care, morbidity, and mortality. Early diagnosis and well-organized treatment of depression has a positive influence on these aspects. Earlier research in the USA has reported good results with regard to the treatment of depression with a collaborative care approach and an antidepressant algorithm. In the UK 'Problem Solving Treatment' has proved to be feasible. However, in the general hospital setting this approach has not yet been evaluated.

METHODS/DESIGN

CC: DIM (Collaborative Care: Depression Initiative in the Medical setting) is a two-armed randomised controlled trial with randomisation at patient level. The aim of the trial is to evaluate the treatment of depressive disorder in general hospitals in the Netherlands based on a collaborative care framework, including contracting, 'Problem Solving Treatment', antidepressant algorithm, and manual-guided self-help. 126 outpatients with diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular diseases will be randomised to either the intervention group or the control group. Patients will be included if they have been diagnosed with moderate to severe depression, based on the DSM-IV criteria in a two-step screening method. The intervention group will receive treatment based on the collaborative care approach; the control group will receive 'care as usual'. Baseline and follow-up measurements (after 3, 6, 9, and 12 months) will be performed by means of questionnaires. The primary outcome measure is severity of depressive symptoms, as measured with the PHQ-9. The secondary outcome measure is the cost-effectiveness of these treatments according to the TiC-P, the EuroQol and the SF-36.

DISCUSSION

Earlier research has indicated that depressive disorder is a chronic, mostly recurrent illness, which tends to cluster with physical comorbidity. Even though the treatment of depressive disorder based on the guidelines for depression is proven effective, these guidelines are often insufficiently adhered to. Collaborative care and 'Problem Solving Treatment' will be specifically tailored to patients with depressive disorders and evaluated in a general hospital setting in the Netherlands.

Symptomchecklisten bei Patienten mit chronischen Schmerzen

Symptom checklists, in particular the SCL-90-R, are widely used in screening for psychological distress in patients with chronic pain. A detailed analysis reveals that this may lead to wrong diagnoses in many cases. The problem of using the SCL-90-R in patients with chronic pain is (a) that scale means are elevated due to items asking for pain-associated symptoms and (b) that there is a lack of specificity of the various dimensions of the SCL-90-R. Numerous short forms of the SCL-90-R are compared to the original one and analysed with respect to their applicability in patients with chronic pain. Other screening questionnaires not related to the SCL-90-R were analysed for the same purpose. As a result, the SCL-27, K9, HADS and PHQ are judged to be applicable for screening in patients with chronic pain.

Teaching systems-based practice to primary care physicians to foster routine implementation of evidence-based depression care

Although health care organizations seeking to improve quality often must change the system for delivering care, there is little available evidence on how to educate staff and providers about this change. As part of a 2002-2003 Veterans Health Administration multisite project using collaborative care to improve the management of depression, the authors implemented the Translating Initiatives for Depression into Effective Solutions (TIDES) program. Five steps were followed for teaching systems-based practice: (1) determine providers' educational needs (through administrative data, expert opinion, and provider discussion), (2) develop educational materials (based on needs assessed), (3) help each of seven sites develop an educational intervention, (4) implement the intervention, and (5) monitor the intervention's effectiveness. Sites relied primarily on passive educational strategies. There was variable implementation of the different components (e.g., lecture, educational outreach). No site chose to write up its education plan, as was suggested. The authors thus suggest that the educational model was successful at identifying providers' needs and creating appropriate materials, because the program was not advertised in other ways and because almost all providers referred patients to the program. However, the educational model was only partially successful at getting sites to develop and implement an educational plan, although provider behavior did change. Overall, the program was somewhat effective at teaching systems-based practice. The authors believe the best way to enhance effectiveness is to build education into the system rather than rely on a separate system for education.

Chronic disease management for depression in primary care: a summary of the current literature and implications for practice

OBJECTIVE

To review randomized controlled trials (RCTs) evaluating chronic disease management models for depression in primary care and to look at the implications for clinical practice in Canada.

METHODS

We reviewed all RCTs conducted between 1992 and 2006, including other reviews and analyses of pooled data. Using various search terms, we searched PsycINFO, Cinahl (1982 to May 2005), MEDLINE (1995 to 2005), EMBASE, The Cochrane Library, and PubMed.

RESULTS

There is conclusive evidence for the benefits of changing systems of care delivery to support the more effective management of depression in primary care. Most studies have demonstrated improved outcomes in terms of symptom reduction, relapse prevention, functioning in the community, adherence to treatment, community and workplace involvement, and satisfaction with care received.

CONCLUSIONS

Primary care practices need to examine how they can incorporate different concepts and models for managing depression. Components to consider include case registries, care managers or coordinators, treatment algorithms, follow-up and monitoring after a treated episode, care and relapse prevention plans, visits by psychiatrists, and training and ongoing education for all providers.

Improving treatment of depression among low-income patients with cancer: the design of the ADAPt-C study

OBJECTIVE

This article describes the randomized clinical trial methodology for a population-based study of oncology patients receiving cancer care in a public sector medical center. The primary goal is to test the effectiveness of socioculturally tailored collaborative care intervention in improving depression and quality of life outcomes among low-income ethnic minority patients with major depression and cancer.

METHODS

The Patient Health Questionnaire (PHQ-9) depression scale was used to identify patients meeting criteria for major depression (one cardinal depression symptom plus a PHQ-9 score of > or =10). Study-eligible patients were >/=90 days from cancer diagnosis who were receiving acute cancer treatment or follow-up care in oncology clinics. Patients with advanced disease limiting life expectancy to <6 months, acutely suicidal or on antipsychotic medication were excluded. Allowing for attrition due to death or loss to follow-up, the study was powered at the 80% level to detect a 20% difference between study arms in the proportion of patients with >/=50% reduction in PHQ-9 symptoms at 12 months.

RESULTS

Of 2330 patients screened, 23.2% met criteria. An 82.4% enrollment rate resulted in 446 primarily women being recruited and randomized to intervention or usual care.

CONCLUSION

The study applies methods used in primary care depression trials with adaptations for oncology care clinics and for low-income minority patients.

The prevalence of unrecognized depression in patients with acute coronary syndrome

BACKGROUND

Depression in patients with acute coronary syndrome (ACS) is common and independently prognostic of a higher mortality and worse health status. Despite great attention to its prevalence and prognostic import, little is known about how often hospitalized patients with ACS who have significant depressive symptoms are recognized while receiving routine cardiovascular care.

METHODS

We performed a cross-sectional study of 1181 consecutive patients with confirmed ACS. Detailed reviews of hospital records were performed for the documentation that depressive symptoms were recognized. Multivariable regression analysis was used to identify factors associated with unrecognized depressive symptoms.

RESULTS

The prevalence of moderate/severe depressive symptoms was 17.6%. Only 24.5% had documentation that their depressive symptoms were recognized. In multivariable regression analysis, characteristics associated with unrecognized depressive symptoms were race (minorities vs whites; odds ratio [OR] = 6.73, 95% confidence interval [CI] 2.62-19.33), ejection fraction (EF < 0.40 vs EF > or = 0.40; OR = 3.45, 95% CI 1.06-11.23), and education level (no college vs some college; OR = 2.77, 95% CI 1.38-5.69).

CONCLUSIONS

Despite its prognostic importance and prevalence, moderate to severe depressive symptoms are poorly recognized in hospitalized patients with ACS. Better interventions are warranted to increase the recognition and improve the management of depressive symptoms in patients with ACS.

A Fidelity Measure for Integrated Management of Depression in Primary Care

BACKGROUND

Integrated models of primary care depression management improve outcomes. Subsequent dissemination efforts and their evaluation need a fidelity measure.

OBJECTIVES

We sought to develop and validate a fidelity measure using data gathered during routine clinical application of the clinical model.

METHODS

Longitudinal outcome data on depression severity were obtained from 224 subjects experiencing major depression or dysthymia and assigned to a 3-component model (3CM) intervention. Data on 10 essential 3CM process-of-care components were obtained from telephone logs maintained by care managers administering 3CM care. Stakeholders (n = 23), including researchers, health care administrators, and care managers, independently rated the importance of the 10 elements distributing 100 points among the elements. Mean ratings were used as weights to construct a fidelity score. Predictive validity was assessed using logistic regression for patient response and remission at 3 and 6 months.

RESULTS

3CM fidelity was high, with a mean of 74.1 at 3 months and 75.9 at 6 months. Given a large gap in the scores' distribution, subjects were classified into zero, low-, and high-fidelity groups. Logistic regressions adjusting for baseline depression found a distinct continuum. Patients that were provided high fidelity 3CM were significantly more likely to achieve treatment response and remission at 3 months. At 6 months, high-fidelity care was again significantly more likely to produce a response, but remission rate did not differ from patients provided low fidelity.

CONCLUSIONS

Most patients received a substantially implemented "3CM dose." Even within this high implementation, however, a higher fidelity score was associated with better outcomes. The easily applied measure is a promising tool for monitoring the quality of implementation of integrated care.

Job performance deficits due to depression

OBJECTIVE

This study assessed the relationship between depression severity and job performance among employed primary care patients.

METHOD

In a 2001-2004 longitudinal observational study of depression's affect on work productivity, 286 patients with DSM-IV major depressive disorder and/or dysthymia were compared to 93 individuals with rheumatoid arthritis, a condition associated with work disability, and 193 depression-free healthy control subjects. Participants were employed at least 15 hours per week, did not plan to stop working, and had no major medical comorbidities. Measures at baseline, six, 12, and 18 months included the Work Limitations Questionnaire for work outcomes, and the Patient Health Questionnaire-9 for depression.

RESULTS

At baseline and each follow-up, the depression group had significantly greater deficits in managing mental-interpersonal, time, and output tasks, as measured by the Work Limitations Questionnaire: The rheumatoid arthritis group's deficits in managing physical job demands surpassed those of either the depression or comparison groups. Improvements in job performance were predicted by symptom severity. However, the job performance of even the "clinically improved" subset of depressed patients remained consistently worse than the control groups.

CONCLUSIONS

Multiple dimensions of job performance are impaired by depression. This impact persisted after symptoms have improved. Efforts to reduce work-impairment secondary to depression are needed.

painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain

OBJECTIVE

Nociceptive and neuropathic components both contribute to pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is highly desirable. As low back pain (LBP) patients constitute an important subgroup of chronic pain patients, we addressed the following issues: (i) to establish a simple, validated screening tool to detect neuropathic pain (NeP) components in chronic LBP patients, (ii) to determine the prevalence of neuropathic pain components in LBP in a large-scale survey, and (iii) to determine whether LBP patients with an NeP component suffer from worse, or different, co-morbidities.

METHODS

In co-operation with the German Research Network on Neuropathic Pain we developed and validated the painDETECT questionnaire (PD-Q) in a prospective, multicentre study and subsequently applied it to approximately 8000 LBP patients.

RESULTS

The PD-Q is a reliable screening tool with high sensitivity, specificity and positive predictive accuracy; these were 84% in a palm-top computerised version and 85%, 80% and 83%, respectively, in a corresponding pencil-and-paper questionnaire. In an unselected cohort of chronic LBP patients, 37% were found to have predominantly neuropathic pain. Patients with NeP showed higher ratings of pain intensity, with more (and more severe) co-morbidities such as depression, panic/anxiety and sleep disorders. This also affected functionality and use of health-care resources. On the basis of given prevalence of LBP in the general population, we calculated that 14.5% of all female and 11.4% of all male Germans suffer from LBP with a predominant neuropathic pain component.

CONCLUSION

Simple, patient-based, easy-to-use screening questionnaires can determine the prevalence of neuropathic pain components both in individual LBP patients and in heterogeneous cohorts of such patients. Since NeP correlates with more intense pain, more severe co-morbidity and poorer quality of life, accurate diagnosis is a milestone in choosing appropriate therapy.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial

BACKGROUND

Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame.

OBJECTIVE

To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone.

DESIGN

Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment.

PARTICIPANTS

Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM).

MEASUREMENTS

Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups.

RESULTS

The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group.

CONCLUSIONS

There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.

Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders

Half of all outpatient encounters are precipitated by physical complaints, of which one third to one half are medically unexplained symptoms, and 20% to 25% are chronic or recurrent. Many of the patients suffer from one or more discrete symptoms, whereas others have functional somatic syndromes. Individual symptoms and somatic syndromes are associated with impaired quality of life, increased health care use, and diminished patient and provider satisfaction. This article provides an overview of (1) unexplained symptoms and somatization; (2) limitations of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in classifying somatoform disorders; (3) predictors of psychiatric comorbidity in patients who have physical symptoms; and (4) measurement and management of symptoms.

Routine PHQ-9 depression screening in home health care: depression, prevalence, clinical and treatment characteristics and screening implementation

This study aimed to examine: the prevalence and correlates of depression among adults age 65 and over on admission to diverse home health care programs; nurse compliance with routine screening using the PHQ-9; and concordance between the number of depressed individuals identified by the PHQ-9 and Medicare-mandated nursing assessment following targeted nurse training in identifying depression among the elderly using a standard diagnostic screen. Data are drawn from routine screening of 9,178 patients (a 77% screening compliance rate). Of all patients screened, 782 (8.5%) met criteria for probable major depression and 148 (1.6%) for mild depression. Concordance between nurse identified depression via PHQ-9 and OASIS depression assessment improved over that reported in previous studies. Findings suggest that the use of a routine screening tool for depression can be implemented with minimal in-house training and improves detection of depression among older adults with significant physical and functional impairment.

Responsiveness of the PHQ-9 to Psychopharmacological Depression Treatment

This is the first study that investigates the responsiveness of the Patient Health Questionnaire-9 (PHQ-9), a standard 9-item self-report depression scale, to antidepressant medication. Authors analyzed data from 1,788 depressed outpatients (66.8% women; mean age, 50.3 years), participating in a prospective, open-label, non-interventional, observational study of sertraline. On the 0-27-point PHQ-9 scale, the total sample gained 10.3 points at 12 weeks, corresponding to a standardized effect size of -1.85. With reference to two independent criterion standards, the PHQ-9 change scores were considerably greater in therapy responders than in nonresponders. The PHQ-9 was equally responsive in men and women. Therefore, the PHQ-9 qualifies as a practical tool for gauging response to pharmacological treatment in depressed patients.

Validity of the Patient Health Questionnaire-9 in assessing depression following traumatic brain injury

OBJECTIVE

To test the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) for diagnosing major depressive disorder (MDD) among persons with traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

PARTICIPANTS

135 adults within 1 year of complicated mild, moderate, or severe TBI.

MAIN OUTCOME MEASURES

PHQ-9 Depression Scale, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID).

RESULTS

Using a screening criterion of at least 5 PHQ-9 symptoms present at least several days over the last 2 weeks (with one being depressed mood or anhedonia) maximizes sensitivity (0.93) and specificity (0.89) while providing a positive predictive value of 0.63 and a negative predictive value of 0.99 when compared to SCID diagnosis of MDD. Pearson's correlation between the PHQ-9 scores and other depression measures was 0.90 with the Hopkins Symptom Checklist depression subscale and 0.78 with the Hamilton Rating Scale for Depression. Test-retest reliability of the PHQ-9 was r = 0.76 and kappa = 0.46 when using the optimal screening method.

CONCLUSIONS

The PHQ-9 is a valid and reliable screening tool for detecting MDD in persons with TBI.

Medical patients' attitudes toward emotional problems and their treatment. What do they really want?

BACKGROUND

Understanding medical patients' attitudes toward emotional problems and their management is crucial to overcoming obstacles to efficient depression treatment.

OBJECTIVE

To investigate attitudes toward emotional problems, psychotherapy, antidepressants, alternative treatment approaches, and self-management techniques in depressed and nondepressed medical outpatients.

DESIGN

Cross-sectional interview study, including quantitative and qualitative methods.

PATIENTS

Eighty-seven depressed subjects (mean age, 41.0 years; 66% female) and 91 nondepressed subjects (mean age, 41.4 years; 67% female) from 7 internal medicine outpatient clinics and 12 family practices (participation rate, 91%).

MEASUREMENTS

Depression diagnoses were established using a structured diagnostic interview, and patient attitudes were investigated with open-ended interview questions regarding treatment preferences, factors improving and impairing emotional well-being, and patients' self-management to improve well-being.

RESULTS

Among the depressed patients, psychotherapy was the most frequently preferred treatment (29%) and the most common factor reported to improve emotional well-being (36%). Twenty-two percent of the depressed patients desired depression treatment within their current medical system, but requested substantially more time to communicate with their physician. Antidepressants were rarely mentioned as a preferred treatment (6%) or factor improving well-being (11%). Thirty-eight percent of the depressed patients attributed their impaired mood to health problems. Compared with the depressed patients, the nondepressed controls preferred significantly less frequent depression-specific therapies.

CONCLUSIONS

The vast majority of medical outpatients prefer treatment approaches for emotional problems that go beyond antidepressant medication therapy. Health care providers should consider providing sufficient time to communicate with their patients, the strong preference for psychotherapy, and an appropriate treatment of comorbid physical conditions.

The Economics of Integrated Depression Care: The University of Michigan Study

A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care.

Efficacy, predictors of therapy response, and safety of sertraline in routine clinical practice: prospective, open-label, non-interventional postmarketing surveillance study in 1878 patients

BACKGROUND

It is well established that subjects participating in controlled clinical trials may not be representative of patients seen in actual practice. Given that efficacy and safety of sertraline have been investigated almost exclusively in controlled clinical trials, the aim of this study was to investigate efficacy, safety, and predictors of treatment response to sertraline in routine clinical practice.

METHODS

A total of 1878 depressed outpatients (69.5% female; mean age, 50.3 years) participated in this prospective, open-label, non-interventional, postmarketing surveillance study of sertraline. The primary study outcome was change in depression severity as assessed independently with the Patient Health Questionnaire (PHQ-9) depression scale and Clinical Global Impression (CGI) scales after 12 weeks of treatment. Stepwise logistic regression analyses were used to identify independent predictors of treatment response.

RESULTS

Using standard criteria to define clinical improvement, responder rates were 87.7% (PHQ-9) and 87.2% (CGI), respectively. Remission, i.e. a PHQ-9 score of 5 or below, occurred in 56.9% of patients. Independent baseline predictors of CGI treatment response were: non-chronic course of depression (OR=2.8, p < 0.001), non-psychiatric treatment setting (OR=2.5, p < 0.001), absence of comorbid physical disease (OR=1.9, p < 0.001), depression-related work disability (OR=1.9, p < 0.001), and no previous antidepressant medication (OR=1.5, p=0.03). Adverse events were reported by 4.8% of patients.

LIMITATIONS

Lack of a control group limits the conclusions that can be drawn from this study.

CONCLUSIONS

For treatment of depressive disorders in routine outpatient settings, sertraline is safe and efficacious. Patients without prior episodes of depression, without medical comorbidity, and those with higher levels of depression-related functional limitations are most likely to respond to sertraline treatment.

Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer

PURPOSE

To assess the prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer, receipt of antidepressant medications or counseling services, and correlates of depression.

PATIENTS AND METHODS

Study patients were 472 women receiving cancer care in an urban public medical center. Women had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IIIB). A diagnostic depression screen and baseline questionnaire were administered before or during active treatment or during active follow-up. Self-report data were collected on receipt of depression treatment, use of supportive counseling, pain and receipt of pain medication, functional status and well-being, and perceived barriers to cancer care.

RESULTS

Twenty-four percent of women reported moderate to severe levels of depressive disorder (30% of breast cancer patients and 17% of gynecologic cancer patients). Only 12% of women meeting criteria for major depression reported currently receiving medications for depression, and only 5% of women reported seeing a counselor or participating in a cancer support group. Neither cancer stage nor treatment status was correlated with depression. Primary diagnosis of breast cancer, younger age, greater functional impairment, poorer social and family well-being, anxiety, comorbid arthritis, and fears about treatment side effects were correlated with depression.

CONCLUSION

Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.

Detecting and monitoring depression with a two-item questionnaire (PHQ-2)

OBJECTIVE

This study evaluates the two-item Patient Health Questionnaire (PHQ-2) as a measure for diagnosing and monitoring depression.

METHODS

We assessed construct validity in a cross-sectional sample of 1619 medical outpatients (mean age 43+/-14 years, 64% female) by comparing the PHQ-2 to four longer self-report questionnaires. Criterion validity was established in a subsample of 520 participants with reference to the Structured Clinical Interview for DSM-IV (SCID). Sensitivity to change was investigated in a prospective study of 167 patients who completed the SCID both at baseline and the 1-year follow-up.

RESULTS

With reference to the SCID, the PHQ-2 had a sensitivity of 87% and a specificity of 78% for major depressive disorder and a sensitivity of 79% and a specificity of 86% for any depressive disorder. Its diagnostic performance was comparable with that of longer depression scales. PHQ-2 change scores accurately reflected improved, unchanged, and deteriorated depression outcomes.

CONCLUSION

The PHQ-2 performed favorably with respect to a standard diagnostic interview, as well as established depression scales and proved sensitive to change. Thus, the PHQ-2 appears promising as a brief multipurpose measure for detecting depression, grading its severity, and monitoring outcomes over time.