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

Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study

BACKGROUND

while it is well established that individual patient preferences regarding cardiopulmonary resuscitation (CPR) may change with time, the stability of population preferences, especially during periods of social and economic change, has received little attention.

OBJECTIVE

to elicit the resuscitation preferences of older Irish inpatients and to compare the results with an identical study conducted 15 years earlier.

METHODS

one hundred and fifty older medical inpatients awaiting discharge in a university teaching hospital or a district general hospital subjects were asked about resuscitation preferences. Results were compared to those elicited from a hundred subjects in 1992.

RESULTS

most patients (94%) felt it was a good idea for doctors to discuss CPR routinely with patients, compared with 39% in 1992. In their current health, 6% in 2007 and 76% in 1992 would refuse CPR. The independent predictors of refusal of CPR in current health on logistic regression were age and year of assessment. In the final model, those aged 75-84 years [OR 2.77 (95% CI 1.25-6.13), P = 0.02] and 85 years or more [OR 15.19 (4.26-54.15), P < 0.0001] were more likely than those aged 65-74 years (reference group) to refuse CPR. Those questioned in 2007 [OR 0.04 (0.02-0.81), P < 0.0001] were less likely than those questioned in 1992 (reference group) to refuse CPR.

CONCLUSIONS

there has been a significant shift in the attitudes of older Irish inpatients over 15 years towards favouring greater patient participation in decision making and an increased desire for resuscitation.

Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population

OBJECTIVE

There is a high prevalence of delirium in older medical intensive care unit (ICU) patients and delirium is associated with adverse outcomes. We need to identify modifiable risk factors for delirium, such as medication use, in the ICU. The objective of this study was to examine the impact of benzodiazepine or opioid use on the duration of ICU delirium in an older medical population.

DESIGN

Prospective cohort study.

SETTING

Fourteen-bed medical intensive care unit in an urban university teaching hospital.

PATIENTS

304 consecutive admissions age 60 and older.

INTERVENTIONS

None.

MAIN OUTCOME MEASUREMENTS

The main outcome measure was duration of ICU delirium, specifically the first episode of ICU delirium. Patients were assessed daily for delirium with the Confusion Assessment Method for the ICU and a validated chart review method. Our main predictor was receiving benzodiazepines or opioids during ICU stay. A multivariable model was developed using Poisson rate regression.

RESULTS

Delirium occurred in 239 of 304 patients (79%). The median duration of ICU delirium was 3 days with a range of 1-33 days. In a multivariable regression model, receipt of a benzodiazepine or opioid (rate ratio [RR] 1.64, 95% confidence interval [CI] 1.27-2.10) was associated with increased delirium duration. Other variables associated with delirium duration in this analysis include preexisting dementia (RR 1.19, 95% CI 1.07-1.33), receipt of haloperidol (RR 1.35, 95% CI 1.21-1.50), and severity of illness (RR 1.01, 95% CI 1.00-1.02).

CONCLUSIONS

The use of benzodiazepines or opioids in the ICU is associated with longer duration of a first episode of delirium. Receipt of these medications may represent modifiable risk factors for delirium. Clinicians caring for ICU patients should carefully evaluate the need for benzodiazepines, opioids, and haloperidol.

Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomised controlled trial protocol

BACKGROUND

Non-pharmacological, non-surgical interventions are recommended as the first line of treatment for osteoarthritis (OA) of the hip and knee. There is evidence that exercise therapy is effective for reducing pain and improving function in patients with knee OA, some evidence that exercise therapy is effective for hip OA, and early indications that manual therapy may be efficacious for hip and knee OA. There is little evidence as to which approach is more effective, if benefits endure, or if providing these therapies is cost-effective for the management of this disorder. The MOA Trial (Management of OsteoArthritis) aims to test the effectiveness of two physiotherapy interventions for improving disability and pain in adults with hip or knee OA in New Zealand. Specifically, our primary objectives are to investigate whether:1. Exercise therapy versus no exercise therapy improves disability at 12 months;2. Manual physiotherapy versus no manual therapy improves disability at 12 months;3. Providing physiotherapy programmes in addition to usual care is more cost-effective than usual care alone in the management of osteoarthritis at 24 months.

METHODS

This is a 2 x 2 factorial randomised controlled trial. We plan to recruit 224 participants with hip or knee OA. Eligible participants will be randomly allocated to receive either: (a) a supervised multi-modal exercise therapy programme; (b) an individualised manual therapy programme; (c) both exercise therapy and manual therapy; or, (d) no trial physiotherapy. All participants will continue to receive usual medical care. The outcome assessors, orthopaedic surgeons, general medical practitioners, and statistician will be blind to group allocation until the statistical analysis is completed. The trial is funded by Health Research Council of New Zealand Project Grants (Project numbers 07/199, 07/200).

DISCUSSION

The MOA Trial will be the first to investigate the effectiveness and cost-effectiveness of providing physiotherapy programmes of this kind, for the management of pain and disability in adults with hip or knee OA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ref: ACTRN12608000130369.

Test performance of two-question screening for postpartum depressive symptoms

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is commonly used to screen for postpartum depression, but it is difficult to consistently administer it to all mothers during busy well-child visits owing to the fact that it is time-consuming. The purpose of the present paper was to evaluate the performance of a concise, two-question screening tool in the detection of mothers with postpartum depressive symptoms who had a high EPDS score.

METHODS

The study involved 103 mothers attending a single hospital for 1 month well-child visits. The primary outcome measure was the detection of mothers with postpartum depressive symptoms, using the EPDS score as the reference standard. Visiting mothers were asked to complete both the EPDS questionnaire and a two-question questionnaire covering depressive mood and anhedonia while in the hospital waiting room. The sensitivity, specificity, predictive value, and likelihood ratio of the two-question instrument was evaluated using the EPDS as standard.

RESULTS

Taking EPDS as standard, sensitivity of the two-question instrument was 88% (95% confidence interval [CI]: 64-99%), specificity was 76% (95%CI: 65-84%), positive predictive value was 42% (95%CI: 26-59%), and negative predictive value was 97% (95%CI: 90-100%). The stratified likelihood ratios of each of the two-question instrument test scores 0, 1, and 2 were 0.2 (95%CI: 0.04-0.6), 3.4 (95%CI: 1.8-6.2) and 4.2 (95%CI: 1.5-12.3), respectively.

CONCLUSIONS

With the cut-off point set at 1, the two-question instrument had high sensitivity in detecting postpartum depressive symptoms at 1 month well-child visits. In primary care setting, negative result with the two-question instrument may be a good indicator of no need for further evaluation for postpartum depression.

Postpartum depression and help-seeking behavior

The objective of this analysis was to investigate the demographic differences between women who report postpartum depression symptoms (PPDS) and seek help versus those who report symptoms but who do not seek help, using data from the Utah Pregnancy Risk Assessment Monitoring System (PRAMS) 2004 dataset. Overall, 14.7% of Utah women reported experiencing PPDS in 2004. Sixty percent of the women who reported having PPDS did not seek help. Seeking help for depression during pregnancy was associated with help-seeking behavior postpartum (adjusted odds ratio [aOR] = 0.1; 95% confidence interval [CI], 0.04-0.2). Other factors associated with seeking help included having an infant admitted to the intensive care unit (aOR = 0.4; 95% CI, 0.2-0.9) and rural residency (aOR = 0.3; 95% CI, 0.2-0.7). Nonwhite women were 12.1 times (95% CI, 3.0-48.5) more likely to not seek help for depression compared to white women. Further, Hispanic women (aOR = 3.2; 95% CI, 1.3-8.1) and women who experienced emotional abuse had increased odds of not seeking help (aOR = 2.9; 95% CI, 1.3-6.2). Nearly 15% of Utah women in this study reported PPDS, yet fewer than half sought help. Target populations, such as nonwhite, Hispanic, emotionally abused, and urban women, have been identified for public health interventions.

A qualitative study of mild to moderate psychological distress during pregnancy

BACKGROUND

Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild-moderate psychological distress.

OBJECTIVE

This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care.

DESIGN

A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis.

SETTING

A large teaching maternity hospital in North West England.

PARTICIPANTS

Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care.

RESULTS

Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements.

CONCLUSIONS

Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have.

Frequent early discontinuation of SSRI prescribed by primary care physicians in young males in Japan

OBJECTIVE

In the present study, we tried to clarify the prevalence of selective serotonin reuptake inhibitor (SSRI) prescription and early discontinuation of SSRI in a outpatient unit where primary care physicians are working in Japan.

MATERIALS AND METHODS

Consecutive outpatients who newly visited the Department of General Medicine, Asahikawa Medical College Hospital, Asahikawa, Japan between April 2004 and March 2008 were analyzed. Each parameter such as age, sex, diagnosis, period of continuation of SSRI or reason why they discontinued SSRI was investigated.

RESULTS

Among 4670 patients, 126 patients (2.7%) had been prescribed SSRI because of depressive state (n=117) or panic disorder (n=9). Female patients with depression received SSRI (84/2714 = 3.10%) more frequently than male patients (33/1956 = 1.69%). Out of 117 patients with depression who had been prescribed SSRI, 28 (23.9%) patients discontinued SSRI within 4 weeks. Male patients (30.5%) discontinued SSRI within 4 weeks due to patient's decision more frequently than female patients (11.1%). The rate of patients who discontinued SSRI within 4 weeks due to patient's decision was particularly high (6/9; 67%) in male patients aged 20 to 29 years.

CONCLUSION

These results suggest for the first time that there is a high prevalence of early discontinuation of SSRI in young male patients in Japan.

Postpartum depressive symptoms and smoking relapse

BACKGROUND

Smokers with depressive symptoms are more likely to relapse after attempting to quit than those without depressive symptoms. Little is known about the relationship between depressive symptoms and relapse during the postpartum period; thus the aim of the present study is to assess the relationship between postpartum smoking relapse and depressive symptoms.

METHODS

Analysis of 2004 Pregnancy Risk Assessment Monitoring System (PRAMS) data from women in 16 states who reported smoking 3 months before pregnancy and reported abstinence from smoking during the last 3 months of pregnancy (n=2566). For women experiencing postpartum depressive symptoms, chi-square tests were computed for homogeneity of distribution between two groups (sustained abstinence versus relapsed) and an OR for relapsing during the postpartum period. Potential confounders, including demographic characteristics, intensity of smoking before pregnancy, and time since delivery, were computed.

RESULTS

Compared to women who did not experience postpartum depressive symptoms, women who did were 1.86 (95% CI=1.31, 2.65) times as likely to relapse during the postpartum period. After adjusting for demographic characteristics, intensity of smoking, and time since delivery, the association decreased slightly (adjusted OR=1.77, 95% CI=1.21, 2.59).

CONCLUSIONS

Women who quit smoking during pregnancy may be more likely to relapse if they experience depressive symptoms. Further research is needed into the screening and treatment of postpartum depressive symptoms as a possible method for preventing postpartum smoking relapse.

Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9

PURPOSE

Postpartum depression affects up to 22% of women who have recently given birth. Most mothers are not screened for this condition, and an ideal screening tool has not been identified. This study investigated (1) the validity of a 2-question screen and the 9-item Patient Health Questionnaire (PHQ-9) for identifying postpartum depression and (2) the feasibility of screening for postpartum depression during well-child visits.

METHODS

Study participants were English-literate mothers registering their 0- to 1-month-old infants for well-child visits at 7 family medicine or pediatric clinics. They were asked to complete questionnaires during well-child visits at 0 to 1, 2, 4, 6, and 9 months postpartum. Each questionnaire included 2 depression screens: the 2-question screen and the PHQ-9. The mothers also completed the depression component of the Structured Clinical Interview for DSM-IV (SCID) initially, and again at a subsequent interval if either screening result was positive for depression.

RESULTS

The response rate was 33%. Of the 506 women who participated, 45 (8.9%) had major depression (ie, they had a positive result on the SCID). The screen sensitivities/specificities over the course of the study were 100%/44% with the 2-question screen, 82%/84% with the PHQ-9 using simple scoring, and 67%/92% with the PHQ-9 using complex scoring. In addition, the corresponding values for the first 2 items of the PHQ-9 (ie, the 2-item Patient Health Questionnaire or PHQ-2) were 84%/79%. Some 38% of women completed their 2- to 6-month questionnaires during well-child visits; the rest completed them by mail (29%) or telephone (33%).

CONCLUSIONS

The 2-question screen was highly sensitive and the PHQ-9 was highly specific for identifying postpartum depression. These results suggest the value of a 2-stage procedure for screening for postpartum depression, whereby a 2-question screen that is positive for depression is followed by a PHQ-9. These screens can be easily administered in primary care clinics; feasibility of screening during well-child visits was moderate but may be better in clinics using a mass-screening approach.

Diabetes mellitus and co-morbid depression: treatment with milnacipran results in significant improvement of both diseases (results from the Austrian MDDM study group)

Co-morbid depression is common in patients with diabetes mellitus and has a negative impact on diabetes self-care, adherence to treatment and the development of complications. Effective treatment of depression has been associated with improvement in metabolic parameters. We evaluated the feasibility of a two question screen for co-morbid depression in diabetic patients and studied the effect of the serotonin norepinephrine reuptake inhibitor antidepressant, milnacipran, on metabolic and psychological parameters in 64 type 2 diabetic patients with co-morbid depression. The severity of depression was evaluated using the Beck Depression Inventory (BDI). Patients received milnacipran, and diabetes was treated according to the guidelines of the Austrian Diabetes Association in a 6-month open label study. Metabolic parameters and BDI were measured at baseline and after 1, 3 and 6 months. 46 patients satisfied the criteria for an antidepressant response (reduction of baseline BDI score of at least 50%). Hemoglobin A1c, fasting blood glucose, body mass index, total and LDL-cholesterol and serum triglyceride levels were all significantly decreased in these patients at the end of the study whereas in antidepressant non-responders these parameters were not significantly changed. Diagnosis and treatment of depression is an important factor for the improvement of metabolic control in patients with type 2 diabetes and co-morbid depression.

Perinatal depression

Despite the fact that childbirth is often a time of joy for a family, the occurrence of perinatal depression is very common. It is essential for the depressed patient to be identified and treated during the pregnancy or postpartum because the failure to treat can have significant morbidity and even mortality for the woman and the child. Despite various concerns several antidepressant medications are generally safe and, after a careful risk/benefit analysis and informed consent, indicated for the severely depressed pregnant or lactating patient.

Long-term smoking cessation outcomes among childhood cancer survivors in the Partnership for Health Study

PURPOSE

Partnership for Health (PFH) was found to increase smoking cessation among smokers in the Childhood Cancer Survivors Study (CCSS) at the 8- and 12-month postbaseline follow-up. This report provides outcomes at 2 to 6 years postbaseline; the primary outcome is a four-category smoking status variable (quit at all follow-ups, quit at final follow-up only, smoker at all follow-ups, and smoker at final follow-up only); quit attempts among those who reported smoking at the final follow-up is a secondary outcome.

METHODS

PFH was a randomized control trial with two conditions, peer phone counseling (PC) and self-help (SH), that involved smokers (n = 796) enrolled in the CCSS cohort.

RESULTS

Long-term quit rates were higher in PC versus SH participants. Long-term smoking cessation outcomes were lower among those who were nicotine dependent, of lower educational levels, and among men, and were higher among those who used nicotine replacement therapy and who had higher levels of situational self-efficacy. There were no significant differences in relapse rates between conditions or in quit attempts among continued smokers.

CONCLUSION

Cessation rates continue to be significantly higher among participants in the PC condition versus SH, although the differences were not large. This article highlights differences in long-term engagement with smoking cessation among those who received the intervention.

Screening for depressive symptoms in an online sample of men who have sex with men

Depression is a debilitating disorder and relatively high rates have been reported in studies of men who have sex with men (MSM). This study was undertaken to assess the utility of screening for, and characteristics associated with, depressive symptoms in an online survey of MSM. In 2003-2004, an online cross-sectional study was conducted among 2,964 MSM from the US and Canada. Using the two-item Patient Health Questionnaire (PHQ-2), 18% of the study participants screened positive for depressive symptoms within the past three months. Characteristics associated with a positive PHQ-2 screen for depressive symptoms in multivariate analysis included: having less than a high school or college degree; being single (not having a primary male partner) or being married to a woman; being HIV-positive; and not having recent sex. Additionally, among men who screened positive on the PHQ-2, predictors of not having treatment from a mental health provider in the past year were: low education; being black/African American/Canadian or Hispanic; and having no primary care provider. The Internet is a viable medium to reach and screen men at-risk for depression. Future work is needed for online outreach and connection to offline assessment as well as intervention.

The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors

BACKGROUND

Tobacco use, unhealthy diet, physical inactivity, and risky alcohol use are leading causes of preventable death. As there are many barriers that prevent primary care clinicians from effectively assisting patients with these behaviors, connecting patients with health behavior resources may reduce these unhealthy behaviors.

METHODS

A new adjunct role in primary care practice, the community health educator referral liaison (CHERL), was tested in 15 practices in three Michigan communities. All practices were advised how to access this liaison, and nine practices were randomly selected to receive support to develop a systematic referral process. Adult patients needing improvement in at least one of the four unhealthy behaviors were eligible for referral. The CHERL contacted referred patients by telephone; assessed health risks; provided health behavior-change counseling, referral to other resources, or both; and sent patient progress reports to referring clinicians. Data were collected from February 2006 through July 2007.

RESULTS

The CHERLs received 797 referrals over 8 months, a referral rate of 0%-2% per practice. Among referred patients, 55% enrolled, and 61% of those participated in multiple-session telephone counseling; 85% were referred to additional resources. Among patients enrolling, improvements (p<0.001) were reported at 6 months for BMI, dietary patterns, alcohol use, tobacco use, health status, and days of limited activity in the past month.

CONCLUSIONS

The results of this study suggest that through relationships with practices, patients, and community resources, these liaisons successfully facilitated patients' behavior change. The CHERL role may fill a gap in promoting healthy behaviors in primary care practices and merits further exploration.

A proposed approach to suicide prevention in Japan: the use of self-perceived symptoms as indicators of depression and suicidal ideation

The incidence of suicide in Japan has increased markedly in recent years, making suicide a major social problem. Between 1997 and 2006, the annual number of suicides increased from 24,000 to 32,000; the most dramatic increase occurred in middle-aged men, the group showing the greatest increase in depression. Recent studies have shown that prevention campaigns are effective in reducing the total number of suicides in various areas of Japan, such as Akita Prefecture. Such interventions have been targeted at relatively urban populations, and national data from public health and clinical studies are still needed. The Japanese government has established the goal of reducing the annual number of suicides to 22,000 by 2010; toward this end, several programs have been proposed, including the Mental Barrier-Free Declaration, and the Guidelines for the Management of Depression by Health Care Professionals and Public Servants. However, the number of suicides has not declined over the past 10 years. Achieving the national goal during the remaining years will require extensive and consistent campaigns dealing with the issues and problems underlying suicide, as well as simple screening methods for detecting depression. These campaigns must reach those individuals whose high-risk status goes unrecognized. In this review paper, we propose a strategy for the early detection of suicide risk by screening for depression according to self-perceived symptoms. This approach was based on the symposium Approach to the Prevention of Suicide in Clinical and Occupational Medicine held at the 78th Conference of the Japanese Society of Hygiene, 2008.

Race-ethnic differences in factors associated with inhaled steroid adherence among adults with asthma

RATIONALE

Adherence to inhaled corticosteroid (ICS) medication is known to be low overall, but tends to be lower among African-American patients when compared with white patients.

OBJECTIVES

To understand the factors that contribute to ICS adherence among African-American and white adults with asthma.

METHODS

Eligible individuals had a prior diagnosis of asthma, one or more ICS prescriptions, and were members of a large health maintenance organization in southeast Michigan. Individuals were sent a survey that included questions about internal factors (e.g., patient beliefs, knowledge, and motivation) and external factors (e.g., socioeconomic status, barriers to care, social support, and stressors) potentially related to ICS adherence. Adherence was calculated using electronic prescription and fill data. Stepwise regression was used to identify factors associated with adherence before and after stratifying by race-ethnicity.

MEASUREMENTS AND MAIN RESULTS

Surveys were returned by 1,006 (56.3%) of 1,787 eligible patients. Adjusting for internal factors, but not external factors, diminished the relationship between race-ethnicity and ICS adherence. Among African-American patients, readiness to take ICS medication was the only internal or external factor significantly associated with ICS adherence; it explained 5.6% of the variance in adherence. Among white patients, perceived ICS necessity, ICS knowledge, doctors being perceived as the source of asthma control, and readiness to take medication were the internal factors associated with ICS adherence; these accounted for 19.8% of the variance in adherence.

CONCLUSIONS

Factors associated with ICS adherence appear to differ between African-American and white patients, suggesting that group-specific approaches are needed to improve adherence.

Screening older people with musculoskeletal pain for depressive symptoms in primary care

BACKGROUND

Older patients presenting to GPs with musculoskeletal pain are at high risk of having concurrent depression.

AIM

To investigate the performance of ultra-short (1-4 items tools) screening questions used during the consultation, and through a patient questionnaire to detect depressive symptoms among older adults presenting with musculoskeletal pain to general practice.

DESIGN OF STUDY

Cross-sectional survey, linked GP consultation data.

SETTING

General practices in central Cheshire, UK.

METHOD

Consecutive patients aged > or =50 years presenting with non-inflammatory musculoskeletal pain were eligible to participate. GPs screened all patients in the consultation for the presence of depressive symptoms using two questions. All patients were sent a postal questionnaire within 1 week of consultation containing the Hospital Anxiety and Depression Scale and the written version of the depression screening questions.

RESULTS

The total number of patients included in the study was 428. In total, 35.5% of consulters had comorbid depressive symptoms, with 13.5% experiencing moderate or severe symptoms. Just over half of participants (n = 218/242; 51.4%) screened positive on self-administered screening at home compared with only 78 (20.8%) on GP-administered screening in the consultation. There was little difference between GP-administered and self-administered screening in the probability of depressive symptoms among those who screened positive with regard to exhibiting signs of having depressive symptoms.

CONCLUSION

Older patients consulting their GP with musculoskeletal pain frequently have comorbid mental ill health. Ultrashort depression screening questions administered during the consultation miss a large number of those with depressive symptoms, including six out of eight patients with severe symptoms. An improvement in the performance of screening questions in this patient group or narrowing the definition of 'high risk' from all patients aged > or =50 years presenting with musculoskeletal pain could help to improve detection.

Challenges and opportunities for preventing depression in the workplace: a review of the evidence supporting workplace factors and interventions

OBJECTIVE

To explore the literature regarding prevention of depression in the workplace.

METHOD

Literature review of what the author believes are seminal articles highlighting workplace factors and interventions in preventing depression in the workplace.

RESULTS

Employees can help prevent depression by building protective factors such as better coping and stress management skills. Employees may be candidates for depression screening if they have certain risk factors such as performance concerns. Organizational interventions such as improving mental health literacy and focusing on work-life balance may help prevent depression in the workplace but deserve further study.

CONCLUSION

A strategy to prevent depression in the workplace can include developing individual resilience, screening high-risk individuals and reducing that risk, improving organizational literacy, and integrating workplace and health care systems to allow access to proactive quality interventions.

Burnout and patient care in junior doctors in Mexico City

BACKGROUND

Burnout is known to occur in public service workers leading to a reduction in effectiveness at work.

AIM

To estimate the prevalence of burnout in junior doctors and its impact on patient care.

METHODS

A cross-sectional study of junior doctors at three hospitals in Mexico City was conducted. Measures used included the Maslach Burnout Inventory (MBI), measuring depersonalization (DP), emotional exhaustion (EE) and personal achievement (PA), a questionnaire about patient care practices and attitudes and one on sociodemographic characteristics. Logistic regression analysis was used to assess the association between burnout and suspected risk factors.

RESULTS

A total of 312 junior doctors participated (response rate 65%). In total, 57% were male and the average age was 28. Average scores in MBI subscales were EE: 18.2, DP: 6.9 and PA: 37.6. Burnout prevalence was 40% (126). Junior doctors with burnout were more likely to report suboptimal patient care practices occurring monthly (OR 5.5; 95% CI 2.7-11.2) and weekly (OR 5.2; 95% CI 1.6-16.3). The logistic regression model for burnout included shifts lasting >12 h, current depression, former major depression, first- or second-year junior doctors, male gender and single status.

CONCLUSIONS

Burnout was most strongly associated with shifts >12 h and with both current and previous depression. Reported suboptimal patient care was also associated with working shifts of >or=12 h. Burnout may be adversely affecting junior doctors' health and their patients' care.

Effectiveness of a multifactorial cardiovascular risk reduction clinic for diabetes patients with depression

INTRODUCTION

Depression may attenuate the effects of diabetes interventions. Our ongoing Cardiovascular Risk Reduction Clinic simultaneously addresses hyperglycemia, hypertension, smoking, and hyperlipidemia. We examined the relationship between depression diagnosis and responsiveness to the Cardiovascular Risk Reduction Clinic.

METHODS

We studied Cardiovascular Risk Reduction Clinic participants with diabetes who had a depression diagnosis and those with no mental health diagnosis. Our outcome measure was change in 20-year cardiovascular mortality risk according to the United Kingdom Prospective Diabetes Study (UKPDS) score.

RESULTS

Of 231 participants, 36 (15.6%) had a depression diagnosis. Participants with a depression diagnosis had a higher baseline UKPDS score (56.8 [SD 21.3]) than participants with no mental health diagnosis (49.5 [SD 18.7], P = .04). After Cardiovascular Risk Reduction Clinic participation, mean UKPDS scores did not differ significantly (37.8 [SD 15.9] for no mental health diagnosis and 39.4 [SD 18.6] for depression diagnosis). Mean UKPDS score reduction was 11.6 [SD 15.6] for no mental health diagnosis compared with 18.4 [SD 15.9] for depression diagnosis (P = .03). Multivariable linear regression that controlled for baseline creatinine, number of Cardiovascular Risk Reduction Clinic visits, sex, and history of congestive heart failure showed significantly greater improvement in UKPDS score among participants with a depression diagnosis (beta = 6.0, P = .04) and those with more Cardiovascular Risk Reduction Clinic visits (beta = 2.1, P < .001).

CONCLUSION

The Cardiovascular Risk Reduction Clinic program reduced cardiovascular disease risk among patients with diabetes and a diagnosis of depression. Further work should examine how depressive symptom burden and treatment modify the effect of this collaborative multifactorial program and should attempt to determine the durability of the effect.

Identifying postpartum depression: are 3 questions as good as 10?

BACKGROUND

Postpartum depression is the most common medical problem that new mothers face. Anxiety is a more prominent feature of postpartum depression than of depression that occurs at other times in life. Routine, universal screening significantly improves detection in primary health care settings. Thus, an ultrabrief scale that could be incorporated into a general health survey or interview would be useful.

OBJECTIVE

We tested the hypothesis that, during the first 6 postpartum months, the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale is a better ultrabrief depression screener than 2 Edinburgh Postpartum Depression Scale questions that are almost identical to the widely used Patient Health Questionnaire.

METHODS

A cohort of 199 14- to 26-year-old participants in an adolescent-oriented maternity program completed the Edinburgh Postpartum Depression Scale at well-child visits during the first 6 postpartum months. Three subscales of the Edinburgh Postpartum Depression Scale were examined as ultrabrief alternatives: the anxiety subscale (3 items; Edinburgh Postpartum Depression Scale-3), the depressive symptoms subscale (7 items; Edinburgh Postpartum Depression Scale-7), and 2 questions that resemble the Patient Health Questionnaire (Edinburgh Postpartum Depression Scale-2). The reliability, stability, and construct validity of the Edinburgh Postpartum Depression Scale and 3 subscales were compared. Criterion validity was assessed by comparison with a score of >/=10 on the full, 10-item Edinburgh Postpartum Depression Scale.

RESULTS

A total of 41 mothers (20.6%) met study criteria for referral for evaluation of depression (Edinburgh Postpartum Depression Scale-10 score >/= 10). The Edinburgh Postpartum Depression Scale-3 exhibited the best screening performance characteristics, with sensitivity at 95% and negative predictive value at 98%. It identified 16% more mothers as depressed than the Edinburgh Postpartum Depression Scale did. The performance of the Edinburgh Postpartum Depression Scale-2 was markedly inferior, with sensitivity at 48% to 80%. Moreover, the Edinburgh Postpartum Depression Scale-2 was unreliable for mothers who had not been depressed in the past.

CONCLUSION

The brevity, reliability, and operating characteristics of the Edinburgh Postpartum Depression Scale-3 make it an attractive postpartum depression screening tool for primary health care settings in which the goal is to detect depression, not to assess its severity. Validation by diagnostic psychiatric interview is needed.

The Lausanne cohort Lc65+: a population-based prospective study of the manifestations, determinants and outcomes of frailty

Background

Frailty is a relatively new geriatric concept referring to an increased vulnerability to stressors. Various definitions have been proposed, as well as a range of multidimensional instruments for its measurement. More recently, a frailty phenotype that predicts a range of adverse outcomes has been described. Understanding frailty is a particular challenge both from a clinical and a public health perspective because it may be a reversible precursor of functional dependence. The Lausanne cohort Lc65+ is a longitudinal study specifically designed to investigate the manifestations of frailty from its first signs in the youngest old, identify medical and psychosocial determinants, and describe its evolution and related outcomes.

Methods/Design

The Lc65+ cohort was launched in 2004 with the random selection of 3054 eligible individuals aged 65 to 70 (birth year 1934–1938) in the non-institutionalized population of Lausanne (Switzerland). The baseline data collection was completed among 1422 participants in 2004–2005 through questionnaires, examination and performance tests. It comprised a wide range of medical and psychosocial dimensions, including a life course history of adverse events. Outcomes measures comprise subjective health, limitations in activities of daily living, mobility impairments, development of medical conditions or chronic health problems, falls, institutionalization, health services utilization, and death. Two additional random samples of 65–70 years old subjects will be surveyed in 2009 (birth year 1939–1943) and in 2014 (birth year 1944–1948).

Discussion

The Lc65+ study focuses on the sequence "Determinants → Components → Consequences" of frailty. It currently provides information on health in the youngest old and will allow comparisons to be made between the profiles of aging individuals born before, during and at the end of the Second World War.

The relationship between maternal and child symptom change in community mental health

The mental health of mothers and children are closely linked. This study examined the relationship between child and maternal symptom change during a period in which children participated in community mental health treatment. Symptom change was measured using the Child Behavior Checklist for children and the Beck Depression Inventory for Mothers. Results indicate that mothers whose children improve in community mental health treatment are significantly more likely to report a reduction in maternal depressive symptoms than mothers whose children do not improve. Implications of these findings for mental health service settings are discussed.

Strategies for identifying and channeling patients for depression care management

OBJECTIVE

To determine optimal methods of identifying enrollees with possible depression for additional depression screening in the context of a care management program for chronically ill Medicare recipients.

STUDY DESIGN

Observational analysis of telephone and mail survey and claims data collected for the Medicare Health Support (MHS) program.

METHODS

This study examines data from 14,902 participants with diabetes mellitus and/or congestive heart failure in the MHS program administered by Green Ribbon Health, LLC. Depression screening was performed by administering a 2-item screen (the Patient Health Questionnaire 2 [PHQ-2]) by telephone or by mail. Additional information about possible depression was drawn from International Classification of Diseases, Ninth Revision (ICD-9) depression diagnoses on claims and from self-reported use of antidepressant medications. We evaluated positive depression screens using the PHQ-2 administered via telephone versus mail, examined variations in screener-positive findings by care manager, and compared rates of positive screens with antidepressant use and with claims diagnoses of depression.

RESULTS

Almost 14% of participants received an ICD-9 diagnosis of depression during the year before program enrollment; 7.1% reported taking antidepressants, and 5.1% screened positive for depression on the PHQ-2. We found substantial variation in positive depression screens by care manager that could not be explained by case mix, prior depression diagnoses, or current depression treatment. After adjusting for demographic and clinical differences, the PHQ-2-positive screen rates were 6.5% by telephone and 14.1% by mail (P <.001).

CONCLUSION

A multipronged effort composed of mail screening (using the PHQ-2), self-reported antidepressant use, and claims diagnoses of depression may capture the greatest number of enrollees with possible depression.

Efficiency of a two-item pre-screen to reduce the burden of depression screening in pregnancy and postpartum: an IMPLICIT network study

OBJECTIVE

Systems for efficient case finding of women with major depression during pregnancy and postpartum are needed. Here we assess the diagnostic accuracy of a modified 2-item patient health questionnaire (PHQ-2) as a pre-screen in assessing depression.

METHODS

Cross-sectional assessments at 15 weeks' gestation (n = 414), 30 weeks' gestation (n = 334), and 6 to 16 weeks postpartum (n = 193) among women from a diverse set of races/ethnicities, participating in the IMPLICIT maternal care quality improvement network. The Edinburgh Postnatal Depression Scale score (>or=13) was used as the criterion measure for the PHQ-2.

RESULTS

A positive 2-item screen had sensitivity of 93%, 82%, and 80% and specificity of 75%, 80%, and 86% for Edinburgh Postnatal Depression Scale score of >or=13 for assessment at 15 and 30 weeks gestational age and postpartum, respectively. The positive/negative predictive values for the PHQ-2 were 44/98, 24/91, and 30/98 for each time point, respectively. Areas under the receiver operating characteristic curve analysis suggested that 2-item assessments at each time point had approximately equal diagnostic validity.

CONCLUSIONS

Two questions were efficient to rule out depression and reduced the need for further screening of approximately 60% to 80% of women, depending on the point in pregnancy or postpartum. A diagnostic interview follow-up of women screening positive is still required.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Differences in the patterns of health care system distrust between blacks and whites

CONTEXT

Although health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked to multidimensional trust or distrust.

OBJECTIVE

To test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than to competence distrust.

DESIGN

Cross-sectional telephone survey.

PARTICIPANTS

Two hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department of a large, urban Mid-Atlantic health system.

PRIMARY MEASURES

Race, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence distrust.

RESULTS

In univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs 24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03-6.58), but there was no significant association between race and competence distrust.

CONCLUSIONS

Racial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and for the development and testing of novel strategies for reducing these disparities.

Screening for maternal depression in a low education population using a two item questionnaire

OBJECTIVE

To assess a two-question screening tool, the Patient Health Questionnaire-2 (PHQ-2), for identifying depressive symptomatology in economically disadvantaged mothers of children in pediatric settings and to explore risk factors associated with a positive depression screen.

METHODS

A convenience sample of mothers was enrolled at an inner city well-child clinic with children age 3 days to 5 years. The PHQ-2 and Edinburgh Postnatal Depression Scale (EPDS) (as reference scale) were completed.

RESULTS

Ninety-four mothers participated. Agreement of the PHQ-2 and EPDS was moderate. The sensitivity of the PHQ-2 for identifying a positive screen on the EPDS was 43.5%; the specificity was 97.2%. The sensitivity of the PHQ-2 was higher for mothers with education beyond high school compared to those with less education. Perceived lack of support with child care and having two or more children were associated with a positive screen. The rate of positive screen was similar for mothers with infants and with older children.

CONCLUSION

Given the low sensitivity of the PHQ-2 in lower educated mothers, additional research in populations with varying sociodemographic characteristics is indicated. Similar rates of symptoms for mothers within and beyond the postpartum period and mothers previously screened support the need for periodic screening.

Headache chronification: screening and behavioral management of comorbid depressive and anxiety disorders

A growing body of literature implicates comorbid psychopathology as a risk factor for chronification of headache. Despite their prevalence, comorbid psychiatric conditions are not routinely assessed among headache patients. Consequently, efforts to manage such conditions are not commonplace either. The present article briefly reviews a variety of strategies and measures for psychiatric screening among headache patients, focusing primarily on those that have been validated in medical settings, that can be administered quickly, and that involve minimal associated costs. We also describe basic strategies for behavioral management of comorbid depression and anxiety in headache patients.

Religion, risk, and medical decision making at the end of life

OBJECTIVE

The purpose of this study is to present empirical evidence about whether religious patients are more or less willing to undergo the risks associated with potentially life-sustaining treatment.

METHODS

At least every 4 months 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease were asked questions about several dimensions of religiousness and about their willingness to accept potentially life-sustaining treatment.

RESULTS

Results were mixed but persons who said that during their illness they grew closer to God (odds ratio [OR] = 1.79; 95% confidence intervals [CI] = 1.15, 2.78) or those grew spiritually (OR = 1.61; 95% CI = 1.03, 2.52) were more willing to accept risk associated with potentially life-sustaining treatment than were persons who did not report such growth.

DISCUSSION

Not all dimensions of religiousness have the same association with willingness to undergo potentially life-sustaining treatment. Seriously ill older, religious patients are not especially predisposed to avoid risk and resist treatment.

Association between serum levels of C-reactive protein and personality traits in women

BACKGROUND

While low-grade inflammation has consistently been observed in subjects with depression, studies on the possible relationship between inflammation and other aspects of brain function are as yet sparse. In this study, we aimed to investigate the possible association between serum levels of the inflammation marker C-reactive protein (CRP) and personality traits.

METHODS

In this study, serum levels of high-sensitivity CRP were determined by ELISA in a population of 270 42-year-old women recruited from the population registry who had been assessed using the Temperament and Character Inventory. Self-reported previous or ongoing depression was also recorded. Unpaired two-tailed t-tests were used for comparison between two groups and correlations were evaluated by the calculation of Pearson's r-coefficient.

RESULTS

The temperament trait harm avoidance was positively (r = 0.227, p < 0.05) and the character trait self-directedness was negatively (r = -0.261, p < 0.01) associated with serum levels of CRP (p-values corrected for multiple comparisons). The correlations between the personality traits and CRP were observed also after exclusion of subjects reporting ongoing depression (n = 26). Whereas women reporting ongoing depression showed significantly increased levels of CRP as compared to non-depressed women (n = 155), women reporting a history of depression displayed no significant difference in CRP levels as compared to women that reported that they had never been depressed.

CONCLUSION

Serum levels of CRP in women was found to be associated with the personality traits harm avoidance and self-directedness. In addition, moderately elevated levels may be a state dependent marker of depression.

High impact of depression in heart failure: Early diagnosis and treatment options

Depressive syndromes in chronic heart failure (CHF) are common and are associated with a poorer prognosis, particularly with increased morbidity and mortality. CHF as a severe physical disorder may increase the risk of developing depressive syndromes or vice-versa as an interaction of possible common psycho-organic etiological aspects. Depression in CHF is associated with impaired NYHA status and daily activities, resulting in enhanced hospitalisation rates and medical costs with a great impact on long-term health. Only a fraction of comorbid patients receives antidepressants. Therefore, identification of risk factors and prevention by optimizing cardiological and psychiatric therapeutic strategies appear essential for these patients. Early diagnosis and treatment of both CHF and depression may prevent further pathophysiological effects on the heart and brain. This review gives a comprehensive overview of the occurrence, risk factors and shared pathophysiology of depression in CHF, and focuses on improving insufficient diagnosis and therapy of depression. Special attention is given on the cardiac effects of psychopharmacological and alternate non-pharmacological antidepressant therapy in CHF. Recommendations are made for treating depression in CHF patients for a better prevention of this disabling physical and psychosocial condition.

Factor structure and diagnostic efficiency of the BDI-II in treatment-seeking substance users

Screening instruments are needed to rapidly and efficiently identify depression in drug and alcohol users. The Beck Depression Inventory-Second Edition (BDI-II) has excellent validity in psychiatric, normative and primary care samples, but its diagnostic efficiency has not been examined in substance users. Using a large sample of treatment-seeking substance users and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) to establish diagnosis, we examined the factor structure of the BDI-II and its ability to detect clinical depression, defined as the presence of a Major Depressive Disorder (MDD) or substance-induced depression. A three-factor structure provided the best fit, and the diagnostic efficiency of the BDI-II was moderate, and independent of gender and substance of abuse. Subscores had lower diagnostic efficiency than the BDI-II total score. A range of possible cutoff scores with corresponding sensitivity, specificity, positive predictive power and negative predictive power is provided to aid clinicians and researchers in choosing the optimal parameters for their screening needs.

Getting beyond "Don't ask; don't tell": an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan

OBJECTIVES

We sought to evaluate outcomes of the Veterans Administration (VA) Afghan and Iraq Post-Deployment Screen for mental health symptoms.

METHODS

Veterans Administration clinicians were encouraged to refer Iraq or Afghanistan veterans who screened positive for posttraumatic stress disorder, depression, or high-risk alcohol use to a VA mental health clinic. Multivariate methods were used to determine predictors of screening, the proportions who screened positive for particular mental health problems, and predictors of VA mental health clinic attendance.

RESULTS

Among 750 Iraq and Afghanistan veterans who were referred to a VA medical center and 5 associated community clinics, 338 underwent postdeployment screening; 233 (69%) screened positive for mental health problems. Having been seen in primary care (adjusted odd ratio [AOR]=13.3; 95% confidence interval [CI]=8.31, 21.3) and at a VA community clinic (AOR=3.28; 95% CI=2.03, 5.28) predicted screening. African American veterans were less likely to have been screened than were White veterans (AOR=0.45; 95% CI=0.22, 0.91). Of 233 veterans who screened positive, 170 (73%) completed a mental health follow-up visit.

CONCLUSIONS

A substantial proportion of veterans met screening criteria for co-occurring mental health problems, suggesting that the VA screens may help overcome a "don't ask, don't tell" climate that surrounds stigmatized mental illness. Based on data from 1 VA facility, VA postdeployment screening increases mental health clinic attendance among Iraq and Afghanistan veterans.

Elucidating the relationship between negative affectivity and symptoms: the role of illness-specific affective responses

BACKGROUND

More than 20 years of research confirm a positive association of trait negative affect (NA) with reports of physical symptoms. As the mechanisms underlying the association of trait NA and symptom reporting have not been identified, the meaning of the association remains unclear.

PURPOSE

We attempted to clarify the processes underlying this association by examining the relationship of trait NA and illness-specific worry to both vague, general symptoms and illness-specific symptoms. We tested the hypothesis that trait NA has both a "biasing" effect when ambiguous symptoms are interpreted as a sign of physical illness and an "accuracy" effect on the reports of illness-specific symptoms mediated by illness-specific worry.

METHOD

We examined the relationship of trait and state NA to symptoms reports in both cross-sectional and longitudinal data from inner-city adults with moderate and severe asthma.

RESULTS

Whereas high levels of trait NA were associated with reports of both asthma and nonasthma symptoms, only the relationship of trait NA to symptoms specific to asthma was mediated by asthma worry. In addition, these data showed that trait NA was not associated with the misattribution of symptoms to disease.

CONCLUSIONS

We concluded that NA motivates individuals, through asthma worry, to be more aware of illness-specific symptoms and correctly report and attribute these symptoms to asthma.

Mood disorder screening among adult emergency department patients: a multicenter study of prevalence, associations and interest in treatment

OBJECTIVE

Planning for emergency department (ED)-initiated interventions for mood disorders requires confirmation of prevalence data, identification of predictors, and an assessment of patient interest in such interventions.

METHOD

For two 24-h periods, consecutive patients aged 18+ years presenting to four Boston EDs were enrolled. We collected data on demographics, medical history, psychiatric history, healthcare utilization, depressive symptoms, manic symptoms and interest in hypothetical ED-initiated interventions. Patients with severe illness, altered mental status or severe emotional disturbance were excluded.

RESULTS

Of 476 screened patients, 152 (32%; 95% CI, 28-36%) screened positive for depression and 17 (4%; 95% CI, 2-6%) for mania. Depressed patients were more likely than nondepressed patients (all P<.01) to have income <20,000/year (43% vs. 25%), a substance abuse history (19% vs. 5%), a chronic medical condition (67% vs. 53%), use tobacco (42% vs. 22%), have at least one ED visit in the past 6 months (76% vs. 56%) and have at least one hospitalization for substance abuse in the past 6 months (5% vs. 1%). About 50% of patients who screened positive for any mood disorder were interested in at least one ED-based intervention.

CONCLUSION

ED patients screening positive for mood disorder symptoms are likely to have complex psychiatric, medical and social histories, which will be necessary to take into account when designing ED-initiated interventions.

Recognition of depression by non-psychiatric physicians--a systematic literature review and meta-analysis

BACKGROUND

Depression, with up to 11.9% prevalence in the general population, is a common disorder strongly associated with increased morbidity. The accuracy of non-psychiatric physicians in recognizing depression may influence the outcome of the illness, as unrecognized patients are not offered treatment for depression.

OBJECTIVES

To describe and quantitatively summarize the existing data on recognition of depression by non-psychiatric physicians.

METHODS

We searched the following databases: MEDLINE (1966-2005), Psych INFO (1967-2005) and CINAHL (1982-2005). To summarize data presented in the papers reviewed, we calculated the Summary receiver operating characteristic (ROC) and the summary sensitivity, specificity and odds ratios (ORs) of recognition, and their 95% confidence intervals using the random effects model.

MEASUREMENTS AND MAIN RESULTS

The summary sensitivity, specificity, and OR of recognition using the random effects model were: 36.4% (95% CI: 27.9-44.8), 83.7% (95% CI: 77.5-90.0), and 4.0 (95% CI: 3.2-4.9), respectively. We also calculated the Summary ROC. We performed a metaregression analysis, which showed that the method of documentation of recognition, the age of the sample, and the date of study publication have significant effect on the summary sensitivity and the odds of recognition, in the univariate model. Only the method of documentation had a significant effect on summary sensitivity, when the age of the sample and the date of publication were added to the model.

CONCLUSION

The accuracy of depression recognition by non-psychiatrist physicians is low. Further research should focus on developing standardized methods of documenting non-psychiatric physicians' recognition of depression.

Brief screening for adolescent depressive symptoms in the emergency department

BACKGROUND

Depression is the most common psychiatric disorder among adolescents and is more prevalent among those seeking care in the emergency department (ED). However, adolescents are rarely screened for depressive symptoms in the pediatric emergency department (PED).

OBJECTIVES

To evaluate the sensitivity and specificity of one- and two-item screens for depressive symptoms compared to the 20-question Center for Epidemiologic Studies Depression Scale (CESD) among adolescents seeking care in a PED.

METHODS

This was a cross-sectional study of a convenience sample of adolescents 12-17 years old presenting to an urban PED with subcritical illness or injury. Participants completed three screening instruments: the two-question screen, the single-question screen, and the CESD.

RESULTS

A total of 321 patients were approached to enter the study, of whom 212 (66%) agreed to participate. Seventy-eight (37%) of the study participants screened positive for depression on the CESD using a cutoff score of >or=16. The two-question screen had a sensitivity of 78% (95% confidence interval [CI] = 73% to 84%) and specificity of 82% (95% CI = 77% to 87%) for depressive symptoms compared with the CESD. The single-question screen had a sensitivity of 56% (95% CI = 50% to 63%) and specificity of 93% (95% CI = 90% to 96%) compared with the CESD.

CONCLUSIONS

The two-question screen is a sensitive and specific initial screen for depressive symptoms in adolescents being seen in the PED. This quick, simple instrument would be ideal for use in the busy PED setting and would allow clinicians to identify adolescents who require more extensive psychiatric evaluation.

Improving the efficiency of screening for major depression in people with spinal cord injury

BACKGROUND/OBJECTIVE

To investigate the metric properties, relative efficiency, sensitivity and specificity, and positive predictive value of a short form of the Patient Health Questionnaire-9 (PHQ-9) that may be used as a screening test for depression.

METHODS

Data from the National Spinal Cord Injury Statistical Center Database containing 3,652 records with complete data for the PHQ-9 were analyzed using Confirmatory Factor Analysis, Item Response Theory Graded Response Model analysis, and sensitivity and specificity analysis of classification.

RESULTS

A scale comprised of items 1, 2, and 6 from the PHQ-9 has a relative efficiency of 0.66 compared to the 9-item scale. Using this 3-item scale and a cutoff score of 3 or more provides specificity of 0.93 and sensitivity of 0.87; a cutoff of 4 provides specificity of 0.95 and sensitivity of 0.82. The shorter version of the scale reduces the effect of response bias caused by gender. The relative efficiency of the 9-item scale is 0.88 for women compared to men; the 3-item scale increases the relative efficiency to 0.93.

CONCLUSION

A 3-item scale provides adequate information for clinical screening purposes. Cutoff scores of either 3 or 4 are acceptable and present options for decision making within a particular clinical setting. Additionally, the 3-item scale reduces the effect of gender of the respondent on the score obtained.

Depression in the patient with COPD

This paper explores the recent literature surrounding comorbid depression and COPD. The literature reveals a high prevalence of depression in patients with COPD and some evidence that the depression is a result of the disease. The literature highlights the negative impact of depression on quality of life and a possible impact on mortality. Depression also negatively impacts on compliance and smoking cessation. Treatment of depression in COPD, particularly by cognitive behavioral therapy, has positive impact on quality of life. Tricyclic antidepressants have a positive impact on mood and COPD, but side effects limit their use. The advent of the new antidepressants may improve acceptability and outcomes, but the research is yet to be undertaken. Physical rehabilitation may have a positive impact on mood. This paper highlights the difficulty in screening for depression in patients with COPD due to the overlap of symptoms between the two diseases. Despite the difficulties, it is important to recognize and treat depression in patients with COPD because of the significant likelihood of improvement in quality of life.

Indicators of a major depressive episode in primary care patients with a chief complaint of headache

OBJECTIVE

To identify the indicators of major depressive episode (MDE) in primary care patients with a chief complaint of headache.

BACKGROUND

MDE is very frequent among headache patients in primary care. However, primary care physicians often fail to recognize the coexistence of MDE.

METHODS

A total of 177 consecutive new adult patients who visited 19 primary care clinics from January 2002 to December 2002 with a chief complaint of headache were enrolled in the study. All subjects completed a self-report questionnaire that included questions regarding the duration and severity of their headaches, changes in headache severity, and other symptoms. The questionnaire also identified distressed high utilizers (patients who consulted different doctors for the same episode of an illness, without being referred). MDE was diagnosed using a module of the mini international neuropsychiatric interview (MINI). To identify potential indicators of depression, both univariate analysis and multiple logistic regression analysis were performed.

RESULTS

Forty-five of 177 patients (25.4%) fulfilled the diagnostic criteria for MDE. Univariate analysis revealed that severe headache, longer duration of headaches, multiple somatic symptoms, and being a distressed high utilizer were associated with MDE. Multiple logistic regression analysis revealed that patients with headaches lasting 6 months or longer and those with multiple somatic symptoms were more likely to be suffering from MDE (adjusted odds ratios: 3.1, 95% CI: 1.7-10.6; and 3.9, 95% CI: 1.2-8.1, respectively).

CONCLUSIONS

MDE is highly prevalent in headache patients visiting a primary care setting. Multiple somatic symptoms and longer duration (> or =6 months) of headaches are particularly useful indicators of MDE.

Outcomes of a quality improvement project integrating mental health into primary care

OBJECTIVE

Depression is commonly seen, but infrequently adequately treated, in primary care clinics. Improving access to depression care in primary care clinics has improved outcomes in clinical trials; however, these interventions are largely unstudied in clinical settings. This study examined the effectiveness of a quality improvement project improving access to mental healthcare in a large primary care clinic.

METHODS

A before-after study evaluating the efficacy of the integration of a primary mental healthcare (PMHC) clinic into a large primary care clinic at the White River Junction, Vermont Veterans Affairs Medical Center (VAMC). In the before period (2003), a traditional referral and schedule model was used to access mental healthcare services. Patients who had screened positive for depression using a depression screen for 6 months after entry into either model were retrospectively followed. VA clinics without a PMHC were used as a control. The proportion of patients who received any depression treatment and guideline-adhering depression treatment in each model was compared, as well as the volume of patients seen in mental health clinics and the wait time to be seen by mental health personnel.

RESULTS

383 and 287 patients screened positive for depression at VAMC and the community-based outreach clinic, respectively. Demographics of the before and after cohorts did not differ. The PMHC model was associated with a greater proportion of patients who had screened positive for depression obtaining some depression treatment (52.3% vs 37.8%; p<0.001), an increase in guideline-adherent depression treatment for depression (11% vs 1%; p<0.001).

CONCLUSIONS

Implementation of the PMHC model was associated with more rapid and improved treatment for depression in the population of patients who screened positive for depression. More widespread implementation of this model should be investigated.

Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology

BACKGROUND

Studies show that 30-50% of medical oncologists experience burnout, but little is known about burnout among surgical oncologists. We hypothesized that wide variation in burnout and career satisfaction exist among surgical oncologists.

PATIENTS AND METHODS

In April 2006, members of the Society of Surgical Oncology (SSO) were sent an anonymous, cross-sectional survey evaluating demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments.

RESULTS

Of the 1519 surgical oncologists surveyed, 549 (36%) responded. More than 50% of respondents worked more than 60 hours per week while 24% performed more than 10 surgical cases per week. Among the respondents, 72% were academic surgical oncologists and 26% spent at least 25% of their time to research. Seventy-nine percent stated that they would become a surgical oncologist again given the choice. Overall, 28% of respondents had burnout. Burnout was more common among respondents age 50 years or younger (31% vs 22%; P = .029) and women (37% vs 26%; P = .031). Factors associated with a higher risk of burnout on multivariate analysis were devoting less than 25% of time to research, had lower physical QOL, and were age 50 years or younger. Burnout was associated with lower satisfaction with career choice.

CONCLUSIONS

Although surgical oncologists indicated a high level of career satisfaction, nearly a third experienced burnout. Factors associated with burnout in this study may inform efforts by program directors and SSO members to promote personal health and retain the best surgeons in the field of surgical oncology. Additional research is needed to inform evidenced-based interventions at both the individual and organizational level to reduce burnout.