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

The optometrist’s role in the management of clinical depressive disorders

The long-term relationship that optometrists have with their patients enables them to note changes in affect, behavior, and functioning that could indicate serious mental illness, including clinical depression. Given the significant disability associated with this disease and the increased risk of suicide, appropriate management is critical. This article reviews the diagnosis and treatment of clinical depression and its appropriate referral.

Under-diagnosis of common chronic diseases: prevalence and impact on human health

AIMS

The disability-adjusted life years (DALY) and its components, namely the years lived with disability and the years of life lost, are measures of the impact of disease on human health. Our impression was that several common chronic diseases responsible for many DALYs are frequently under-diagnosed.

METHODS

We attempted to summarise data regarding the under-diagnosis of common chronic diseases of the developed world, which are associated with considerable mortality and/or disability. We searched PubMed and Current Contents to identify relevant studies (1980-2005). Two reviewers extracted data concerning DALYs and prevalence of under-diagnosis of common chronic diseases.

RESULTS

Studies regarding the first 15 diseases (or group of diseases) based on DALYs were reviewed. The under-diagnosis of common chronic diseases in the developed world ranges from about 20% for dementia and cirrhosis to 90% for depression and osteoarthritis. The delay in the prompt diagnosis and initiation of treatment is associated with increased morbidity and mortality for most of the reviewed diseases.

CONCLUSION

The available evidence suggests that the prevalence of under-diagnosis of common chronic diseases is considerable. Physicians should be aware of the prevalence of under-diagnosis of chronic diseases and its impact on human health.

Psychosocial correlates of depression symptoms during the third trimester of pregnancy

OBJECTIVE

To explore the psychosocial correlates of depression symptoms during the third trimester of pregnancy.

DESIGN

Cross-sectional design guided by Selye's theory of stress.

SETTING

Prenatal care provider offices or mutually agreeable locations in the Pacific Northwest.

PARTICIPANTS

One hundred thirty-nine women in their third trimester of pregnancy. The majority was Caucasian and married. Fifty-two of the participants (38%) had scores greater than or equal to 16 on the Centers for Epidemiologic Studies Depressed Mood Scale.

MAIN OUTCOME MEASURE

The Centers for Epidemiologic Studies Depressed Mood Scale.

RESULTS

Stepwise linear regression indicated that 46% of the variance of third-trimester depressive symptoms was due to brief and intermittent negative mood states that occurred primarily during the first trimester, a lack of marital satisfaction and social support, and gravida. Lifetime abuse did not contribute significantly to third-trimester depression symptoms.

CONCLUSIONS

One third of the sample reported subclinical levels of depression symptoms. Prenatal care providers may want to consider these minor and brief mood changes as predictive of depression symptoms later in pregnancy, particularly when experienced during the first trimester.

Maternal depression and infant temperament characteristics

One hundred-thirty-nine women participated in this longitudinal study from the third trimester of pregnancy through 8-months postpartum. Women completed depression scales at several time points and rated their infant's characteristics and childcare stress at 2- and 6-months postpartum. Mothers' reports of infant temperament were significantly different for depressed and non-depressed mothers, with depressed mothers reporting more difficult infants at both measurement points. These differences remained after controlling for histories of maternal abuse or prenatal anxiety, which occurred more often in the depressed mothers. There were no significant differences in childcare stress or perceived support between the groups. Infant temperament and childcare stress did not change over time. Recommendations for practice include consistent ongoing evaluations of the "goodness of fit" within the dyad and exploring interventions for depressed mothers that provide guidance about interactions with their infants and the appropriateness of the infant behaviors.

One question as a screening instrument for depression in people with multiple sclerosis

OBJECTIVE

To evaluate how effectively one question 'Are you depressed?' works as a screening tool for depression in people with multiple sclerosis.

DESIGN

The results from a single question were compared with formal clinical diagnosis and the classification from a standard questionnaire.

SETTING

Estonian Multiple Sclerosis Centre, from October 2001 to April 2002.

SUBJECTS

One hundred and thirty-four consecutive inpatients with multiple sclerosis.

INTERVENTION

During two weeks of inpatient stay the mood disorder was analysed. On the basis of clinical interview and Beck Depression Inventory the diagnosis of depression was confirmed.

MAIN MEASURES

Beck Depression Inventory and structured clinical interview.

RESULTS

Fifty-seven per cent (77/134) of people with multiple sclerosis answered 'Yes' to the question 'Are you depressed?'. The diagnosis of depression was confirmed in 94% (72/77) of people with multiple sclerosis and not confirmed in 6% (5/77). Hence, the screening test sensitivity was 91%. Forty-three per cent (57/134) answered 'No'; 70% (40/57) did not have depression. In this case the sensitivity was 54%. In this group 30% (17/57) were actually depressed according to tests and clinical impression. The age, sex, duration of disease, cognitive abilities and physical disability did not influence consistency of the answers with test results and clinical opinion.

CONCLUSIONS

One-question interview is a useful tool for screening for depression in people with multiple sclerosis as it confirms existing depression (sensitivity 91%), but the results should be treated with caution if the person denies mood problems.

The impact of increased body mass index on systemic lupus erythematosus: data from LUMINA, a multiethnic cohort (LUMINA XLVI) [corrected]

OBJECTIVE

The aim of this study was to examine the impact of an increased body mass index (BMI) on disease activity, damage accrual, fatigue, self-reported health-related quality of life (HRQOL), and fibromyalgia in patients with lupus using longitudinal data from LUMINA, a large multiethnic cohort.

METHODS

SLE patients (>/=4 ACR revised criteria), </=5 years disease duration at entry into the cohort (T0), of Hispanic (from Texas or from the Island of Puerto Rico), African American, or white ethnicity were included. BMI was ascertained at T0 or first recorded. The average scores from all visits for disease activity (SLAM-R), self-reported HRQOL (physical and mental component summary measures of the SF-36) and fatigue (Fatigue Severity Scale), the score at last visit for damage accrual (SLICC Damage Index), and fibromyalgia (ACR criteria), if present at any visit, were examined for their association with an increased BMI by univariable and multivariable analyses.

RESULTS

Three-hundred sixty-four patients were included; 28% were obese (BMI >/=30 kg/m). An increased BMI was associated with older age, less social support, higher degree of helplessness, depression, more abnormal illness-related behaviors, poorer self-reported HRQOL, fatigue, and fibromyalgia, but not with disease activity or damage accrual by univariable analyses. In multivariable analyses, BMI was independently associated with fibromyalgia but not with disease activity, fatigue, or self-reported HRQOL.

CONCLUSIONS

An increased BMI is independently associated with presence of fibromyalgia but not with disease activity, damage accrual, fatigue or self-reported quality of life in patients with SLE. Optimizing weight merits investigation to see if it can significantly impact this pervasive SLE-associated manifestation.

Screening for depression among patients with multiple sclerosis: two questions may be enough

BACKGROUND

Depression among patients with multiple sclerosis (MS) is common and has a significant impact on quality of life. As many as two-thirds of depressed MS patients receive no treatment for their depression. While guidelines for depression management suggest screening, the only validated screening tools are questionnaires, which have not been widely implemented in practice. This is the first study on the effectiveness of using two questions assessing mood and anhedonia (loss of interest or pleasure) in screening for major depressive disorder (MDD) in MS.

METHODS

MS patients under the care of neurologists were recruited from a large health maintenance organization (HMO). The MDD module of the Structured Clinical Interview for the DSM-IV and screening questions was administered.

RESULTS

Of the 260 participants, 26% met the criteria for MDD. Among patients with MDD, 67% received no anti-depressant medication. The MDD screen identified 99% (95% CI: 91-100%) of cases.

DISCUSSION

A brief, two question screen is reliable in identifying MS patients with MDD. This suggests that asking these two brief questions could identify almost all MS patients meeting MDD criteria, with minimal numbers of false positives.

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.

A shot in the dark: failing to recognize the link between physical and mental illness

A 74-year-old widowed white man with chronic rheumatoid arthritis presented with nausea and weight loss. He was diagnosed with failure to thrive and admitted for hydration. Misoprostol was determined to be the etiology of his symptoms and he was discharged home. Three days later, he killed himself with a gunshot to the head. Clinicians often fail to recognize those at high risk for suicide. Suicidal risk is increased in both psychiatric and physical illness, and particularly when both are present. Psychiatric illness, particularly depression, often underlies chronic medical illness. The purpose of this case report is to remind health care providers of the strong association between depression and chronic medical illness, and to consider this in all patients, including those who present solely with physical symptoms. Recognizing this association and screening for it, as recommended by the U.S. Preventive Services Task Force, may prevent the unnecessary tragedy of suicide.

Recognition of depression in older medical inpatients

BACKGROUND

Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression.

OBJECTIVES

(1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression.

METHODS

In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression.

RESULTS

Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0-37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9-98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition.

CONCLUSION

Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used.

Electrostimulating device in the management of xerostomia

INTRODUCTION

The present study was undertaken to evaluate the safety and effectiveness of a recently developed electrostimulating device mounted on an individualized intra-oral removable appliance.

MATERIALS AND METHODS

The device, containing electrodes, a wetness sensor, an electronic circuit and a power source, was tested on patients with xerostomia in a crossover, randomized, sham-controlled, double-blinded, multicenter study. Electrical stimulation and also sham were delivered during 10 min to the oral mucosa, in the mandibular third molar region. Oral dryness was measured by the sensor. As the primary outcome, sensor dryness and xerostomia symptom changes as a result of device wearing were assessed, and compared between active and sham modes. In addition, side-effects were recorded.

RESULTS

Electrostimulation resulted in a significant decrease in sensor dryness, leading to a beneficial effect on patients' subjective condition. No significant side-effects were observed.

Do brief measures of readiness to change predict alcohol consumption and consequences in primary care patients with unhealthy alcohol use?

BACKGROUND

Assessing readiness to change is recommended as part of brief interventions for patients with unhealthy alcohol use. However, the utility and predictive validity of readiness measures have not been well established.

METHODS

In a prospective cohort study, we assessed primary care patients with unhealthy alcohol use (past-month drinking of risky amounts, or any amount and an affirmative response to CAGE alcohol screening questionnaire) and reassessed them 6 months later. At study entry, we assessed readiness to change using 1 multi-item measure of stage of change, and 5 single-item measures (readiness per se, importance of changing, confidence in ability to change, intention to cut down, intention to abstain). Outcomes included alcohol consumption and alcohol-related consequences. Multivariable regression models were fit for each measure of readiness and each outcome.

RESULTS

Of 312 patients with unhealthy alcohol use, 228 (73%) were assessed at study entry and 6 months later and had complete data. Among readiness measures, only confidence and intention to abstain (1 point changes on single-item measures) were associated with consumption 6 months later: less heavy episodic drinking [adjusted odds ratio (AOR) 0.88, 95% CI 0.80-0.98 and AOR 0.79, 0.64-0.98, respectively], and less drinking of risky amounts (AOR 0.89, 0.79-1.00 and AOR 0.78, 0.62-0.98, respectively). Intention to abstain was also associated with more abstinence (AOR 1.43, 1.09-1.88). Single-item measures of readiness, importance, and intention to cut down were significantly associated with higher odds of alcohol consequences. Greater confidence (single item) was associated with a lower odds of any consequences (AOR 0.88, 0.79-0.98).

CONCLUSIONS

Greater readiness, as measured by several brief assessments, was associated with more consequences and was not predictive of consumption. However, assessing confidence in the ability to change one's alcohol use may have a role in predicting subsequent decreases in both consumption and consequences in primary care patients.

Changes in preferences for life-sustaining treatment among older persons with advanced illness

BACKGROUND

There are conflicting assumptions regarding how patients' preferences for life-sustaining treatment change over the course of serious illness.

OBJECTIVE

To examine changes in treatment preferences over time.

DESIGN

Longitudinal cohort study with 2-year follow-up.

PARTICIPANTS

Two hundred twenty-six community-dwelling persons age > or =60 years with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease.

MEASUREMENTS

Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would: a) undergo high-burden treatment at a given likelihood of death and b) undergo low-burden treatment at a given likelihood of severe disability, versus a return to current health.

RESULTS

There was little change in the overall proportions of participants who would undergo therapy at a given likelihood of death or disability from first to final interview. Diversity within the population regarding the highest likelihood of death or disability at which the individual would undergo therapy remained substantial over time. Despite a small magnitude of change, the odds of participants' willingness to undergo high-burden therapy at a given likelihood of death and to undergo low-burden therapy at a given likelihood of severe cognitive disability decreased significantly over time. Greater functional disability, poorer quality of life, and lower self-rated life expectancy were associated with decreased willingness to undergo therapy.

CONCLUSIONS

Diversity among older persons with advanced illness regarding treatment preferences persists over time. Although the magnitude of change is small, there is a decreased willingness to undergo highly burdensome therapy or to risk severe disability in order to avoid death over time and with declining health status.

Perimenopause and depression: strength of association, causal mechanisms and treatment recommendations

Perimenopause represents a significant transition in a woman's life. The evidence to support an association between perimenopause and depression is mixed, yet recent prospective studies have provided stronger evidence to support such an association. Interpretation of study data are complicated by methodological issues, such as a lack of standard definition for perimenopause or depression, reducing comparability. A variety of causal factors, including psychological, genetic and physiological, have been implicated in depression during perimenopause, which lends weight to a multifactorial model. Physicians should consider initiating dialogue about menopause and symptom relief at age 40 and screening perimenopausal women for depressive symptoms. Selective serotonin reuptake inhibitors are a first line of treatment for depression, but hormone therapy could be considered for women experiencing menopausal symptoms unless there are contraindications. Future research should focus on establishing temporality and studying these potential relationships among women of different ethnicities.

Validity of the Patient Health Questionnaire 2 (PHQ-2) in Identifying Major Depression in Older People

OBJECTIVES

To determine the performance of the Patient Health Questionnaire 2 (PHQ-2) against the criterion standard for diagnosing major depression, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and to examine its performance across age, sex, and racial/ethnic groups.

DESIGN

Cross-sectional observational study.

SETTING

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (2001/02), a nationally representative survey of the noninstitutionalized U.S. household population.

PARTICIPANTS

The 8,205 adults aged 65 and older who participated in NESARC.

MEASUREMENTS

The PHQ-2's criterion validity (sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) against the DSM-IV) and construct validity (Spearman correlations between the PHQ-2 and the six scales of the Medical Outcomes Study 12-item Short Form Questionnaire (SF-12)) were calculated.

RESULTS

The PHQ-2's criterion validity for major depression was good (sensitivity=100%, specificity=77%, AUC=0.88). Its sensitivity was 100% for each subgroup. Specificity increased with age, was higher for men than for women, and differed across racial and ethnic groups. For the total sample and each sex, all six SF-12 scales were significantly lower in people who tested positive using the PHQ-2. For each age and racial or ethnic group, most of the six scales differed significantly between those who tested positive and tested negative.

CONCLUSION

The PHQ-2 is a valid screening tool for major depression in older people but should be followed by a more-comprehensive diagnostic process. Although its specificity differs by age, sex, and racial and ethnic groups, these differences appear to be of little clinical significance.

Sensitivity and specificity of a two-question screening tool for depression in a specialist palliative care unit

OBJECTIVES

The primary objective in this study is to determine the sensitivity and specificity of a two-item screening interview for depression versus the formal psychiatric interview, in the setting of a specialist palliative in-patient unit so that we may identify those individuals suffering from depressive disorder and therefore optimise their management in this often-complex population.

METHODS

A prospective sample of consecutive admissions (n = 167) consented to partake in the study, and the screening interview was asked separately to the formal psychiatric interview.

RESULTS

The two-item questionnaire, achieved a sensitivity of 90.7% (95% CI 76.9-97.0) but a lower specificity of 67.7% (95% CI 58.7-75.7). The false positive rate was 32.3% (95% CI 24.3-41.3), but the false negative rate was found to be a low 9.3% (95% CI 3.0-23.1). A subgroup analysis of individuals with a past experience of depressive illness, (n = 95), revealed that a significant number screened positive for depression by the screening test, 55.2% (16/29) compared to those with no background history of depression, 33.3% (22/66) (P = 0.045).

CONCLUSION

The high sensitivity and low false negative rate of the two-question screening tool will aid health professionals in identifying depression in the in-patient specialist palliative care unit. Individuals, who admit to a previous experience of depressive illness, are more likely to respond positively to the two-item questionnaire than those who report no prior history of depressive illness (P = 0.045).

Orientations in adolescent use of information and communication technology: a digital divide by sociodemographic background, educational career, and health

AIMS

The role of information and communication technology (ICT) in adolescents' lives was studied, with emphasis on whether there exists a digital divide based on sociodemographic background, educational career, and health. The assumption was that some groups of adolescents use ICT more so that their information utilization skills improve (computer use), while others use it primarily for entertainment (digital gaming, contacting friends by mobile phone).

METHODS

Data were collected by mailed survey from a nationally representative sample of 12- to 18-year-olds (n=7,292; response 70%) in 2001 and analysed using ANOVA.

RESULTS

Computer use was most frequent among adolescents whose fathers had higher education or socioeconomic status, who came from nuclear families, and who continued studies after compulsory education. Digital gaming was associated with poor school achievement and attending vocational rather than upper secondary school. Mobile phone use was frequent among adolescents whose fathers had lower education or socioeconomic status, who came from non-nuclear families, and whose educational prospects were poor. Intensive use of each ICT form, especially of mobile phones, was associated with health problems. High social position, nuclear family, and a successful educational career signified good health in general, independently of the diverse usage of ICT.

CONCLUSIONS

There exists a digital divide among adolescents: orientation to computer use is more common in educated well-off families while digital gaming and mobile phone use accumulate at the opposite end of the spectrum. Poorest health was reported by mobile phone users. High social background and success at school signify better health, independently of the ways of using ICT.

An examination of depression through the lens of spinal cord injury. Comparative prevalence rates and severity in women and men

PURPOSE

This study describes the prevalence of probable major depressive disorder (MDD) as well as other depressive disorders (ODD) and severity of depressive symptoms in a national sample of women with spinal cord injury (SCI) and compares them with a case-matched sample of men with SCI.

METHODS

A sample of 585 women was drawn and case-matched with men from the SCI Model System National SCI Database according to level/completeness of injury, follow-up year, and age. The outcome measure of depression was the Patient Health Questionnaire.

MAIN FINDINGS

Prevalence rates for women were 7.9% for probable MDD and 9.7% for ODD; rates for men were 9.9% and 10.3%, respectively. Logistic regression revealed that women who were divorced or at year 1 follow-up had a higher odds of having probable MDD (odds ratio [OR], 3.4 and 2.9, respectively). Employed women and men had significantly lower odds of probable MDD (OR, 0.274 and 0.358, respectively). Statistically significant differences were not found in gender comparisons for either probable MDD or symptom severity, which also were not associated with injury characteristics.

CONCLUSION

The most significant, and unexpected, research finding is the absence of gender differences in probable MDD and symptom severity. Results challenge notions that depression will necessarily follow SCI; that injury characteristics determine the development and severity of depression; and that women experience a greater burden of depression than men. The main clinical implication is that depression screening and referral should be a routine feature of health care for women living with SCI, as well as for their male counterparts. Furthermore, nearly one fourth of women and men reported experiencing some or greater difficulty in daily life and relationships in the absence of probable depressive disorder, warranting monitoring of subsyndromal depression as well.

Learning by doing: a novel approach to improving general practitioners' diagnostic skills for common mental disorders

INTRODUCTION

Two strategies have been proposed to increase the rather low recognition rate of common mental disorders in primary care: (1) the use of screening instruments and (2) extensive psychiatric training for general practitioners. We have chosen a "middle-of-the-road" approach to teach general practitioners by means of a time-saving psychiatric training programme how to make their own psychiatric diagnoses. This pilot study aimed at assessing the acceptance of this programme, its impact on general practitioners' knowledge of 12 ICD-10 disorders - depressive, anxiety and alcohol-related disorders - and the short-term persistence of the knowledge acquired.

METHODS

The training programme consisted of two 3-hour sessions four weeks apart. An educational instrument, a short interview named TRIPS (Training for Interactive Psychiatric Screening), a shortened and adapted form of PRIME-MD, was used to train single-handed general practitioners in Vienna, Austria. TRIPS had to be used by the participants in daily practice in between sessions. Five weeks after the second training session a follow-up evaluation was held to assess the persistence of the knowledge acquired. The perceived usefulness of TRIPS was assessed by a short questionnaire. Knowledge was assessed by a separate 15-item questionnaire.

RESULTS

Of the 31 participating general practitioners 26 attended all three sessions. There was a significant increase in the mean number of correctly answered questions between baseline (5.5 of 15) and session two (9.8; p<0.0001), and a further increase between the second and the follow-up session (11.3; p<0.05). Also, general practitioners rated TRIPS as a practical and useful tool for family practice and stated that its use met with patients' approval.

CONCLUSION

The format chosen was successful in its intended educational endpoints. According to participants TRIPS is appropriate for the family practice situation and is accepted by patients.

Dopamine receptor genes (DRD2, DRD3 and DRD4) and gene-gene interactions associated with smoking-related behaviors

Cigarette smoking, like many addictive behaviors, has a genetic component, and the dopamine D2-like receptor genes (DRD2, DRD3 and DRD4) are candidates for contributing to these behaviors. Phenotypic information concerning smoking-related behaviors from a nationally representative sample of research volunteers was analyzed for association with polymorphisms in these genes. Genotype status at the DRD2 intron 2 simple tandem repeat was related to cigarettes per day (P = 0.035) and heaviness of smoking index (P = 0.049). The presence of the glycine allele at the S9G polymorphism of the DRD3 gene was associated with frequency/quantity measures of smoking [log-transformed time to first cigarette (P = 0.031) and heaviness of smoking index (P = 0.035)]. There was a trend for DRD4 long alleles of the variable number of tandem repeats polymorphism to be associated with reduced severity of three withdrawal symptoms [desire/craving (P = 0.054); anger/irritability (P = 0.10); and trouble sleeping (P = 0.068)]. Interactions between genotypes at all three genes were associated with nervousness (P = 0.020) and trouble sleeping (P = 0.015). An interaction between DRD2 and DRD3 was found for trouble concentrating (P = 0.020). These relationships present possible dopamine-related responses to nicotine that warrant further study.

Screening for depression in an urban pediatric primary care clinic

OBJECTIVES

The goals were to estimate the prevalence of parental depressive symptoms among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, and positive and negative predictive values of a very brief screen for parental depression.

METHODS

A total of 216 mothers (because 96% of caregivers were mothers, we use this term) bringing in children <6 years of age for child health supervision completed a parent screening questionnaire in a primary care clinic. The parent screening questionnaire, a brief screen for psychosocial problems developed for the study, includes 2 questions on depressive symptoms. Mothers then completed the computerized study protocol within 2 months. This included the parent screening questionnaire as well as the Beck Depression Inventory II. Different combinations of the depression questions were evaluated against Beck Depression Inventory II clinical cutoff values.

RESULTS

Twelve percent of the mothers met the Beck Depression Inventory II clinical cutoff value for at least moderate depressive symptoms. There was moderate stability of the screening questions. When a positive response to either or both of the 2 questions was considered, the sensitivity was 74%, the specificity was 80%, the positive predictive value was 36%, and the negative predictive value was 95%.

CONCLUSIONS

Maternal depressive symptoms are prevalent. A very brief screen can identify reasonably those who could benefit from additional evaluation and possible treatment. This should benefit mothers, families, and children.

Anxiety and stress reduction in medical education: an intervention

OBJECTIVES

To assess the effectiveness of a stress reduction elective on Year 2 medical students and to assess the sustainability of any noted improvement.

METHODS

A new elective entitled 'Mind-Body Medicine: an Experiential Elective' was offered to Year 2 medical students. It was based on a course developed by the Center for Mind-Body Medicine. Enrolled students were surveyed on the first (time 1) and last (time 2) days of the elective and again 3 months later (time 3). Four validated self-report instruments were used to examine effects on anxiety, stress, mood states and depression. A comparison group of non-enrolled classmates completed the same instruments during the same timeframes. The study began in autumn 2004 and ended in June 2005.

RESULTS

Participating students had higher initial anxiety scores than students in the comparison group. Anxiety in the study group declined significantly during the course, with enrolled students becoming indistinguishable from non-enrolled counterparts. These decreased anxiety levels were sustained for 3 months following the conclusion of the course.

CONCLUSIONS

This elective was successful in attracting students who were more anxious than their peers. Enrolees had higher baseline anxiety levels than their peers. The course decreased anxiety levels. The significant drop in anxiety scores of the study group suggests that this mind-body elective was an effective way to decrease anxiety in these pre-clinical medical students. Decreases in anxiety were sustained 3 months after the course ended, indicating that the benefits of the course may be longlasting.

How do distress and well-being relate to medical student empathy? A multicenter study

OBJECTIVE

To determine whether lower levels of empathy among a sample of medical students in the United States are associated with personal and professional distress and to explore whether a high degree of personal well-being is associated with higher levels of empathy.

DESIGN

Multi-institutional, cross-sectional survey.

SETTING

All medical schools in Minnesota (a private medical school, a traditional public university, and a public university with a focus in primary care).

PARTICIPANTS

A total of 1,098 medical students.

MEASUREMENTS

Validated instruments were used to measure empathy, distress (i.e., burnout and symptoms of depression), and well-being (high quality of life).

RESULTS

Medical student empathy scores were higher than normative samples of similarly aged individuals and were similar to other medical student samples. Domains of burnout inversely correlated with empathy (depersonalization with empathy independent of gender, all P < .02, and emotional exhaustion with emotive empathy for men, P = .009). Symptoms of depression inversely correlated with empathy for women (all P < or = .01). In contrast, students' sense of personal accomplishment demonstrated a positive correlation with empathy independent of gender (all P < .001). Similarly, achieving a high quality of life in specific domains correlated with higher empathy scores (P < .05). On multivariate analysis evaluating measures of distress and well-being simultaneously, both burnout (negative correlation) and well-being (positive correlation) independently correlated with student empathy scores.

CONCLUSIONS

Both distress and well-being are related to medical student empathy. Efforts to reduce student distress should be part of broader efforts to promote student well-being, which may enhance aspects of professionalism. Additional studies of student well-being and its potential influence on professionalism are needed.

Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies

BACKGROUND

Guidance from the National Institute for Health and Clinical Excellence recommends one or two questions as a possible screening method for depression. Ultra-short (one-, two-, three- or four-item) tests have appeal due to their simple administration but their accuracy has not been established.

AIM

To determine whether ultra-short screening instruments accurately detect depression in primary care.

DESIGN OF STUDY

Pooled analysis and meta analysis.

METHOD

A literature search revealed 75 possible studies and from these, 22 STARD-compliant studies (Standards for Reporting of Diagnostic Accuracy) involving ultra-short tests were entered in the analysis.

RESULTS

Meta-analysis revealed a performance accuracy better than chance (P<0.001). More usefully for clinicians, pooled analysis of single-question tests revealed an overall sensitivity of 32.0% and specificity of 97.0% (positive predictive value [PPV] was 55.6% and negative predictive value [NPV] was 92.3%). For two- and three-item tests, overall sensitivity on pooled analysis was 73.7% and specificity was 74.7% with a PPV of only 38.3% but a pooled NPV of 93.0%. The Youden index for single-item and multiple item tests was 0.289 and 0.47 respectively, suggesting superiority of multiple item tests. Re-analysis examining only 'either or' strategies improved the 'rule in' ability of two- and three-question tests (sensitivity 79.4% and NPV 94.7%) but at the expense of being able to rule out a possible diagnosis if the result was negative.

CONCLUSION

A one-question test identifies only three out of every 10 patients with depression in primary care, thus unacceptable if relied on alone. Ultra-short two- or three-question tests perform better, identifying eight out of 10 cases. This is at the expense of a high false-positive rate (only four out of 10 cases with a positive score are actually depressed). Ultra-short tests appear to be, at best, a method for ruling out a diagnosis and should only be used when there are sufficient resources for second-stage assessment of those who screen positive.

An evidence-based approach to the management of depression

Increasing numbers of patients are using complementary medicine for the treatment of depression, which complicates management. What is the evidence in support of one medication over another? What medications are safe to use in children and pregnant women? Is there any evidence supporting over-the-counter supplements? These are just a few of the questions that primary care physicians face on a daily basis. This article attempts to answer these questions and many others in an evidence-based approach to the management of depression, which focuses on diagnosis, medical management, and complementary treatments.

The need to adapt standardized outcomes measures for community mental health

In order to determine whether evidence-based practices are effective in community settings, the use of measurement tools that accurately capture symptoms and functioning in the community context is imperative. Without accurate measurement, researchers face the troubling possibility that tests of effective treatments may not attain positive results because of measurement error. The authors have experienced apparently serious problems with measurement validity in community mental health practice settings in which we are conducting diffusion research. Features of survey design that strengthen measurement in the university setting (where survey instruments are designed and treatments are usually tested) appear to work against us in community settings. Problems are compounded when it is necessary to measure across several domains, and thus, to employ multiple questionnaires. Here, we discuss the problems we have experienced with three common survey design strategies: (1) the use of multiple, similar items; (2) the use of reverse-coded items; and (3) the use of graded response-items. These strategies result in measures whose length and cognitive complexity may compromise their validity in community settings. Race is an especially important issue in diffusion research, as we lack even basic information concerning efficacy and effectiveness for some important evidence-based treatments. Invalid measures could seriously delay transfer and development of appropriate treatments. Careful psychometric work is badly needed, but such work is time intensive and costly. In the meantime, we encourage researchers to consider the modifications suggested here.

Screening for depression in a diabetic outpatient population

Depression occurs twice as often in patients with diabetes and is associated with reduced compliance with exercise, diet, and medications. It is also associated with hyperglycemia and increased diabetic complications. Despite evidence that successful treatment is associated with improved glycemic control, many cases of depression are left untreated. Objectives. (1) Evaluate a combination screening strategy in an outpatient population; and (2) explore the association between glycemic control and depressive symptomatology. Methods. Ninety-two patients completed the Patient Health Questionnaire (PHQ-2). Patients with a PHQ-2 score ≥ 1 completed the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16). Using the QIDS-SR16, a score of ≤5 corresponded to normal mood, with scores above 5 corresponding to increasing severity of depressive symptoms. Glycemic control was assessed by glycosylated hemoglobin (HbA1c). Results. Using a PHQ-2 cut-off score of ≥3, 37% of the sample screened positive for major depressive disorder (MDD), with an additional 27% reporting sub-threshold symptoms. The depressed group reported significantly more difficulty with reduced interests, insomnia, concentration, self-criticism, energy/fatigue and depressed mood. In terms of glycemic control, there was a marginally significant effect for race and HbA1c. Conclusion. The combined PHQ-2 and QIDS-SR16 can facilitate prompt detection of MDD and provide a means of monitoring specific symptoms and progress once treatment commences.

Current practices in depression care

Despite improved awareness among the medical community concerning common mental health disorders, the high prevalence of depression in the United States remains unchanged and has been compounded by increasing evidence of gaps in mental health care for ethnic and racial minorities. Thus, there is a strong need for the timely creation of comprehensive educational initiatives aimed at improving the quality of care provided by mental health professionals and primary care physicians. Fundamental to this process is the examination of current treatment standards, as well as identification of practices that require improved physician education. Consistent use of appropriate screening tools, diagnostic accuracy and timeliness, continual assessment of illness severity, adherence to practice guidelines, and individualized patient care need heightened attention to improve outcomes. This article describes the most prevalent types of depression and summarizes current practices in depression care, with an emphasis on treatment standards and opportunities for improved performance.

Psychosocial and psychiatric challenges of diabetes mellitus

Diabetes mellitus is a chronic endocrine disorder that places considerable psychologic stress on individuals and their families. This article discusses psychosocial issues associated with diabetes and its management, and common psychiatric disorders in diabetes population. Psychosocial challenges and psychiatric disorders in people with diabetes can hinder patients' successful diabetes self-management and well-being. An understanding of mental health issues in diabetes is critical for all health care professionals who provide treatment to people with diabetes.

Below the belt: approach to chronic pelvic pain

OBJECTIVE

To present a practical approach to the symptom complex called chronic pelvic pain (CPP). Chronic pelvic pain is defined as nonmenstrual pain lasting 6 months or more that is severe enough to cause functional disability or require medical or surgical treatment.

SOURCES OF INFORMATION

MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched from January 1996 to December 2004.

MAIN MESSAGE

While the source of pain in CPP can be gynecologic, urologic, gastrointestinal, musculoskeletal, or psychoneurologic, 4 conditions account for most CPP: endometriosis, adhesions, interstitial cystitis, and irritable bowel syndrome. More than one source of pain can be found in the same patient. Management involves treating the underlying condition, the pain itself, or both. Nonnarcotic analgesics are first-line therapy for pain relief; hormonal therapies are beneficial if the pain has a cyclical component. A multidisciplinary approach addressing environmental factors and incorporating medical management with physiotherapy, psychotherapy, and dietary modifications works best.

CONCLUSION

Although caring for patients with CPP can be challenging and frustrating, family physicians are in an ideal position to manage and coordinate their care.

Predictors of quality of life among women with coronary heart disease

BACKGROUND

Health-related quality of life (HRQOL) is an increasingly relevant outcome as the population ages and associated morbidities increase. The purpose of this study was to evaluate predictors of HRQOL among ethnically diverse women hospitalized for coronary heart disease (CHD) and determine the impact of a brief, educational intervention on HRQOL 6 months post-hospitalization.

METHODS

Women (n = 160; mean age 63 years, 53% minority) admitted for CHD at three academic hospitals who completed a 6 month secondary prevention trial were studied. The SF-36 was administered at admission and 6 months. Multiple linear regressions were used to identify significant independent predictors of 6 month HRQOL.

RESULTS

Significant improvements in HRQOL were noted from admission to 6 months post-hospitalization. Subjects reporting better HRQOL at 6 months included those who were employed, married, physically active, enrolled in cardiac rehabilitation, and not depressed. Women who received an educational intervention had significantly less bodily pain at 6 months compared with usual care in a model adjusted for baseline HRQOL and physical activity goal adherence (p = 0.04).

CONCLUSIONS

Baseline HRQOL (8 SF-36 subscales), physical activity (3 SF-36 subscales) and marital status (1 SF-36 subscale) were the major determinants of HRQOL at 6 months post-hospitalization. Future interventions and preventive efforts should be targeted to women with CHD who have impaired HRQOL and may be at increased risk of poor clinical outcomes.

A multicenter study of burnout, depression, and quality of life in minority and nonminority US medical students

OBJECTIVE

To determine the well-being of minority medical students in a multicenter sample of US medical students.

PARTICIPANTS AND METHODS

All 1098 medical students at 3 medical schools in Minnesota were surveyed in April 2004. Validated instruments were used to assess burnout, depression, and quality of life (QOL). Students were also asked about the prevalence of significant personal life events in the previous 12 months and strategies used to cope with stress.

RESULTS

Although symptoms of depression and overall burnout were similar among minority and nonminority students, minority students were more likely to have a low sense of personal accomplishment (P=.02) and lower QOL In a number of domains (all P< or =.05). These differences persisted on multivariate analysis that controlled for demographic characteristics and recent life events. Minority students were also more likely to have a child (P=.01), originate from outside Minnesota (P<.001), and experience a major personal Illness in the last 12 months (P=.03).

CONCLUSION

As a group, the minority medical students in this survey had a lower sense of personal accomplishment and QOL than nonminority students. Additional studies are needed to provide insight regarding the causes of these inequities and the unique challenges faced by minority medical students. Efforts to improve minority students' well-being, QOL, and learning experience may help prevent attrition among minority medical students and promote diversification in the physician workforce.

Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the Veterans Health Administration

OBJECTIVE

Our objective was to describe the adequacy of follow-up care for depression and its association with antidepressant treatment duration among veterans with and without diabetes mellitus (DM).

METHOD

This was a retrospective study (1997-2005) of 2178 veterans (33% with DM) in a Midwestern Veterans Health Administration facility who had a new episode of unipolar depression. Adequate follow-up care was defined by a health care visit within 7 and 14 days, and >/=3 visits following antidepressant treatment initiation. Adequate treatment duration was defined by a medication possession ratio of >/=80%. Multivariate logistic regression was used to calculate odds ratios (ORs) adjusted for demographic, clinical and health care utilization characteristics.

RESULTS

Only 27% received >/=3 follow-up visits within 12 weeks, and <23% received follow-up within 2 weeks of antidepressant initiation. Subjects with DM were 1.36-fold more likely [95% confidence interval (95% CI)=1.05-1.75] to have received >/=3 visits but were similarly likely to have received follow-up within 7 days (OR=1.02; 95% CI=0.74-1.41) or 14 days (OR=1.08; 95% CI=0.83-1.40) of antidepressant initiation. Adequate follow-up care was the most important predictor of adequate treatment duration (OR=2.10; 95% CI=1.54-2.88).

CONCLUSION

DM had little influence on the adequacy of follow-up care for depression, with few exceptions. Follow-up care for depression is underutilized and has a significant impact on antidepressant treatment duration. Strategies to more effectively manage depression treatment are required.

Disability and patient's appraisal of general health contribute to depressed mood in rheumatoid arthritis in a large clinical study in Japan

The aim of this study was to evaluate the factors responsible for depressed mood in rheumatoid arthritis (RA). Clinical and laboratory measures were collected from 4558 RA patients enrolled in a large clinical cohort study for RA conducted at the Institute of Rheumatology, Tokyo Women's Medical University (IORRA study). A two-question depressed screening included in the U.S. Preventive Services Task Force recommendation were utilized to identify "depressed patients." A total of 1875 (41.1%) were identified as "depressed patients" who presented with symptoms suggestive of depression. Patient's Visual Analog Scale (VAS) for general health (43.3 mm vs 24.6 mm, P < 0.0001) and pain (40.9 mm vs 23.8 mm, P < 0.0001) and the disability index scores measured by the Health Association Questionnaire (HAQ) (0.986 vs 0.574, P < 0.0001) were significantly higher in depressed patients than in nondepressed patients. The presence of three or more comorbidities (odds ratio [OR] 2.157, P < 0.0001), infection (OR 1.754, P < 0.0001), and joint surgery (OR 1.878, P < 0.0001) were significantly correlated with depressed mood in RA. The results of the Generalized Linear Model analysis showed that HAQ disability index (P < 0.0001) and patient's VAS for general health (P < 0.0001) were also strongly and significantly associated to the response variable "probability of depressed patients." Patient appraisal of poor general health and greater disability were associated with depressed mood in RA.

Two-question depression-screeners - the solution to all problems?

Depression constitutes a considerable issue in medicine and it is anticipated that the amount of people suffering from affective disorders will increase significantly. It would be useful to have a simple, fast screening procedure which would help detect depression. In four recently published articles a two-question depression-screener is recommended.

METHOD

Sensitivity, specificity, likelihood ratios, negative and positive predictive values were compared.

RESULTS

For four different clinical samples and one sample that was representative of the German population the prevalence for depression ranged from 6.9 % to 18.1 %. Sensitivity and specificity reached values from 72.6 % to 96.6 % and from 56.9 % to 90.0 % respectively. All negative predictive values were high (< 97 %) opposed to positive predictive values (17.8 % to 38.5 %).

CONCLUSION

Overall, it seems that the two-question screenings are well suited for the exclusion of a major depression. It is possible that regular screening could further lower the percentage of undiagnosed cases.

Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms

BACKGROUND

Post-traumatic stress disorder (PTSD) may develop in the aftermath of an acute myocardial infarction (MI). Whether PTSD is a risk factor for cardiovascular disease (CVD) is elusive. The biological mechanisms linking PTSD with atherosclerosis are unclear.

DESIGN

A critical review of 31 studies in the English language pursuing three aims: (i) to estimate the prevalence of PTSD in post-MI patients; (ii) to investigate the association of PTSD with cardiovascular endpoints; and (iii) to search for low-grade systemic inflammatory changes in PTSD pertinent to atherosclerosis.

METHODS

We located studies by PubMed electronic library search and through checking the bibliographies of these sources.

RESULTS

The weighted prevalence of PTSD after MI was 14.7% (range 0-25%; a total of 13 studies and 827 post-MI patients). Two studies reported a prospective association between PTSD and an increased risk of cardiovascular readmission in post-MI patients and of cardiovascular mortality in combat veterans, respectively. In a total of 11 studies, patients with PTSD had increased rates of physician-rated and self-reported cardiovascular diseases. Various cytokines and C-reactive protein were investigated in a total of seven studies suggesting that PTSD confers a pro-inflammatory state.

CONCLUSIONS

Increasing evidence suggests that PTSD specifically related to MI develops considerably frequently in post-MI patients. More research is needed in larger cohorts applying a population design to substantiate findings suggesting PTSD is an atherogenic risk factor and to understand better the suspected behavioural and biological mechanisms involved.

Difficulty taking medications, depression, and health status in heart failure patients

BACKGROUND

Little is known about medication nonadherence in heart failure populations. We evaluated the association between 1 aspect of medication nonadherence, patient-reported difficulty taking medications as directed, and health status among heart failure outpatients, and then examined whether this association was explained by depression.

METHODS AND RESULTS

A total of 522 outpatients with left ventricular ejection fraction <0.40 completed clinical evaluation, Kansas City Cardiomyopathy Questionnaire (KCCQ), Medical Outcomes Study-Depression questionnaire, and categorized their difficulty taking medications (5-level Likert-scale question). Multivariable regression was used to evaluate the cross-sectional association between difficulty taking medications and health status, with incremental adjustment for medical history and depressive symptoms. Patients with difficulty taking medications (n = 64; 12.2%) had worse health status (8.2 +/- 2.7 point lower mean KCCQ summary scores; P = .008) and more depressive symptoms (43.8% versus 27.1%; P = .006). Adjusting for demographic and clinical factors had little effect on the association between difficulty taking medications and health status (8.0 +/- 3.2 point lower KCCQ scores; P = .01); however, the relationship was attenuated with adjustment for depressive symptoms (4.7 +/- 2.9 point lower KCCQ scores; P = .11).

CONCLUSIONS

Among heart failure outpatients, difficulty taking medications is associated with worse health status. This association appears to be explained, in part, by coexistent depression. Future studies should evaluate interventions such as depression treatment to improve medication adherence and health status.

Assessment of lymphoedema of the lower limbs by the community nurse

Community nurses are increasingly at the frontline in supporting patients in the management of long-term conditions. They are therefore likely to be involved in identifying and providing care for people who are affected by lymphoedema. Community practitioners will need to develop the skills to recognize patients who have, or are at risk for developing, lymphoedema. Aspects of the nursing assessment of lymphoedema include taking a detailed history and conducting a comprehensive physical and psychosocial assessment of the impact of this condition. The assessment is multifaceted and will often require intervention from other members of the multidisciplinary team.

A Review of Screening Tools for Psychiatric Comorbidity in Headache Patients

Psychiatric comorbidity, especially depression and anxiety, has been well documented in patients with primary headache disorders. The presence of psychiatric comorbidity in headache patients is associated with decreased quality-of-life, poorer prognosis, chronification of disease, poorer response to treatment, and increased medical costs. Despite the prevalence and impact, screening for psychiatric disorders in headache patients is not systematically performed, either clinically or in research studies, and there are no guidelines to suggest which patients should be screened or in what manner. We review a variety of screening methods and instruments, focusing primarily on self-report measures and those available in the public domain. Informal verbal screening may be sufficient in a primary care setting, but should include screening for both anxiety and depression. Explicit screening for anxiety is important, as anxiety may have a more significant impact on headache than does depression and may occur in the absence of clinical depression. Formal screening with instruments that can identify a variety of psychiatric disorders is appropriate for patients with daily headache syndromes, patients who are refractory to usual care, and patients referred for specialty evaluation. Limitations of screening instruments include the influence of transdiagnostic symptoms and the need for confirmatory diagnostic interview. The following instruments appear most suitable for use in headache patients: for depression, the Patient Health Questionnaire Depression Module, the Beck Depression Inventory-II, or the Beck Depression Inventory-Primary Care; for anxiety, the Beck Anxiety Inventory and the Generalized Anxiety Disorder 7-item Scale; and for multidimensional psychiatric screening, the Patient Health Questionnaire or Primary Care Evaluation of Mental Disorders.

Patient-reported economic burden and the health status of heart failure patients

BACKGROUND

Heart failure (HF) guidelines recommend treatment with multiple medications to improve survival, functioning, and quality of life. Yet, HF treatments can be costly, resulting in significant economic burden for some patients. To date, there are few data on the impact of patients' perceived difficulties in affording medical care on their health outcomes.

METHODS AND RESULTS

Comprehensive clinical data, health status, and the perceived economic burden of 539 HF outpatients from 13 centers were assessed at baseline and 1 year later. Health status was quantified with the Kansas City Cardiomyopathy Questionnaire overall summary score. Cross-sectional and longitudinal (1-year) analyses were conducted comparing the health status of patients with and without self-reported economic burden. Patients with economic burden had significantly lower health status scores at both baseline and 1 year later. Although baseline perceptions of economic burden were associated with poorer health status, patients' perceived difficulty affording medical care at 1 year was a more important determinant of lower 1-year health status.

CONCLUSION

HF patients reporting difficulty affording their medical care had lower perceived health status than those reporting little to no economic burden. More research is needed to further evaluate this association and to determine whether addressing perceived economic difficulties affording health care can improve HF patients' health status.

The Diagnosis of Major Depression in Patients With Cancer: A Comparative Approach

Depressive symptoms not only impair quality of life in cancer patients but constitute an independent risk factor for increased mortality. In order to accurately and efficiently identify depression in cancer patients, the authors developed a biostatistical strategy to identify items of the 21-item, observer-rated Hamilton Rating Scale for Depression (Ham-D) that would optimize the diagnosis of depression among cancer patients. Exhibiting a relatively high sensitivity and specificity, our most optimal diagnostic tool contained six Ham-D items (late insomnia, agitation, psychic anxiety, diurnal mood variation, depressed mood, and genital symptoms). This study may serve as a prototype to generate valid instruments accurate for the diagnosis of major depression in other populations of cancer patients.

Development of a Standardized Patient Instructor to Teach Functional Assessment and Communication Skills to Medical Students and House Officers

Professional societies have called for increased geriatrics training for all medical students and physicians. A Geriatrics Standardized Patient Instructor (GSPI) was developed in which learners assess the functional status of a patient preparing for hospital discharge. Standardized patients (SPs) rate learners on functional assessment and communication skills, and provide feedback. Seventeen SPs were trained. Correlations of ratings by SPs with ratings by three geriatricians of videotaped encounters indicated good reliability (correlation coefficient = 0.69 and 0.70 for functional assessment and communication skills, respectively). Results from two learner groups illustrated the utility and feasibility of the GSPI. First, 138 house officers in nine specialties experienced the GSPI as a formative evaluation during implementation of new geriatrics curricula. Mean scores+/-standard deviation (on a 100-point scale) for functional assessment and communication skills were 78+/-16 and 86+/-11, respectively. House officers rated the overall experience positively (mean rating (1 = poor, 5 = excellent) 3.9+/-0.8). Second, 171 first-year medical students (M1 s) encountered the GSPI as part of an intense, multimodal educational intervention. Mean scores on functional assessment and communication skills were 93+/-10 and 93+/-7, respectively. Mean overall rating of the experience by M1 s was 4.1+/-0.8. After demonstrated success as a teaching tool in these two groups of learners, the GSPI has been successfully used with second- and third-year (M3) medical students and house officers from a total of 12 specialties and incorporated into multistation Objective Standardized Clinical Examination exercises for incoming house officers and M3 s. Unlike existing diagnosis-oriented SPs, the GSPI can be used to assess and teach geriatrics skills to physician learners across disciplines and levels of training.

Myths and Realities of Aging

As the aging population expands, it will become increasingly important for health care providers to become aware of and sensitive to the needs and concerns of older adults.Ageismis a term that describes negative stereotyping of older adults and discrimination because of older age. Health concerns and symptoms in the elderly may be overlooked or dismissed as part of the normal aging process. Consequently, several conditions in olders adults are significantly underdiagnosed and undertreated. Misconceptions about aging frequently encountered in medicine and in society at large include issues involving sexuality, sleep disturbance, depression, cognitive impairment, and substance abuse. We can learn to recognize ageist notions that influence medical practice. Perhaps by becoming more aware of myths and realities of aging, we can improve the health and quality of life of our elderly patients.