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

Decline in Physical Performance Among Women With a Recent Transient Ischemic Attack or Ischemic Stroke

BACKGROUND AND PURPOSE

Physical performance for walking, reaching, turning, and other common tasks is a major determinant of functional independence after stroke. Current strategies to preserve physical performance focus on prevention of recurrent stroke. Loss of physical performance, however, may occur in the absence of recurrence. To examine this possibility, we measured change in physical performance, independent of subsequent stroke, among women with a recent ischemic stroke or transient ischemic attack (TIA).

METHODS

Among 664 postmenopausal women who participated in a clinical trial of estrogen therapy after stroke or TIA, we administered the Physical Performance Test (PPT) at baseline (mean 58 days from the cerebrovascular event) and annually. Women who died or had a stroke during follow-up were censored. Decline or improvement in physical performance was defined as a change in the PPT score from baseline of at least 3 points. Sustained decline or improvement was defined as 2 consecutive years during which the score had declined or improved, respectively, relative to the baseline score.

RESULTS

With each year of follow-up, a smaller proportion of the cohort demonstrated improvement (16% in year 1, 6% in year 5) and a larger proportion demonstrated decline (15% in year 1, 35% in year 5). In an analysis restricted to 259 women with 3 years of follow-up, 46 (18%) experienced a nonsustained decline in physical performance, and 39 (15%) experienced a sustained decline.

CONCLUSIONS

Decline in physical performance is common after an ischemic stroke or TIA even in the absence of a recurrent neurological event. Our findings suggest that specific interventions to maintain and improve physical performance may be important for reducing long-term disability.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Performance of the PHQ-9 as a screening tool for depression after stroke

BACKGROUND AND PURPOSE

The purpose of this study was to examine the performance of the Patient Health Questionnaire (PHQ)-9, a 9-item depression scale, as a screening and diagnostic instrument for assessing depression in stroke survivors.

METHODS

As part of a randomized treatment trial for poststroke depression (PSD), subjects with and without PSD completed the PHQ-9, a 9-item summed scale, with scores ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily). Subjects endorsing 2 or more symptoms of depression were administered the criterion standard Structured Clinical Interview for Depression (SCID). Receiver operating characteristic analysis was used to examine the sensitivity and specificity of the PHQ-9

RESULTS

Of 316 subjects enrolled, 145 met SCID criteria for major depression or other depressive disorder, and 171 were not depressed. PHQ-9 scores discriminated well between subjects with any versus no depressive disorder, with an area under the curve (AUC) of 0.96, as well as between subjects with and without major depression (AUC=0.96). The AUC was similar regardless of patient age, gender, or ethnicity. A PHQ-9 score > or =10 had 91% sensitivity and 89% specificity for major depression, and 78% sensitivity and 96% specificity for any depression diagnosis.

CONCLUSIONS

The PHQ-9 performs well as a brief screener for PSD with operating characteristics similar or superior to other depression measures and similar to its characteristics in a primary care population. Moreover, PHQ-9 scores discriminate equally well between those with and without PSD regardless of age, gender, or ethnicity.

Facilitating Self-Management of Substance Use Disorders with Online Counseling: The Intervention and Study Design

This paper describes a pilot study using online counseling for court-involved parents who have been charged with child abuse and neglect related to substance use. All families resided in the medically underserved area of Newark, New Jersey and were recruited from halfway houses and the Family Court. The sample consisted of 30 participants randomly assigned to control (n=15) and experimental (n=15) groups. Of the participants, 83% were Black, 13% were White, and 3% were Hispanic. The control group had access to usual face-to-face treatment at a local treatment center where typical court-ordered offenders were referred. Usual face-to-face treatment often involved being wait-listed for periods of months even for a detox bed. The experimental group had immediate access to the online counseling intervention. The online counseling software and the live counseling components of the intervention were developed with a stages of change theoretical framework. Preliminary findings show promise for the feasibility of online interventions for underserved populations.

‘A little bitty spot and I'm a big man’: patients' perspectives on refusing diagnosis or treatment for lung cancer

Patient refusal of physicians' recommendations may partially account for variations in lung cancer treatment affecting survival. Reasons for refusal have not been well researched, and patients who refuse are often labeled derogatorily as irrational or enigmatically non-compliant. This study explored why patients refused recommendations for further diagnosis or treatment of lung cancer. We conducted in-depth interviews with nine patients, identified and recruited over a 2-year period, with documented refusal of doctors' recommendations. Recruiting was hampered by deaths, logistics, and refusal to participate. Questions focused on participants' understanding of disease, medical recommendations, and perceptions of decision-making. Transcripts were analyzed using a grounded theory approach. Participants emphasized self-efficacy, minimizing threat, fatalism or faith, and distrust of medical authority; explanations were often multi-dimensional. Comments included complaints about communication with physicians, health system discontinuities, and impact of social support. Explanations of participants' decisions reflected several ways of coping with an undesirable situation, including strategies for reducing, sustaining, and increasing uncertainty. Problematic Integration Theory helps to explain patients' difficulties in managing uncertainty when assessments of disease outcomes and treatment recommendations diverge. Implications for clinical communication include increasing trust while delivering bad news, understanding the source of resistance to recommendations, and discussing palliative care.

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Why is depression bad for the failing heart? A review of the mechanistic relationship between depression and heart failure

BACKGROUND

Depression is 4 to 5 times as common in heart failure (HF) patients as in the general population, might confer a higher risk of developing HF, and negatively affects prognosis in established HF.

METHODS AND RESULTS

A review was undertaken via Medline (1966-2003) and PsycINFO (1872-2003) searches using the subject headings "depressive disorder" and "heart failure, congestive." Our findings suggest that the link between depression and HF may be due to shared pathophysiology. Depression may augment catecholamine release, arrhythmias, elaboration of proinflammatory cytokines, and platelet activation--processes that may influence prognosis in HF. Depression is also associated with a higher risk of noncompliance and lower levels of social support, which have been shown to worsen prognosis in HF. The impact of pharmacologic or behavioral treatment for depression on physiologic parameters or clinical outcomes in HF remains unclear. Inherent difficulties in recognition of depression in the setting of HF may decrease the likelihood that depressed patients receive the treatment they need.

CONCLUSIONS

Depression is common in HF, may contribute to the development of HF in susceptible populations, and is independently predictive of poor clinical outcomes. Pathophysiologic pathways and psychosocial issues that are shared between the 2 conditions might explain these observations and represent potential therapeutic targets. Vigilant attention to the recognition and treatment of depression in HF patients is warranted.

Symptoms of major depression in people with spinal cord injury: implications for screening

OBJECTIVES

To provide psychometric data on a self-report measure of major depressive disorder (MDD) and to determine whether somatic symptoms are nonspecific or count toward the diagnosis.

DESIGN

Survey.

SETTING

Data from the National Spinal Cord Injury Statistical Center representing 16 Model Spinal Cord Injury Systems.

PARTICIPANTS

Eight hundred forty-nine people with spinal cord injury who completed a standardized follow-up evaluation 1 year after injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 (PHQ-9), a measure of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition . We computed descriptive statistics on rates of depressive symptoms and probable MDD, evaluated internal consistency and construct validity, and analyzed the accuracy of individual items as predictors of MDD.

RESULTS

Exactly 11.4% of participants met criteria for probable MDD. Probable MDD was associated with poorer subjective health, lower satisfaction with life, and more difficulty in daily role functioning. Probable MDD was not related to most demographic or injury-related variables. Both somatic and psychologic symptoms predicted probable MDD.

CONCLUSIONS

The PHQ-9 has promise as a tool with which to identify probable MDD in people with SCI. Somatic symptoms should be counted toward the diagnosis and should alert health care providers to the likelihood of MDD. More efficient screening is only one of the quality improvement efforts needed to enhance management of MDD.

Cognitive complexity of self-administered depression measures

BACKGROUND

Self-administered depression measures are important tools for research and practice, but their utility depends on the quality of the measurements they yield. Respondent comprehension is essential for meaningful measurement and prior studies have used readability indices to assess comprehensibility. Readability, however, is only one aspect of comprehension and empirical evidence shows that comprehension and measurement quality decrease as the cognitive complexity of standardized questions increases. Thus, cognitive complexity may provide a useful guide for selecting measures to maximize measurement quality.

METHODS

This study compared the cognitive complexity of 15 self-administered depression measures. Four aspects of cognitive complexity (length, readability, linguistic problems and number) were combined to characterize overall complexity.

RESULTS

Measures varied considerably. The most cognitively complex measures, likely to be most difficult to comprehend, were the Inventory to Diagnose Depression (IDD), the Hamilton Depression Inventory (HDI, Full and Short Versions), and the Beck Depression Inventory (BDI, BDI-II, BDI-PC). The least complex measures, likely to be easiest to comprehend, were the Harvard National Depression Screening Day Scale (HANDS), the Revised Hamilton Rating Scale for Depression Self-Report Problem Inventory (RHRSD) and the Zung Self-Rated Depression Scale (SDS). This multidimensional approach to assessing complexity and comprehensibility yielded different results than readability indices alone.

LIMITATIONS

This study did not include all self-administered depression measures and did not examine the relationship of cognitive complexity to actual responses to depression measures.

CONCLUSIONS

Since cognitive complexity is likely to limit comprehension and reduce measurement accuracy, it merits consideration in selection of self-administered depression measures.

Identifying and Treating Depression in Patients With Heart Failure

Depression is a common comorbid condition in patients with heart failure (HF) that often goes undiagnosed and untreated. Unless symptoms of depression are specifically looked for, they can be easily missed or mistaken for HF. Clinical depression is a syndromal diagnosis based on patient history, the report of signs and symptoms, and the exclusion of competing diagnoses. This article describes the recommended strategies for recognizing and diagnosing depression. General, psychotherapeutic, and pharmacological approaches to treatment of depression in HF are also discussed. General treatment measures include optimization of medical therapy, patient education, exercise, social support, and family care. Although there are many types of psychotherapy, cognitive-behavioral therapy is particularly appropriate for patients with HF and is described in this article. Categories of antidepressant drugs, including serotonin reuptake inhibitors, tricyclic antidepressants, and miscellaneous antidepressants, are reviewed relative to treating depression in patients with HF. Given the high prevalence and adverse impact of untreated depression in patients with HF, it is essential for advanced practice nurses to develop the requisite knowledge and skills for the identification and treatment of depression.

Screening for depression in primary care: what do we still need to know?

The United States Preventive Services Task Force (USPSTF) recently issued the recommendation that primary care physicians screen adult patients for depression. A policy to screen primary care patients for depression has appeal as a strategy to reduce the personal and societal costs of undiagnosed and untreated depression. Such appeal may be justified if the evidence supports the screening policy in three areas: effectiveness, cost-effectiveness, and feasibility. The USPSTF recommendation leaves many issues in each of these areas unresolved and physicians are left the choice of two important program characteristics: screening instrument and screening interval. We discuss how uncertainties in the screening protocol and treatment process affect whether screening is an effective and cost-effective use of resources with respect to other health interventions. We suggest that targeting screening to groups at a higher risk for depression may lead to a more effective use of health care resources. A screening program may not be feasible even if effectiveness and cost-effectiveness are optimized. We discuss uncertainties in the USPSTF recommendation that affect the feasibility of implementing such a program in physicians' practices.

Depression in Japanese community-dwelling elderly--prevalence and association with ADL and QOL

This cross-sectional study examined the prevalence of screening-based depression and compared the scores of activities of daily living (ADL) and quality of life (QOL) between community-dwelling elderly subjects with and without depression in Japan. Elderly subjects aged 65 or older living in four rural towns participated in 2000 or 2001 (n = 5363, female 58.3%, mean (S.D.) age 74.6 (7.0) years). Depressive symptoms were assessed using a 15-item Geriatric Depression Scale (GDS-15) and ADL, higher functions, and medical and social histories were assessed by self-report questionnaires. For assessing subjective QOL, a 100 mm visual analogue scale was used. One thousand seven hundred ninety-eight participants (33.5%, range, 32.3-34.6%) had suggestive depression using cutoff 5/6 of GDS-15. Subjects with depression revealed significantly lower scores for ADL and QOL than those without depression. Prevalence of screening-based depression was similar in the four different rural Japanese towns. However, the reported prevalence of depression varies enormously in different country. Primary physicians and caregivers should pay more attention to depression in the community-dwelling elderly population, especially below the threshold of major depression as minor depression or dysthymia.

Food and nutrient intake in relation to mental wellbeing

Background

We studied food consumption and nutrient intake in subjects with depressed mood, anxiety and insomnia as indices of compromised mental wellbeing.

Methods

The study population consisted of 29,133 male smokers aged 50 to 69 years who entered the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study in 1985–1988. This was a placebo-controlled trial to test whether supplementation with alpha-tocopherol or beta-carotene prevents lung cancer. At baseline 27,111 men completed a diet history questionnaire from which food and alcohol consumption and nutrient intake were calculated. The questionnaire on background and medical history included three symptoms on mental wellbeing, anxiety, depression and insomnia experienced in the past four months.

Results

Energy intake was higher in men who reported anxiety or depressed mood, and those reporting any such symptoms consumed more alcohol. Subjects reporting anxiety or depressed mood had higher intake of omega-3 fatty acids and omega-6 fatty acids.

Conclusions

Our findings conflict with the previous reports of beneficial effects of omega-3 fatty acids on mood.

Depressed mood and smoking experimentation among preteens

The authors examined children's depressed mood, parental depressed mood, and parental smoking in relation to children's smoking susceptibility and experimentation over 20 months in a cohort of 418 preteens (ages 10-12 at baseline) and their parents. Depressed mood in preteens was strongly related to experimentation but not to susceptibility. In cross-sectional analyses parental depressed mood was related to children's experimentation, but in longitudinal analyses parental depressed mood at baseline did not differentiate children who experimented from those who did not. Although parental smoking was strongly related to experimentation, it was not related to susceptibility either cross-sectionally or longitudinally. Depressed mood among preteens and parents appeared to be more strongly related to children's smoking behaviors than to their intentions to smoke.

Screening for depression in primary care: will one or two items suffice?

Small differences in implementation of screening and the associated burden on clinicians and patients could have substantial effects on the sustainability of screening in routine primary care. Therefore, we investigated the psychometric properties of single items and two-item combinations of the "WHO-5 Well Being Index" (WHO-5) and compared the obtained characteristics to those of the original version as well as to another proposed two-item screener (developed from PRIME-MD and BPHQ, respectively). Screening and diagnostic interview data from 431 primary care patients were analysed. Main outcome measures were sensitivity, specificity and AUC values. All test characteristics were assessed using the diagnoses derived from the Composite International Diagnostic Interview (CIDI) as the criterion standard.Single-item screening questions proved rather inadequate. However, only marginal differences in performance were found between two questions and the longer screening instrument with respect to major depression, dysthymia and "any depressive disorder". There were no statistically significant differences between these AUC values and most other test characteristics assessed. The results suggest that screening could be reduced to two questions with a potential advantage in terms of ease of administration and scoring and decreased staff and patient burden and perhaps a reduced stigma associated with a positive screening score.

Anismus: a marker of multi-site functional disorders?

PURPOSE

This study was undertaken to assess the clinical significance of anismus in patients who complain of constipation.

PATIENTS AND METHODS

Thirty control subjects and 93 consecutive patients complaining of functional constipation took part in the study. Colonic transit time study and anorectal manometry were performed. Questions about depression and urinary and sexual diseases were added to a questionnaire based on the Rome II criteria, and visual analog scales about four items (constipation, diarrhoea, abdominal bloating and abdominal pain).

RESULTS

Constipated patients have lower threshold sensation volume, lower constant sensation volume, and lower maximum tolerable volume than controls. Thirty-seven patients (40%) were found to have anismus, based on anorectal manometry. No significant difference was found between constipated patients with anismus and constipated patients without anismus, using anorectal manometry. Constipated patients had longer colorectal transit time than controls, but neither total nor segmental colonic transit time was correlated with the presence or absence of anismus. In patients with anismus, a higher frequency of oesophageal symptoms, dysmotility-like dyspepsia, aerophagia, functional bowel disorders, functional abdominal pain, soiling, and dyschezia was found. In addition, a higher frequency of urinary complaints, sexual complaints, and depression was found. Anismus was associated with increased awareness of constipation, abdominal bloating, and abdominal pain, but not with diarrhoea.

The pediatrician's role in recognizing and intervening in postpartum depression

Increasing evidence of postpartum depression is encouraging pediatricians to include screening and intervention for postpartum depression in standard newborn and infant care. Pediatricians have the most frequent exposure to mothers and infants in the most high-risk time period and they have a vested interest in the well-being of the child and mother. Because the time required to achieve basic screening and referral services is minimal, there is enough evidence that postpartum screening and intervention are crucial components of comprehensive newborn and infant care. It is incumbent upon pediatricians to screen for and intervene in cases of postpartum depression to provide thorough care for infants and their families.

Maternal depressive symptoms and infant health practices among low-income women

OBJECTIVES

To determine the relationships between maternal depressive symptoms and the use of infant health services, parenting practices, and injury-prevention measures.

METHODS

A prospective, community-based survey of women attending Philadelphia public health centers between February 2000 and November 2001 was conducted. Women were surveyed at 3 time points before and after parturition. Depressive symptoms were determined with the Center for Epidemiologic Studies Depression Scale at each time point. We studied 6 outcomes, clustered into 3 categories: 1) infant health service use (adequate well-child care and ever being hospitalized); 2) parenting practices (breastfeeding for > or =1 month and use of corporal punishment); and 3) injury-prevention measures (having a smoke alarm and using the back sleep position).

RESULTS

The sample consisted of 774 largely single (74%), uninsured (63%), African American (65%) women, with a mean age of 24 +/- 6 years and a mean annual income of 8063 dollars. Forty-eight percent of women had depressive symptoms at 1 or 2 time points (ever symptoms) and 12% had depressive symptoms at all points (persistent symptoms). Compared with women who never had depressive symptoms (without symptoms), women with persistent symptoms were nearly 3 times as likely to have their child ever hospitalized (adjusted odds ratio: 2.89; 95% confidence interval: 1.61-5.07) and twice as likely to use corporal punishment (adjusted odds ratio: 1.90; 95% confidence interval: 1.08-3.34). Mothers with persistent depressive symptoms were nearly three-quarters less likely to have smoke alarms in their homes (adjusted odds ratio: 0.28; 95% confidence interval: 0.11-0.70) and one-half as likely to use the back sleep position (adjusted odds ratio: 0.56; 95% confidence interval: 0.35-0.91), compared with women without symptoms. There was no association between maternal depressive symptoms and infant receipt of well-child care or the likelihood of breastfeeding for > or =1 month.

CONCLUSIONS

Maternal depressive symptoms persisting from the prepartum to postpartum periods were associated with increased risks of infant hospitalization and use of corporal punishment and with lower likelihood of having a smoke alarm and using the back sleep position. Additional efforts are needed to identify and evaluate mothers with depressive symptoms to improve the health and safety of young infants.

Parents' Mood and the Content of Pediatric Care for Young Children

OBJECTIVE

To assess the relationship between parents' mood and the provision of anticipatory guidance by pediatric health care providers.

DATA SOURCE

Data analyzed were from the National Survey of Early Childhood Health, a cross-sectional nationally representative survey concerning young children 4-35 months of age (n = 2068). KEY VARIABLES: Parents were asked whether the children's health care providers had discussed 10-12 age-appropriate health promotion topics and 5 psychosocial issues during the past 12 months. Parents also identified missed opportunities for guidance (ie, topics not discussed for which discussion would have been helpful) and reported whether providers should discuss psychosocial issues. Parents' mood was assessed using factor scores derived from the Mental Health Inventory.

ANALYSES

Log-linear regression analyses determined if parents' mood was a significant predictor of the number of topics and issues discussed, the number of missed opportunities, and the reported number of issues that providers should discuss.

RESULTS

Parents who were more often in a positive mood discussed more health promotion topics (B =.06, P <.001) and psychosocial issues (B =.10, P <.01) with their child's health care providers. Parents who were more often in a negative mood identified more missed opportunities (B =.08, P =.02) and more issues that providers should discuss (B =.04, P <.001).

CONCLUSIONS

Increased attention to parents' mood and emotional well-being may help pediatricians identify parents who desire additional anticipatory guidance and ensure that opportunities for the provision of guidance are not inadvertently missed.

Mental health impact of 9/11 Pentagon attack: validation of a rapid assessment tool

BACKGROUND

Following the tragic events of 9/11/2001, the Pentagon Post Disaster Health Assessment (PPDHA) survey was created to identify healthcare needs and concerns among Pentagon personnel and to assure that appropriate care and information was provided. The PPDHA was fielded from October 15, 2001, to January 15, 2002. Fundamental in this assessment was the evaluation of the mental health impact as a result of the attack.

METHODS

Although a number of standardized instruments exist for mental health domains, most are lengthy and could not be used as a rapid health assessment. Instead, a short screening instrument consisting of 17 questions was developed that covered important mental health symptom domains, mental health functioning, and possible predictive risk factors. High-risk groups for post-traumatic stress disorder (PTSD), depression, panic attacks, generalized anxiety, and alcohol abuse were assessed, and validation of risk groups was assessed across functional levels.

RESULTS

Overall, 1837 (40%) respondents met the screening criteria for any of the symptom domains of interest 1 to 4 months after the attack: PTSD (7.9%), depression (17.7%), panic attacks (23.1%), generalized anxiety (26.9%), or alcohol abuse (2.5%). Mental health risk groups were highly correlated with self-reported reduced daily functioning and use of counseling services. Additionally, risk factors known to be associated with mental health problems after traumatic events were strongly predictive of the high-risk categories identified.

CONCLUSIONS

Mental health concerns were common among Pentagon employees in the 4 months after the 9/11 attack. Data from this study suggested that the short mental health screening instrument had validity and can serve as a prototype for rapid public health assessment of the mental health impact of future traumatic events.

Self-report of depressed mood and depression in women with type 2 diabetes

The purpose of this cross-sectional analysis (N = 53) was to (a) describe the self-reported prevalence of depressed mood and depression in women with type 2 diabetes; (b) to describe the antidepressive agents and dosages prescribed for depression treatment in women with type 2 diabetes; and (c) to examine differences in diabetes-related health outcomes (physiologic, psychosocial, and health functioning variables) with respect to depressed mood. Forty-four percent of women in this sample reported a depressed mood and 34% of the sample reported a history of depression. The majority of women with a history of depression were taking an antidepressive agent at the time of assessment (94%). Most women were treated with selective serotonin reuptake inhibitors (SSRIs). Women with depressed mood demonstrated poorer psychosocial adjustment and health functioning compared to women without a depressed mood; however, no differences in physiological outcomes were demonstrated. Only 18% of the participants were currently being treated with psychotherapy in conjunction with medication. Further research on this understudied population is indicated.

Association of dietary amino acids with low mood

Diet may affect mood and cognitive functions. Tryptophan and serine augmentation strategies have been applied for patients with mood or psychotic disorders. We studied the association between dietary intake of amino acids and low mood. We studied 29,133 men aged 50-69 years for 5-8 years in a population-based trial in Finland. Intake of amino acids was calculated from a diet history questionnaire completed by 27,111 men at baseline. Self-reports of depressed mood were recorded thrice a year, data on hospital treatment due to depressive disorders were derived from the national Hospital Discharge Register, and suicides were identified from death certificates. Participants were smokers at study entry. Strengths of our study include detailed data on food consumption, a substantial number of study participants, a long prospective follow-up time, and versatile data on indices of low mood. We found no association between the dietary intake of amino acids and self-report of depressed mood or risk of suicide. However, dietary intake of lysine and serine was associated with risk of hospital treatment due to major depressive disorder but these associations disappeared after excluding from analysis those who had reported depressed mood at study entry. There is no consistent association between dietary intake of amino acids and low mood.

Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure

OBJECTIVES

The purpose of this study was to assess whether depressive symptoms are independently associated with changes in heart failure (HF)-specific health status.

BACKGROUND

Depression is common in patients with HF, but the impact of depressive symptoms on the health status of these patients over time is unknown.

METHODS

We conducted a multicenter prospective cohort study of outpatients with HF. Data from 460 patients who completed a baseline Medical Outcomes Study-Depression Questionnaire and both a baseline and follow-up (6 +/- 2 weeks) Kansas City Cardiomyopathy Questionnaire (KCCQ) were analyzed. The KCCQ measures HF-specific health status, including symptoms, physical and social function, and quality of life. Multivariable regression was used to evaluate depressive symptoms as a predictor of change in KCCQ scores, adjusting for baseline KCCQ scores and other patient variables. The primary outcome was change in KCCQ summary scores (range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change).

RESULTS

Approximately 30% (139/460) of the patients had significant depressive symptoms at baseline. Depressed patients had markedly lower baseline KCCQ summary scores (beta = -19.6; p < 0.001). After adjustment for potential confounders, depressed patients were at risk for significant worsening of their HF symptoms, physical and social function, and quality of life (average change in KCCQ summary score = -7.1 points; p < 0.001). Depressive symptoms were the strongest predictor of decline in health status in the multivariable models.

CONCLUSIONS

Depressive symptoms are a strong predictor of short-term worsening of HF-specific health status. The recognition and treatment of depression may be an important component of HF care.

Consequences and costs of lower extremity injuries

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Comparison of 3 Depression Screening Methods and Provider Referral in a Veterans Affairs Primary Care Clinic

BACKGROUND: Concern about underdiagnosis and undertreatment of depression in primary care has led to support for routine screening. Although multiple screening instruments exist, we are not aware of studies to date that have compared different screening strategies, e.g., how the instrument is administered: by whom and in what setting. This study compared 3 separate screening strategies in terms of patient flow, coverage, patient characteristics, and other factors with the usual care system of provider referral. METHOD: We analyzed existing data from a completed randomized team trial of collaborative care depression treatment in which patients who met DSM-IV criteria for current major depressive disorder, dysthymic disorder, or both were recruited using the usual care system of provider referral (provider) and 3 separate screening strategies: (1) a 2-stage waiting room screening interview (waiting), (2) an in-clinic screen consisting of 2 self-report items embedded in a larger survey (in-clinic), and (3) a 2-stage self-report mail survey (mail). The team trial and analysis were conducted between January 1998 and July 2003. RESULTS: The usual care system of provider referral identified the most depressed patients and had relatively good coverage compared with the 3 screening strategies. Of the 3 screening strategies, the in-clinic strategy had the best coverage, while the mail strategy had the worst coverage. Provider referral patients were younger and had fewer chronic medical illnesses than did other patients. The waiting strategy identified more patients with bipolar affective disorder. CONCLUSION: While different strategies may be optimal for different resource levels and patient characteristics, this study suggests that an in-clinic self-report survey may be the best adjunct to provider referral for efficiently increasing coverage. This study also suggests that different screening strategies may capture different patient populations.

Do depressed older adults who attribute depression to "old age" believe it is important to seek care?

OBJECTIVE

To determine whether depressed older adults who attribute becoming depressed to "old age" rather than illness are more likely to believe it is not important to seek treatment for depression.

DESIGN

Cross-sectional mailed survey.

SETTING

Academically affiliated primary care physicians' network.

PARTICIPANTS

Surveys were mailed to 588 patients age > or =65 years who were randomly identified from patient lists of 20 physicians. Surveys were returned by 429 patients (73%). Patients were eligible for this study if they scored > or =2 points on the 5-item Geriatric Depression Scale (n = 94) and were not missing key variables (final n = 90).

MEASUREMENTS AND MAIN RESULTS

Of the 90 depressed patients, 48 (53%) believed that feeling depressed was very important to discuss with a doctor. In unadjusted analysis, older adults who did not believe it is very important to discuss feeling depressed with a doctor were more likely to attribute becoming depressed to aging (41% vs 17%; P =.012). In a logistic regression model adjusting for sociodemographic characteristics, number of impairments in basic and instrumental activities of daily living, medical comorbidity, and physical (PCS-12) and mental (MCS-12) component summary scores from the Medical Outcomes Study Short-Form-12, depressed older adults who attributed depression to aging had a 4.3 times greater odds than those who attributed depression to illness to not believe it is very important to discuss depression with a doctor (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.3 to 14.5).

CONCLUSIONS

Among older persons with depression, attributing feeling depressed to old age may be an important barrier to care seeking.

Identification, course, and treatment of depression after admission for a cardiac condition: rationale and patient characteristics for the identifying depression as a comorbid condition (IDACC) project

BACKGROUND

Given the prevalence of cardiovascular disease and the high rates of depression among cardiac patients, there is a need to develop practical ways to identify this population and provide pragmatic general-practitioner-based interventions for managing depression as a comorbid condition.

METHOD

The Identifying Depression As a Comorbid Condition (IDACC) study employed a hybrid design, incorporating a randomized controlled trial nested within a prospective cohort study. IDACC screened for depression in patients hospitalized in South Australia for a range of cardiac conditions, with outcome measures monitored for 12 months after discharge. The subgroup identified as depressed was entered into the nested IDACC trial, which tests the hypothesis that identifying depression and offering an evidence-based intervention to general practitioners, incorporating multidisciplinary telephone case conferencing, will reduce levels of depression, improve quality of life, and reduce associated economic costs.

RESULTS

At baseline, 46.3% of 1455 participants screened were classified as depression cases on the basis of their score on the Center for Epidemiological Studies Depression Scale (> or =16) or the Hospital Anxiety and Depression Scale (> or =8). Elevated scores were associated with being younger, female, divorced or separated, not employed, living alone, having a lower level of education, and having poorer health and quality of life. Nearly one fifth (19.4%) of participants had Center for Epidemiological Studies Depression Scale scores >27, which is indicative of major depression.

CONCLUSIONS

This project confirms, in an Australian setting, the high prevalence of depressive symptoms among hospitalized cardiac patients. Follow-up over 12 months will enhance understanding of the natural history of depression in cardiac patients, while the nested trial will inform on effectiveness of an intervention involving tailored advice and support to general practitioners.

Maternal depression: an old problem that merits increased recognition by child healthcare practitioners

PURPOSE OF REVIEW

Maternal depression is an old problem that has received heightened public attention in recent years. Although the prevalence of maternal depression remains considerable, healthcare providers continue to underrecognize and undertreat women with this condition. Currently there is increasing political as well as international support for further study to understand depression and its impact on those directly and indirectly involved. This article will review the magnitude, impact, and suggested screening interventions for maternal depression.

RECENT FINDINGS

Various studies and reviews have documented the prevalence of maternal depression as well as the underrecognition and undertreatment of the problem. The barriers that contribute to this can be related to the individual, the provider, as well as the healthcare delivery system. Depression and even depressive symptoms have been well documented to have deleterious impacts in several domains. These include maternal-child relationships, parenting practices, family functioning, and even children's general development and well-being.

SUMMARY

The care of the mother has not been in the conventional scope of practice for pediatricians. However, child healthcare practitioners play a crucial rule in delivering family-oriented care, including the identification and referral of parents for emotional health problems that adversely affect children and family well-being.

The Patient Health Questionnaire-2: validity of a two-item depression screener

BACKGROUND

A number of self-administered questionnaires are available for assessing depression severity, including the 9-item Patient Health Questionnaire depression module (PHQ-9). Because even briefer measures might be desirable for use in busy clinical settings or as part of comprehensive health questionnaires, we evaluated a 2-item version of the PHQ depression module, the PHQ-2.

METHODS

The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 ("not at all") to 3 ("nearly every day"). The PHQ-2 was completed by 6000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-2 depression severity increased from 0 to 6, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-2 score > or =3 had a sensitivity of 83% and a specificity of 92% for major depression. Likelihood ratio and receiver operator characteristic analysis identified a PHQ-2 score of 3 as the optimal cutpoint for screening purposes. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

The construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening.

Screening for depression in primary care with two verbally asked questions: cross sectional study

OBJECTIVE

To determine the diagnostic accuracy of two verbally asked questions for screening for depression.

DESIGN

Cross sectional criterion standard validation study.

SETTING

15 general practices in New Zealand.

PARTICIPANTS

421 consecutive patients not taking psychotropic drugs.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and likelihood ratios of the two questions compared with the computerised composite international diagnostic interview.

RESULTS

The two screening questions showed a sensitivity and specificity of 97% (95% confidence interval, 83% to 99%) and 67% (62% to 72%), respectively. The likelihood ratio for a positive test was 2.9 (2.5 to 3.4) and the likelihood ratio for a negative test was 0.05 (0.01 to 0.35). Overall, 37% (157/421) of the patients screened positive for depression.

CONCLUSION

Two verbally asked questions for screening for depression would detect most cases of depression in general practice. The questions have the advantage of brevity. As treatment is more likely when doctors make the diagnosis, these questions may have even greater utility.

Predictors of psychiatric comorbidity in medical outpatients

OBJECTIVE

Psychiatric comorbidity in medical outpatients is associated with personal suffering and reduced psychosocial functioning. Simple clinical indicators are needed to improve recognition and treatment of psychiatric comorbidity. This study aimed to identify predictors of psychiatric comorbidity for diagnostic use in busy medical settings and to describe their criterion validity.

METHODS

The SCID was adopted as the independent criterion standard for the presence of a psychiatric comorbidity in 357 patients (68% female; mean age, 43 years) of six internal medicine outpatient clinics and 12 general practices. Potential indicators of psychiatric comorbidity were investigated by means of patient and physician questionnaires. Logistic regression analyses were used to identify independent predictors of psychiatric comorbidity, and their operating characteristics were determined.

RESULTS

Of 18 indicators, the four most important predictors of psychiatric comorbidity were identified: a screening question for nervousness, anxiety, or worries (odds ratio, 11.9; p <.001), a screening question for depressed mood (odds ratio, 8.8; p <.001), the self-report of three or more bothersome physical symptoms (odds ratio, 3.2; p =.001), and feeling distressed by partner difficulties (odds ratio, 2.7; p =.006). The combined assessment of the four predictors resulted in positive predictive values as high as 100%, negative predictive values as high as 91%, sensitivities as high as 86%, and specificities as high as 100%.

CONCLUSIONS

The identification of mental disorders in medical outpatients could be substantially improved by the knowledge and use of four easily accessible predictors. When the presence of one or more of these predictors can be confirmed, it is suggested that the patient undergo further evaluation to determine more precisely the presence and specific type of psychiatric disorder being identified.

Depressive symptoms and health-related quality of life: the Heart and Soul Study

CONTEXT

Little is known regarding the extent to which patient-reported health status, including symptom burden, physical limitation, and quality of life, is determined by psychosocial vs physiological factors among patients with chronic disease.

OBJECTIVE

To compare the contributions of depressive symptoms and measures of cardiac function to the health status of patients with coronary artery disease.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 1024 adults with stable coronary artery disease recruited from outpatient clinics in the San Francisco Bay Area between September 2000 and December 2002. Main Measures Measurement of depressive symptoms using the Patient Health Questionnaire (PHQ); assessment of cardiac function by measuring left ventricular ejection fraction on echocardiography, exercise capacity on treadmill testing, and ischemia on stress echocardiography; and measurement of a range of health status outcomes, including symptom burden, physical limitation, and quality of life, using the Seattle Angina Questionnaire. Participants were also asked to rate their overall health as excellent, very good, good, fair, or poor.

RESULTS

Of the 1024 participants, 201 (20%) had depressive symptoms (PHQ score > or =10). Participants with depressive symptoms were more likely than those without depressive symptoms to report at least mild symptom burden (60% vs 33%; P<.001), mild physical limitation (73% vs 40%; P<.001), mildly diminished quality of life (67% vs 31%; P<.001), and fair or poor overall health (66% vs 30%; P<.001). In multivariate analyses adjusting for measures of cardiac function and other patient characteristics, depressive symptoms were strongly associated with greater symptom burden (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.7; P =.002), greater physical limitation (OR, 3.1; 95% CI, 2.1-4.6; P<.001), worse quality of life (OR, 3.1; 95% CI, 2.2-4.6; P<.001), and worse overall health (OR, 2.0; 95% CI, 1.3-2.9; P<.001). Although decreased exercise capacity was associated with worse health status, left ventricular ejection fraction and ischemia were not.

CONCLUSIONS

Among patients with coronary disease, depressive symptoms are strongly associated with patient-reported health status, including symptom burden, physical limitation, quality of life, and overall health. Conversely, 2 traditional measures of cardiac function-ejection fraction and ischemia-are not. Efforts to improve health status should include assessment and treatment of depressive symptoms.

[Guidelines of the Brazilian Medical Association for the treatment of depression (complete version)]

OBJECTIVE

Depression is a frequent and chronic condition with high levels of functional disability. Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present the original document that originated the abbreviated version available at the electronic address of Brazilian Medical Association.

METHODS

This paper was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. Brazilian Medical Association proposed this methodology for the whole project.

RESULTS

The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Planning of different phases of treatment is22 also discussed.

CONCLUSIONS

Guidelines are a good tool helping clinical decisions and are a reference for an attitude based on levels of evidence.

Quality of life and sexual function after evaluation and treatment at a referral center for vulvovaginal disorders

OBJECTIVES

This study was undertaken to assess sexual function and quality of life of women after evaluation and treatment of vulvovaginal problems at a University Center.

STUDY DESIGN

Subjects were mailed a cover letter and follow-up survey. All new patients (322) referred for evaluation of vulvar problems at a University Vulvar Specialty Clinic between January 1, 1996, and December 31, 1999, were mailed a survey instrument containing specific questions concerning general, vulvar, and sexual health. Medical records from clinic visits were manually abstracted. Groups defined with descriptive statistics and proportional change in symptoms analyzed with chi(2) statistics.

RESULTS

Of the 322 women who met the study criteria, 195 returned valid surveys for an overall response rate of 60.5%. The mean duration of follow-up was 28 months. The most common presenting symptoms were vulvar pain (86%), dyspareunia (71%), itching (35%), and skin changes (20%). At follow-up, 128 (66%) reported improvement in symptoms compared with 14 (7%) that worsened (P <.001). Although subjects did not report an increase in the frequency of sexual activity, significantly more women reported an increase in enjoyment (n = 77, 43%) of sexual activity than a decrease (n = 30, 17%, P <.001).

CONCLUSION

Most women presenting for evaluation of vulvar pain will report improvement in symptoms and sexual function after treatment in a Vulvar Specialty Clinic.

Fluoxetine versus placebo in advanced cancer outpatients: a double-blinded trial of the Hoosier Oncology Group

PURPOSE

To determine whether fluoxetine improves overall quality of life (QOL) in advanced cancer patients with symptoms of depression revealed by a simple survey.

PATIENTS AND METHODS

One hundred sixty-three patients with an advanced solid tumor and expected survival between 3 and 24 months were randomly assigned in a double-blinded fashion to receive either fluoxetine (20 mg daily) or placebo for 12 weeks. Patients were screened for at least minimal depressive symptoms and assessed every 3 to 6 weeks for QOL and depression. Patients with recent exposure to antidepressants were excluded.

RESULTS

The groups were comparable at baseline in terms of age, sex, disease distribution, performance status, and level of depressive symptoms. One hundred twenty-nine patients (79%) completed at least one follow-up assessment. Analysis using generalized estimating equation modeling revealed that patients treated with fluoxetine exhibited a significant improvement in QOL as shown by the Functional Assessment of Cancer Therapy-General, compared with patients given placebo (P =.01). Specifically, the level of depressive symptoms expressed was lower in patients treated with fluoxetine (P =.0005), and the subgroup of patients showing higher levels of depressive symptoms on the two-question screening survey were the most likely to benefit from treatment.

CONCLUSION

In this mix of patients with advanced cancer who had symptoms of depression as determined by a two-question bedside survey, use of fluoxetine was well tolerated, overall QOL was improved, and depressive symptoms were reduced.

Bupropion SR and smoking cessation in actual practice: methods for recruitment, screening, and exclusion for a field trial in a managed-care setting

BACKGROUND

Little is known about the effectiveness of bupropion SR for smoking cessation outside the context of clinical efficacy trials, where in-person screening and treatment occur at a higher level than provided in a typical health care system. This article describes the methods for recruitment, screening for exclusions, and resulting sample in a field trial of bupropion SR undertaken in a managed-care setting.

METHODS

A total of 2979 telephone interviews were conducted to screen and identify eligible volunteers using a detailed protocol that allowed for consultation with study physicians when necessary. The volunteers' primary care physicians were given the option to override their eligibility, and pharmacy databases were used to verify medication reporting.

RESULTS

A total of 1909 (64%) volunteers were considered eligible for the study. The most common reason for exclusion was use of contraindicated medications (32%), followed by recent use of one of the behavioral cessation programs (14%), brain injury that reduced seizure threshold (14%), current depression (14%), and high levels of alcohol use (13%).

CONCLUSIONS

The methods used in this field trial show that it is possible to enroll subjects in an effectiveness trial that is successful from the standpoint of the consumer, provider, and health care system.

Validation of the five-item geriatric depression scale in elderly subjects in three different settings

OBJECTIVES

To test the effectiveness of a five-item version of the Geriatric Depression Scale (GDS) for the screening of depression in community-dwelling older subjects, hospitalized older patients, and nursing home residents.

DESIGN

A cross-sectional study.

SETTING

A geriatric acute care ward, a geriatric outpatient clinic, and a nursing home.

PARTICIPANTS

One hundred eighty-one cognitively intact older subjects.

MEASUREMENT

All the participants had a comprehensive geriatric assessment including a neuropsychological evaluation by a geriatrician experienced in the management of depression. The five-item GDS was compared with the 15-item version of the GDS using the clinical diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as the criterion standard. The sensitivity, the specificity, the overall accuracy, positive and negative predictive values, and positive and negative likelihood ratios were calculated. The agreement between each of two different versions of the GDS and the clinical diagnosis and the test-retest and the interrater reliability of the five-item scale were also evaluated.

RESULTS

In the whole sample, 48.1% of the subjects were depressed. The five-item GDS had a sensitivity of 0.94 (0.91-0.98), a specificity of 0.81 (0.75-0.87), a positive predictive value of 0.81 (0.75-0.87), a negative predictive value of 0.94 (0.90-0.97), a positive likelihood ratio of 4.92 (4.39-5.5), and a negative likelihood ratio of 0.07 (0.06-0.08). The five-item GDS and the 15-item GDS showed a significant agreement with the clinical diagnosis of depression (kappa = 0.74 for both scales). The five-item GDS had good interrater reliability (kappa = 0.88) and test-retest reliability (kappa = 0.84). Similar values were obtained in each setting and in both sexes.

CONCLUSION

The five-item GDS is as effective as the 15-item GDS for the screening of depression in cognitively intact older subjects.

Criminality in the offspring of antenatally depressed mothers: a 33-year follow-up of the Northern Finland 1966 Birth Cohort

BACKGROUND

No epidemiological studies have been reported on the association between mothers' antenatal depression and criminality in their offspring.

METHODS

The material consists of a general population cohort of 12059 children born in 1966 in Northern Finland and followed to the end of 1998. Mothers were asked at midgestation by a nurse at the antenatal clinic if they felt themselves to be depressed. The Finnish Ministry of Justice provided information for all descendants on criminal offences. The associations between maternal depression and subgroups of violent and non-violent, violent recidive and non-recidive criminality in male and female offspring were analysed.

RESULTS

Of the mothers 14% had depressed mood during pregnancy. A total of 607 (10.9%) male and 72 (1.3%) female criminal offenders were included in the cohort. When adjusted for mother's marital status, smoking, wantedness of the pregnancy, place of residence, socioeconomic status and perinatal complications, the odds ratio (OR) for males was 1.4 (95% CI 1.0-1.9) in the association between maternal depression and non-violent offenders, 1.6 (1.1-2.4) between maternal depression and violent offenders and 1.7 (1.0-3.0) between maternal depression and violent recidivists. The adjusted OR for females involved in non-violent crimes was 1.7 (0.9-3.3) and 0.6 (0.1-6.0) for violent crimes.

LIMITATIONS

Maternal depression was not checked using a standardized assessment.

CONCLUSIONS

For male offspring of antenatally depressed mothers there was a significant but slight increase in criminality. The emotional state of a pregnant mother may have some, but limited, influence on later criminality in the offspring.

Depression in adolescence

Major depressive disorder is a common problem for adolescents. It has a wide array of symptoms affecting somatic, cognitive, affective, and social processes. Academic failure, poor peer relationships, behavioral problems, conflict with parents and other authority figures, and substance abuse are some of the consequences of major depressive disorder in this age group. Effective treatments include nontricyclic antidepressants and coping skills training. The nurse is key to depression detection and suicide prevention, especially in primary care settings. Through psychoeducation, nurses can promote recovery from depression by encouraging a healthy lifestyle, enhancing social skills, and assisting the adolescent to identify and use sources of social support. These measures can prevent premature death and promote long-term well-being of the adolescent.

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE

To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting.

DATA SOURCES

Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR.

CONCLUSIONS

Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services.

IMPLICATIONS FOR PRACTICE

This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.

Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.