Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care

Reliability and validity of the brief psychosomatic symptom scale (BPSS) in patients from general hospitals

OBJECTIVES

To verify the Brief Psychosomatic Symptom Scale (BPSS) among patients with psychosomatic-related disorders in general hospitals and determine the threshold of BPSS.

METHODS

The BPSS is a shortened 10-item version of the psychosomatic symptoms scale (PSSS). Data from 483 patients and 388 healthy controls were included for psychometric analyses. Internal consistency, construct validity, and factorial validity were verified. The threshold of BPSS in distinguishing psychosomatic patients from healthy controls were determined using receiver operating characteristic (ROC) curve analysis. The ROC curve of the BPSS was compared with that of the PSSS and patient health questionnaire-15 (PHQ-15) by using Venkatraman's method with 2000 times Monte-Carlo simulations.

RESULTS

The reliability of the BPSS was good with Cronbach's α of 0.831. BPSS was significantly correlated with PSSS (r = 0.886, P < 0.001), PHQ-15 (r = 0.752, P < 0.001), PHQ-9 (r = 0.757, P < 0.001) and GAD-7 (r = 0.715, P < 0.001), which indicated good construct validity. ROC analyses demonstrated that the AUC of the BPSS was comparable with that of PSSS. The gender-specific threshold of BPSS was determined as ≥8 in males and ≥ 9 in females.

CONCLUSIONS

The BPSS is a brief and validated instrument for screening common psychosomatic symptoms.

Associations of multimorbidity and patient-reported experiences of care with conservative management among elderly patients with localized prostate cancer

Background

Many elderly localized prostate cancer patients could benefit from conservative management (CM). This retrospective cohort study examined the associations of patient‐reported access to care and multimorbidity on CM use patterns among Medicare Fee‐for‐Service (FFS) beneficiaries with localized prostate cancer.

Methods

We used linked Surveillance, Epidemiology, and End Results cancer Registry, Medicare Claims, and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey files. We identified FFS Medicare Beneficiaries (age ≥ 66; continuous enrollment in Parts A & B) with incident localized prostate cancer from 2003 to 2013 and a completed MCAHPS survey measuring patient‐reported experiences of care within 24 months after diagnosis (n = 496). We used multivariable models to examine MCAHPS measures (getting needed care, timeliness of care, and doctor communication) and multimorbidity on CM use.

Results

Localized prostate cancer patients with multimorbidity were less likely to use CM (adjusted odds ratio (AOR)=0.42 (0.27‐ 0.66), P < .001); those with higher scores on timeliness of care (AOR = 1.21 (1.09, 1.35), P < .001), higher education attainment (3.21 = AOR (1.50,6.89), P = .003), and impaired mental health status (4.32 = AOR (1.86, 10.1) P < .001) were more likely to use CM.

Conclusion(s)

Patient‐reported experience with timely care was significantly and positively associated with CM use. Multimorbidity was significantly and inversely associated with CM use. Addressing specific modifiable barriers to timely care along the cancer continuum for elderly localized prostate cancer patients with limited life expectancy could reduce the adverse effects of overtreatment on health outcomes and costs.

The impact of comorbid pain and depression in the United States: results from a nationally representative survey

Background and aims The co-morbidity between pain and depression is a target of interest for treatment. However most of the published literature on the topic has used clinical cohorts as the population of interest. The goal of this study was to use a nationally representative sample to explore how health outcomes varied across pain and depression status in a cohort sampled from the general US population. Methods This was a cross-sectional analysis of adults ≥18 years in the 2009-2010 National Health and Nutrition Examination Survey. The cohort was stratified into: no pain/depression, pain alone, depression alone, and pain with depression. The primary outcome was self-reported general health status, and secondary outcomes were healthcare visits, overnight hospital stays and functional limitation. Survey weighted logistic regression was used to adjust for potential confounders. Results The cohort consisted of 4,213 individuals, of which 186 (4.4%) reported concurrent pain and depression. 597 (14.2%) and 253 (6.0%) were classified with either pain or depression alone, respectively. The majority of individuals with co-morbid pain and depression reported poor health (65.1%, p<0.001) and were significantly more likely than those with neither condition to rate their health as poor after adjustment (OR: 7.77, 95% CI: 4.24-14.26, p<0.001). Those with pain only or depression only were also more likely to rate their health as poor, albeit to a lesser extent (OR: 2.21, 95% CI: 1.21-2.34, p<0.001; OR: 3.75, 95% CI: 2.54-5.54, p<0.001, respectively). A similar pattern was noted across all secondary outcomes. Most notably, those with co-morbid pain and depression were the most likely to endorse functional limitation (OR: 13.15, 95% CI: 8.00-21.61, p<0.001). Comparatively, a similar trend was noted amongst those with pain only or depression only, though with a reduced effect size (OR: 4.23, 95% CI: 3.12-4.77, p<0.001; OR: 5.13, 95% CI: 3.38-7.82, p<0.001). Conclusions Co-morbid pain and depression in the general population resulted in markedly worse outcomes versus isolated pain or depression. Further, the effect appears to be synergistic. Given the substantial burdens of pain and depression, future treatments should aim to address both conditions simultaneously. Implications As a result of the co-morbidity between pain and depression, patients presenting with either condition should increase the index of suspicion among clinicians and prompt screening for the reciprocal condition. Early intervention for co-morbid pain and depression has the potential to mitigate future incidence of chronic pain and major depression.

Patterns and predictors of self-reported clinical diagnosis and treatment for depression in prostate cancer survivors

Background

Appropriate depression care is a cancer‐care priority. However, many cancer survivors live with undiagnosed and untreated depression. Prostate cancer survivors may be particularly vulnerable, but little is known about their access to depression care. The goal of this study was to describe patterns and predictors of clinical diagnosis and treatment of depression in prostate cancer survivors.

Methods

Generalized estimating equations were used to evaluate indicators of self‐reported clinical diagnosis and treatment depression as a function of individual‐level characteristics within a longitudinal dataset. The data were from a population‐based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 on the North Carolina‐Louisiana Prostate Cancer Project (N = 1,031), and prospectively followed annually from 2008 to 2011 on the Health Care Access and Prostate Cancer Treatment in North Carolina (N = 805).

Results

The average rate of self‐reported clinical diagnosis of depression was 44% (95% CI: 39%‐49%), which declined from 60% to 40% between prostate cancer diagnosis and 5‐7 years later. Factors associated with lower odds of self‐reported clinical diagnosis of depression include African‐American race, employment, age at enrollment, low education, infrequent primary care visits, and living with a prostate cancer diagnosis for more than 2 years. The average rate of self‐reported depression treatment was 62% (95% CI: 55%‐69%). Factors associated with lower odds of self‐reported depression treatment included employment and living with a prostate cancer diagnosis for 2 or more years.

Conclusion

Prostate cancer survivors experience barriers when in need of depression care.

Nonsymptomatic Factors More Strongly Associated with High-Quality End-of-Life Care than Symptomatic Factors for Community-Dwelling Older Adults with Multiple Chronic Conditions

Background: Information about end-of-life goals and preferences of older adults with multiple chronic conditions (MCCs) is scarce, but necessary for prioritizing resources to care for this population. Objective: The aim of this study was to determine which end-of-life quality domains are associated with excellent overall end-of-life care quality for older adults with MCCs. Design: This study involved retrospective cross-sectional cohort analysis of secondary data derived from the National Health and Aging Trends Study (NHATS), Last Month of Life Interview. Measurements: Weighted bivariable analyses determined unadjusted relationships between overall care quality and end-of-life care quality. Weighted unadjusted and adjusted multiple logistic regression tested the association of ratings of overall care quality with the perception of quality. Results: The final analytic sample included 477 NHATS participants (weighted: 1,123,887 participants). For older adults with MCC, the rating of overall care quality was positively associated with coordination (adjusted odds ratio [aOR] 4.49; 95% confidence interval [CI]: 1.85-10.86), shared decision making (aOR 1.97; 95% CI: 1.12-3.47), respect (aOR 6.36; 95% CI: 3.23-12.52), and spiritual and emotional support (aOR 2.02; 95% CI: 1.23-3.30). We found no significant association between the rating of overall care quality and symptom management (aOR 1.49; 95% CI: 0.81-2.71). Conclusion: Given that nonsymptomatic domains (coordination, shared decision making, respect, and spiritual and emotional support) were most associated with high-quality end-of-life care for older adults with MCC as rated by their proxies, increased attention is needed to strengthen these aspects of care. Symptom management was unrelated to the overall quality rating, and further research is needed to illuminate the meaning of this finding.

Suicide Risk Assessment and Management in the Psychiatry Emergency Service: Psychiatric Provider Experience and Perceptions

The objective of this study was to explore suicide risk identification and flow of patients with differing suicide risk through the Psychiatric Emergency Service (PES) to their clinical dispositions. 3 focus groups (N = 15 psychiatric providers working in the PES of a large urban teaching hospital) discussing suicide risk assessment in the PES were conducted, followed by thematic analysis. A total of 7 themes were identified in 624 coded passages. In focus groups conducted to explore suicide risk assessment, discussions shifted to broader matters, e.g., frustrations with the system in which the providers worked. 4 main messages emerged: screening tools cannot replace clinical judgment; the existing electronic health record is not efficient and sufficiently informative; competing demands challenge PES psychiatrists; and post-discharge patient outcome data are needed. These concerns suggest directions for improving patient care.

Treatment Initiation for New Episodes of Depression in Primary Care Settings

BACKGROUND

Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment.

OBJECTIVE

To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings.

DESIGN

A retrospective observational design was used to analyze electronic health record data.

PATIENTS

A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013.

MAIN MEASURES

ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis.

KEY RESULTS

Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged  ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication.

CONCLUSIONS

Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.

Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders

OBJECTIVE

Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs).

METHODS

2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups.

RESULTS

FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs.

CONCLUSION

Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.

Identifying children with anxiety disorders using brief versions of the Spence Children's Anxiety Scale for children, parents, and teachers

Anxiety disorders are among the most prevalent mental health disorders experienced by children and are associated with significant negative outcomes. Only a minority of affected children, however, access professional help, and a failure to identify children with anxiety disorders presents a key barrier to treatment access. Existing child anxiety questionnaire measures are long and time consuming to complete, limiting their potential for widespread use as identification tools in community settings. We developed a brief questionnaire for parents, children, and teachers using items from the Spence Children’s Anxiety Scale (SCAS) and evaluated the new measure’s psychometric properties, capacity to discriminate between a community (n = 361) and clinic-referred sample (n = 338) of children aged 7–11, and identified optimal cut-off scores for accurate identification of preadolescent children experiencing clinically significant levels of anxiety. The findings provided support for the reliability and validity of 8-item versions of the SCAS, with the brief questionnaire scores displaying comparable internal consistency, agreement among reporters, and convergent/divergent validity to the full-length SCAS scores. The brief SCAS scores also discriminated between the community and clinic-referred samples and identified children in the clinic-referred sample with a moderate-to-good level of accuracy and acceptable sensitivity and specificity. Combining reporters improved sensitivity, but at the expense of specificity, and findings suggested parent report should be prioritized. This new brief questionnaire has potential for use in community settings as a tool to improve identification of children who are experiencing clinically significant levels of anxiety and warrant further assessment and potential support.

We developed and evaluated brief versions of the Spence Children’s Anxiety Scale for parents, children, and teachers. Results provide support for the potential application of this new brief questionnaire in community settings to improve identification of children with anxiety disorders.

Screening for anxiety, depression, and anxious depression in primary care: A field study for ICD-11 PHC

BACKGROUND

In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings.

METHODS

The study was conducted in primary care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted for proposed decision rules in ICD-11 PHC, were administered to 1488 participants.

RESULTS

A score of 3 or more on one or both screening scale predicted 89.6% of above-threshold mood or anxiety disorder diagnoses on the CIS-R. Anxious depression was the most common CIS-R diagnosis among referred patients. However, there was an exact diagnostic match between the screening scales and the CIS-R in only 62.9% of those with high scores.

LIMITATIONS

This study was confined to those in whom the PCP suspected psychological distress, so does not provide information about the prevalence of mental disorders in primary care settings.

CONCLUSIONS

The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially improved case detection as compared to current primary care practice and a realistic alternative to complex diagnostic algorithms used by specialist mental health professionals.

Screening for Problematic Worry in Adults With a Single Item From the Penn State Worry Questionnaire

As the rapid assessment of mental health is a growing need, a quick and valid tool for the early detection of symptoms that can be flexibly deployed across a range of contexts may be especially beneficial. This is particularly true of anxiety problems, which when undetected contribute to health care costs and lost work productivity. Data from more than 10,000 respondents (primarily female undergraduates) were used to test whether a single item from the popular Penn State Worry Questionnaire could serve as a screening tool in settings where administration of the full scale is undesirable. Items were evaluated by examining item response theory models, screening capabilities, stability over time, convergence with other anxiety and depression measures, and a response time analysis that assessed how quickly participants responded to each item. Item 15 ("I worry all the time") emerged as the strongest item: It was the most discriminating and reliable item, had sensitivity and specificity similar to the full scale, had the highest 1-month and 1-year retest coefficients, the highest convergent correlations with measures of anxiety and depression, and was responded to significantly faster than any other item. We suggest that in time-limited contexts, this item is suitable for screening.

Process-oriented dynamic group psychotherapy for depression as a teaching modality in a family medicine residency program- A pilot study

Background and Objectives This pilot study provides a description and evaluation of process-oriented dynamic group psychotherapy for depression as a teaching modality for family medicine residents. The main purpose of using this modality was to teach family medicine residents a variety of psychological clinical skills. A secondary benefit of this modality was to provide in-house, primary care treatment to depressed patients, although the efficacy of this was not evaluated in the present study. Methods A 10-item, self-report, Likert-type questionnaire was administered to a convenience sample of family medicine residents who had participated in the program. Results Completed questionnaires were received from 100% of the family medicine resident participants. Responses to the questionnaires indicate that the residents felt they acquired a variety of clinical skills from the training modality, to include developing active listening and interviewing skills; methods to improve the doctor-patient relationship; increased skills in empathy, intuitive processes, and emotional support; a depth understanding of how intra-psychic conflicts and interpersonal problems contribute to depression; how to give effective feedback that promotes behavioral change; and how to place interventions at the appropriate level of change. Eighty-eight percent of residents indicated they would recommend this learning modality to a family medicine physician colleague. Conclusions The family medicine residents' responses to the questionnaires indicate that they perceived process-oriented dynamic group psychotherapy for depression as a constructive and beneficial modality for both patient care and learning a variety of clinical skills.

Time to follow-up of an abnormal mammogram in women with diabetes: a population-based study

Women with diabetes have a higher breast cancer incidence and mortality. They are also significantly less likely to undergo screening mammography and present with more advanced stage than women without diabetes. The purpose of this study was to examine if women with diabetes are more likely to have delays in follow-up of abnormal mammograms, compared to women without diabetes. Using population-based health databases, this retrospective cohort study examined women between the ages of 50 and 74, with and without diabetes, living in the province of Ontario, Canada, who underwent screening through a centralized program and who had an abnormal mammogram between 2003 and 2012. We compared rates of follow-up of a diagnostic test within 180 days, as well as likelihood of mastectomy or excision procedure and a diagnosis of breast cancer. Following an abnormal screening mammogram, 97.5% of women with diabetes had a diagnostic procedure within 180 days compared to 97.9% of women without diabetes. After adjustment for other factors, women with diabetes were only 3% less likely to have follow-up testing after an abnormal mammogram than women without diabetes (hazard ratio [HR] 0.97, 95% CI: 0.96-0.99, P < 0.001). The majority of Ontario women who underwent screening mammography through a centralized screening program had timely follow-up of an abnormal mammogram, with no meaningful delays in those who had diabetes. The results of this study suggest that diagnostic delays after screening do not significantly contribute to higher breast cancer mortality in women with diabetes.

Rationale and study protocol for a multi-component Health Information Technology (HIT) screening tool for depression and post-traumatic stress disorder in the primary care setting

The prevalence rate of depression in primary care is high. Primary care providers serve as the initial point of contact for the majority of patients with depression, yet, approximately 50% of cases remain unrecognized. The under-diagnosis of depression may be further exacerbated in limited English-language proficient (LEP) populations. Language barriers may result in less discussion of patients' mental health needs and fewer referrals to mental health services, particularly given competing priorities of other medical conditions and providers' time pressures. Recent advances in Health Information Technology (HIT) may facilitate novel ways to screen for depression and other mental health disorders in LEP populations. The purpose of this paper is to describe the rationale and protocol of a clustered randomized controlled trial that will test the effectiveness of an HIT intervention that provides a multi-component approach to delivering culturally competent, mental health care in the primary care setting. The HIT intervention has four components: 1) web-based provider training, 2) multimedia electronic screening of depression and PTSD in the patients' primary language, 3) Computer generated risk assessment scores delivered directly to the provider, and 4) clinical decision support. The outcomes of the study include assessing the potential of the HIT intervention to improve screening rates, clinical detection, provider initiation of treatment, and patient outcomes for depression and post-traumatic stress disorder (PTSD) among LEP Cambodian refugees who experienced war atrocities and trauma during the Khmer Rouge. This technology has the potential to be adapted to any LEP population in order to facilitate mental health screening and treatment in the primary care setting.

Professional interventions for general practitioners on the management of musculoskeletal conditions

BACKGROUND

Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.

OBJECTIVES

To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. 

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.

MAIN RESULTS

Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.

AUTHORS' CONCLUSIONS

There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

Attachment and maternal sensitivity are related to infants' monitoring of animated social interactions

BACKGROUND

Infants have been shown to possess remarkable competencies in social understanding. Little is known, however, about the interplay between the quality of infants' social-emotional experiences with their caregivers and social-cognitive processes in infancy.

METHOD

Using eye-tracking we investigated the relation of infant attachment quality and maternal sensitivity with 12-month-old infants' monitoring patterns during the observation of abstractly depicted interactions of a "parent" and a "baby" figure.

RESULTS

We found that secure infants focused their attention on the "parent" figure relative to the "baby" figure more than insecure infants when the two figures got separated. Infants with more sensitive mothers focused their attention more on the ongoing behavior of the "parent" figure after the separation than infants with less sensitive mothers when distress of the "baby" figure was implied by accompanying baby crying sounds.

CONCLUSION

Our findings support the notion that early social-emotional experiences with the caregiver are related to social information processing and that these social information processing patterns might be markers of infants' developing internal working models of attachment.

Culturally responsive integrated health care: Key issues for medical education

Primary care providers are increasingly responsible for providing mental health care in the United States. For those patients who do receive specialty mental health services, the primary care provider functions as the main entry point into the mental health system. Given the persistent racial and ethnic health disparities in the United States, it is not surprising that mental health disparities also present a difficult challenge for both the U.S. health system and for frontline practitioners. Physicians-in-training require tools for rapid psychiatric assessment that will quickly identify pertinent symptom clusters and distinguish between major psychological disorders. It is incumbent on residency faculty to teach resident physicians how to provide culturally responsive mental health assessment and intervention/referral knowledge and skills toward the elimination of these disparities and toward patient-centered care. This article begins with an overview of health disparities and barriers to health and mental health care access, followed by a discussion of culturally responsive care including an example of a culturally responsive educational program in the United States that is directly targeting the problem of access in that geographic region. It concludes with a review of educational strategies for enhancing culturally responsive behavioral and mental health care by physicians in training.

Health care expenditures associated with depression in adults with cancer

BACKGROUND

The rates of depression in adults with cancer have been reported as high as 38%-58%. How depression affects overall health care expenditures in individuals with cancer is an under-researched area.

OBJECTIVE

To estimate excess average total health care expenditures associated with depression in adults with cancer by comparing those with and without depression after controlling for demographic, socioeconomic, access to care, and other health status variables.

METHODS

Cross-sectional data on 4,766 adult survivors of cancer from 2006-2009 of the nationally representative household survey, Medical Expenditure Panel Survey (MEPS), were used. The patients were older than 21 years. Cancer and depression were identified from the patients' medical conditions files. Dependent variables consisted of total, inpatient, outpatient, emergency department, prescription drugs, and other expenditures. Ordinary least square (OLS) on logged dollars and generalized linear models with log-link function were performed. All analyses (SAS 9.3 and STATA12) accounted for the complex survey design of the MEPS.

RESULTS

Overall, 14% of individuals with cancer reported having depression. In those with cancer and depression, the average annual health care expenditures were $18,401 compared with $12,091 in those without depression. After adjusting for demographic, socioeconomic, access to care, and other health status variables, those with depression had about 31.7% greater total expenditures compared with those without depression. Total, outpatient, and prescription expenditures were higher in individuals with depression than in those without depression. Individuals with cancer and depression were significantly more likely to use emergency departments (adjusted odds ratio, 1.46) compared with their counterparts without depression.

LIMITATIONS

Cancer patients who died during the reporting year were excluded. The financial burden of depression may have been underestimated because the costs of end-of-life care are high. The burden for each cancer type was not analyzed because of the small sample size.

CONCLUSION

In adults with cancer, those with depression had higher health care utilization and expenditures compared with those without depression.

FUNDING/SPONSORSHIP

One author was partially supported by the National Institute of General Medical Sciences, U54GM104942.

Pragmatic characteristics of patient-reported outcome measures are important for use in clinical practice

OBJECTIVES

Measures for assessing patient-reported outcomes (PROs) that may have initially been developed for research are increasingly being recommended for use in clinical practice as well. Although psychometric rigor is essential, this article focuses on pragmatic characteristics of PROs that may enhance uptake into clinical practice.

STUDY DESIGN AND SETTING

Three sources were drawn on in identifying pragmatic criteria for PROs: (1) selected literature review including recommendations by other expert groups; (2) key features of several model public domain PROs; and (3) the authors' experience in developing practical PROs.

RESULTS

Eight characteristics of a practical PRO include: (1) actionability (i.e., scores guide diagnostic or therapeutic actions/decision making); (2) appropriateness for the relevant clinical setting; (3) universality (i.e., for screening, severity assessment, and monitoring across multiple conditions); (4) self-administration; (5) item features (number of items and bundling issues); (6) response options (option number and dimensions, uniform vs. varying options, time frame, intervals between options); (7) scoring (simplicity and interpretability); and (8) accessibility (nonproprietary, downloadable, available in different languages and for vulnerable groups, and incorporated into electronic health records).

CONCLUSION

Balancing psychometric and pragmatic factors in the development of PROs is important for accelerating the incorporation of PROs into clinical practice.

Chronic physical comorbidity burden and the quality of depression treatment in primary care: a systematic review

OBJECTIVE

We examined whether the treatment and follow-up care for depression in routine primary care differs between adults with higher chronic physical comorbidity burden compared to adults with lower chronic physical comorbidity burden and explored factors leading to divergent results across studies.

METHODS

We conducted a systematic review of English and French articles using Medline, Embase, PsycINFO, CINAHL and Cochrane Controlled Trials Register from inception to July 2013. Reference list and reverse citation searches were also conducted. Search terms included depression, primary care, general practitioner, chronic disease and comorbidity. Study eligibility required inclusion of relevant quality indicators and data contrasting participants with higher and lower chronic physical comorbidity burden. Study selection and quality appraisal were carried out independently by two review authors. A narrative synthesis of results was performed.

RESULTS

Our search yielded 5817 unique citations and 46 studies met inclusion criteria. Studies provided data on quality of pharmacotherapy (n=28), psychotherapy (n=4), combined measures of treatment quality (n=14), and follow-up care (n=9). Across studies, evidence that higher chronic physical comorbidity burden was associated with lower depression treatment or follow-up care quality was reported in 13 studies whereas evidence for the opposite relationship was reported in 15 studies. Four studies reported mixed results and 14 studies observed no relationships between comorbidity burden and depression treatment or follow-up care quality.

CONCLUSION

Review findings suggest that chronic physical comorbidity does not consistently lead to lower quality of depression treatment or follow-up care in primary care.

Assessing somatic symptom burden: a psychometric comparison of the patient health questionnaire-15 (PHQ-15) and the somatic symptom scale-8 (SSS-8)

OBJECTIVE

The Patient Health Questionnaire-15 (PHQ-15) is a frequently used questionnaire to assess somatic symptom burden. Recently, the Somatic Symptom Scale-8 (SSS-8) has been published as a short version of the PHQ-15. This study examines whether the instruments' psychometric properties and estimates of symptom burden are comparable.

METHODS

Psychosomatic outpatients (N=131) completed the PHQ-15, the SSS-8 and other questionnaires (PHQ-9, GAD-7, WI-7, SF-12). Item characteristics and measures of reliability, validity, and symptom severity were determined and compared.

RESULTS

The reliabilities of the PHQ-15 and SSS-8 were α=0.80 and α=0.76, respectively and both scales were highly correlated (r=0.83). The item characteristics were comparable. Both instruments showed the same pattern of correlations with measures of depression, anxiety, health anxiety and health-related quality of life (r=0.32 to 0.61). On both scales a 1-point increase was associated with a 3% increase in health care use. The percentile distributions of the PHQ-15 and the SSS-8 were similar. Using the same thresholds for somatic symptom severity (5, 10, and 15 points), both instruments identified nearly identical subgroups of patients with respect to health related quality of life.

CONCLUSION

The PHQ-15 and the SSS-8 showed similar reliability and validity but the comparability of severity classifications needs further evaluation in other populations. Until then we recommend the use of the previously established thresholds. Overall, the SSS-8 performed well as a short version of the PHQ-15 which makes it preferable for assessment in time restricted settings.

The influence of comorbid chronic physical conditions on depression recognition in primary care: a systematic review

OBJECTIVE

People with depression often suffer from comorbid chronic physical conditions and such conditions are widely believed to interfere with primary care providers' ability to recognize their depression. We aimed to examine the evidence related to the influence of chronic physical comorbidity burden on depression recognition in routine, community-based primary care settings.

METHODS

We conducted a systematic review of the literature on depression recognition in primary care that featured comparisons between patient groups with higher and lower burdens of chronic physical comorbidity. Medline, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched from inception to July 2013. Reference list and reverse citation searches were also performed. A narrative synthesis was conducted given clinical and methodological heterogeneity between studies.

RESULTS

Our search identified 5817 unique citations, out of which we identified 13 studies reporting data on the relationship between chronic physical comorbidity burden and depression recognition in primary care. Four studies provided some evidence that higher chronic physical comorbidity burden negatively affected primary care providers' ability to recognize depression. In contrast, two studies reported higher rates of recognition in patients with higher comorbidity burden and seven studies reported no differences in recognition between comorbidity groups.

CONCLUSION

Chronic physical comorbidity burden does not consistently affect depression recognition negatively in primary care. Instead, recognition seems to vary depending on the specific conditions or combination of conditions examined. Methodological choices of authors, such as approaches to measuring recognition and chronic medical comorbidity, also likely explain some divergent results across studies.

Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes

OBJECTIVE

Within Latino culture, there is a belief that strong emotions can cause diabetes. Because of this belief and evidence regarding the bi-directional relationship between depression and diabetes, the objectives of this study were to determine if medical doctors are asking Latinos with diabetes about emotional problems and to assess attitudes toward professional help for emotional problems.

RESEARCH DESIGN AND METHODS

Data come from the nationally representative National Latino and Asian American Study and the National Comorbidity Survey Replication study. Only Latino subsamples were included (n=3076). A smaller subsample with complete data (n=2568) was used for the inquiry outcome variable. Weighted χ(2) analysis and logistic regression were conducted to determine the likelihood of being asked about emotional problems and attitudes toward professional help.

RESULTS

Latinos with mood disorders or anxiety (MD/AX; OR 2.84, 95% CI 2.02 to 4.00), diabetes only (OR 1.69, 95% CI 1.06 to 2.69), and co-occurring diabetes and MD/AX (OR 6.67, 95% CI 2.33 to 19.04) were more likely to be asked about emotional problems, relative to Latinos without diabetes or MD/AX. A minority of respondents with diabetes (32%) were asked about emotional problems. Respondents with diabetes only were more likely to feel comfortable talking to a professional for personal problems compared with those without diabetes or MD/AX (OR 1.44, 95% CI 0.99 to 2.09). Although the relationship between having diabetes and feeling comfortable taking to a professional is not statistically significant, z-test statistics indicate that having diabetes influences attitudes about discussing emotional problems.

CONCLUSIONS

Among Latinos, having diabetes is associated with greater likelihood of being asked about emotional problems and feeling comfortable talking to a professional about personal problems. Consistent with the cultural relevance of emotions as a cause of diabetes, asking about emotional problems may be a useful approach for engaging Latinos into a discussion about their diabetes self-care activities.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

OBJECTIVE

The objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans.

METHODS

Data came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care.

RESULTS

Only 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07-10.31).

CONCLUSIONS

Although individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions

OBJECTIVE

This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions.

METHOD

Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions.

RESULTS

Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46).

CONCLUSIONS

Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.

The economic, public health, and caregiver burden of late-life depression

This article reviews the burden of late-life depression (LLD) from several perspectives, including costs of depression treatment and treatment of other comorbid psychiatric and medical conditions; the impact of LLD on job functioning, disability, and retirement; and how LLD influences others, such as family members and caregivers.

The role of somatic health problems in the recognition of depressive and anxiety disorders by general practitioners

BACKGROUND

Recognition of depression and anxiety by general practitioners (GPs) is suboptimal and there is uncertainty as to whether particular somatic health problems hinder or facilitate GP recognition. The objective of this study was to investigate the associations between somatic health problems and GP recognition of depression and anxiety.

METHODS

We studied primary care patients with a DSM-IV based psychiatric diagnosis of depressive or anxiety disorder during a face-to-face interview (n=778). GPs' registrations of depression and anxiety diagnoses, based on medical file extractions, were compared with the DSM-IV based psychiatric diagnoses as reference standard. Somatic health problems were based on self-report of several chronic somatic diseases and pain symptoms, using the Chronic Pain Grade (CPG), during the interview.

RESULTS

Depression and anxiety was recognized in sixty percent of the patients. None of the health problems were negatively associated with recognition. Greater severity of pain symptoms (OR=1.18, p=.02), and chest pain (OR=1.56, p=.02), in particular, were associated with more GP recognition of depression and anxiety. Mediation analyses showed that depression and anxiety in these patients were better recognized through the presence of more severe psychiatric symptoms.

LIMITATIONS

Some specific chronic diseases had low prevalence.

CONCLUSIONS

This study shows that the presence of particular chronic diseases does not influence GP recognition of depression and anxiety. GPs tend to recognize depression and anxiety better in patients with pain symptoms, partly due to more severe psychiatric symptoms among those with pain.

Depression treatment and short-term healthcare expenditures among elderly Medicare beneficiaries with chronic physical conditions

Background

Research on the impact of depression treatment on expenditures is nascent and shows results that vary from negative associations with healthcare expenditures to increased expenditures. However many of these studies did not include psychotherapy as part of the depression treatment. None of these studies included “no treatment” as a comparison group. In addition, no study has included a broad group of chronic physical conditions in studying depression treatment expenditures.

Objective

We determined the association between depression treatment and short-term healthcare expenditures using a nationally representative sample of Medicare beneficiaries with chronic physical conditions and depression.

Method

In this retrospective cohort study, we examined the association between depression treatment in the baseline year and healthcare expenditures in the following year using data from 2000 through 2005 of the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare beneficiaries. Using the rotating panel design of MCBS, we derived five two-year cohorts: 2000–2001, 2001–2002, 2002–2003, 2003–2004, and 2004–2005. The study sample included 1,055 elderly Medicare beneficiaries aged 65 or over. We compared healthcare expenditures of no depression treatment group with depression treatment groups using t-tests. Linear regressions of log-transformed dollars were used to assess the relationship between depression treatment and healthcare expenditures after controlling for demographic, socio-economic, health status, lifestyle risk factors, year of observation and baseline expenditures.

Results

Compared to no depression treatment ($16,795), the average total expenditures were higher for those who used antidepressants only ($17,425) and those who used psychotherapy with or without antidepressants ($19,733). After controlling for the independent variables, antidepressant use and psychotherapy with or without antidepressants were associated with 20.2% (95% CI: 14.1-26.7%) and 29.4% (95% CI: 18.8-41.0%) increase in total expenditures, respectively. We observed that depression treatment was positively associated with inpatient, medical provider and prescription drug expenditures.

Conclusion

Among the elderly Medicare beneficiaries with chronic physical conditions, depression treatment was associated with greater short-term healthcare expenditures. Future research needs to replicate these findings and also examine whether depression treatment reduces expenditures over a longer period of time.

Detecting Mood Disorder in Resource-Limited Primary Care Settings: Comparison of a self-administered screening tool to general practitioner assessment

Objectives

Although efficacious treatments for mood disorders are available in primary care, under-diagnosis is associated with under-treatment and poorer outcomes. This study compares the accuracy of self-administered screening tests with routine general practitioner (GP) assessment for detection of current mood disorder.

Methods

197 consecutive patients attending primary care centres in Santiago, Chile enrolled in this cross-sectional study, filling out the Patients Health Questionnaire-9 (PHQ-9) for depression and the Mood Disorder Questionnaire (MDQ) for bipolar disorder, after routine GP assessment. Diagnostic accuracy of these self-administered tools was compared with GP assessment, with gold standard diagnosis established by a structured diagnostic interview with trained clinicians (SCID-I).

Results

The sample was 75% female, with a mean age of 48.5 (SD 16.8); 37% had a current mood disorder (positive SCID-I result for depression or bipolar disorder). Sensitivity of the screening instruments (SI) was substantially higher than GP assessment (SI: 0.8, [95% CI 0.71, 0.81], versus GP: 0.2, [95% CI 0.12, 0.25]: p-value < 0.0001), without sacrifice in specificity (SI: 0.9, [95% CI 0.86, 0.96], versus GP: 0.9, [95% CI 0.88, 0.97]: p-value = 0.7). This led to improvement in both positive predictive value (SI: 0.8, [95% CI 0.82, 0.90], versus GP: 0.6, [95% CI 0.50, 0.64]: p-value < 0.001) and negative predictive value (SI: 0.9, [95% CI 0.78, 0.91] versus GP: 0.7, [95% CI 0.56, 0.72]: p-value < 0.01).

Conclusion

Self-administered screening tools are more accurate than GP assessment in detecting current mood disorder in low-income primary care. Such screening tests may improve detection of current mood disorder if implemented in primary care settings.

Depression Treatment Patterns among Elderly with Cancer

Little is known about cancer treatment patterns among the elderly as depression and cancer in this older population have not been well explored. This study seeks to fill a gap in the literature by using data from the Medicare Current Beneficiary Survey from years 2000-2005 to examine depression treatment patterns among elderly diagnosed with both cancer and depression. Depression treatments examined include antidepressants with and without psychotherapy. We found that of those with both cancer and depression, 57.7% reported antidepressant use only, 19.7% received psychotherapy with or without antidepressants, and 22.6% had no depression treatment. We found those with greater comorbidity, of a minority race, with lower levels of education, and living in rural areas were less likely to receive treatment for depression. These findings highlight the need to address disparities in the treatment of depression in the elderly population with cancer.

A cross-sectional study of somatic symptoms and the identification of depression among elderly primary care patients

OBJECTIVE

To examine the relationship between somatization and depression as rated by primary care physicians.

METHOD

This study was a cross-sectional survey of 355 older adults with and without significant depressive symptoms. Physicians' ratings of somatization and depression were obtained for 341 of the 355 patients. Patients were sorted into 4 groups on the basis of physician ratings (no depression/no somatization, somatization only, depression only, and both somatization and depression). Data were collected from 2001-2003.

RESULTS

Patients who were rated as somatizing were 4.03 (95% CI, 2.52-6.45) times as likely to be rated as depressed as well as somatizing. A comparison of the 4 groups defined by physicians' ratings found that functional status, ethnicity, number of medical conditions, depressive symptoms, and anxiety were statistically significantly different (P < .05). Primary care physicians were 3.95 (95% CI, 1.53-10.16) times more likely to identify older black patients as somatizing only versus depressed and somatizing compared to older white patients among patients above a threshold on a standard depression instrument.

CONCLUSIONS

Our study fills a gap in the literature by focusing on the primary care physician ratings of depression and somatization, and also specifically on older primary care patients. Blacks are less likely to be rated as depressed, but this may reflect the tendency of doctors to rate them as somatizing.

Recognition and treatment of depression and anxiety symptoms in heart failure

OBJECTIVE

The aim of this prospective study was to examine the prevalence, recognition, and treatment of depression and anxiety in ambulatory patients with heart failure.

METHOD

A total of 158 heart failure participants were enrolled between November 2006 and April 2007. Each patient completed a telephone screening interview that included an assessment of heart-failure severity (New York Heart Assciation criteria) as well as measures for depression (Geriatric Depression Scale [GDS]) and anxiety (Geriatric Anxiety Inventory [GAI]). Following study recruitment, each patient's electronic medical record was comprehensively reviewed for the 12 months prestudy and 6 months poststudy assessments to determine whether patients had been recognized as having and/or treated for depression or anxiety.

RESULTS

Prevalence of depression (GDS score ≥ 6) was 41.8%, and prevalence of anxiety (GAI score ≥ 9) was 25.3%. Of patients with a positive GDS or GAI result, 57.5% had a diagnosis or medical-record notation for depression and/or anxiety, and 60.3% received mental health treatment during the 18-month period of the EMR review. Of patients with a documented diagnosis of depression or anxiety, 92.3% received mental health treatment. Results showed that higher GDS scores were associated with recognition of depression/anxiety in the medical record, and a positive primary care depression screening predicted documented mental health treatment.

CONCLUSION

These data suggest that symptomatic depression and anxiety are underrecognized in heart failure patients and that mental health screening may be important for receipt of care. Notably, once depression and/or anxiety was documented in the medical record, patients were highly likely to receive mental health treatment.

Mental comorbidity and quality of diabetes care under Medicaid: a 50-state analysis

BACKGROUND

Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees.

METHODS

For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures.

RESULTS

A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82-0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29-1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations.

CONCLUSIONS

Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes. Level of evidence I.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design

BACKGROUND

Despite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.

METHODS

This protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.

CONCLUSIONS

Hybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.

TRIAL REGISTRATION

NCT01149772 at http://www.clinicaltrials.gov/ct2/show/NCT01149772.

A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care

This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care.

Challenges to alcohol and other drug discussions in the general practice consultation

BACKGROUND

There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity.

AIM

To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered.

DESIGN

Analysis of video-recorded primary care consultations.

SETTING

New Zealand General Practice.

METHODS

Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings.

RESULTS

AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change.

CONCLUSIONS

Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients

BACKGROUND

Depression is the most common mental disorder, and suicide is its most serious consequence. The primary objective of this study was to evaluate preliminary evidence for the P4 screener as a brief measure to assess potential suicide risk.

METHOD

The P4 screener was prospectively evaluated in 2 randomized effectiveness trials of primary care (January 2005-June 2008; N = 250) and oncology patients (March 2006-August 2009; N = 309). Potential suicide ideation was assessed at 5 time points in both trials: baseline and 1, 3, 6, and 12 months. The P4 screener asks about the "4 P's": past suicide attempts, suicide plan, probability of completing suicide, and preventive factors. Patients were classified as minimal, lower, and higher risk based upon responses to these 4 items.

RESULTS

A suicide assessment was triggered 1 or more times by 17.6% (44 of 250) of Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) participants and 16.5% (51 of 309) of Indiana Cancer Pain and Depression (INCPAD) participants at some point in the trial. Of the patients who triggered a suicide assessment, the majority (29 of 44 in SCAMP and 27 of 51 in INCPAD) were classified as minimal risk by the algorithm. Only 1 (0.4%) of the SCAMP participants and 5 (1.6%) of the INCPAD participants were classified as higher risk. Among the latter, the most common factors preventing patients from attempting suicide were the "4 F's": faith, family, future hope, and fear of failing in their attempt.

CONCLUSIONS

Preliminary findings suggest that the P4 screener may be useful in assessing potential suicide risk in the clinical care of depressed patients as well as in clinical research.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118430 (SCAMP) and NCT00313573 (INCPAD).

Crowd-out and exposure effects of physical comorbidities on mental health care use: implications for racial-ethnic disparities in access

OBJECTIVES

In disparities models, researchers adjust for differences in "clinical need," including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities.

DATA

Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care.

STUDY DESIGN

First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates.

PRINCIPAL FINDINGS

We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black-white disparities and decreased Latino-white disparities.

CONCLUSIONS

Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.

Psychotropic medication discussions in older adults' primary care office visits: So much to do, so little time

OBJECTIVES

To examine discussions of psychotropic medications during the older patient's visit to primary care physicians, identify how physician's competing demands influence these discussions, describe different scenarios physicians utilize to address mental health complaints of older adults, and recommend best practices for diagnosing and treating such patients.

METHOD

Convenience sample of 59 videotapes of primary care office visits involving mental health discussions in the United States complemented by patient and physician surveys. Videotaped visits were examined using logistic regression for grouped-level data to explore contributions of physician's competing demands to the likelihood of having psychotropic medication discussions. Tape transcripts were selected to provide examples of prescribing and referral behaviors.

RESULTS

One-third of these visits contained no psychotropic medication discussions despite its important role in treating mental illnesses. When prescribing psychotropic medicines, physicians presented information about the medication's purpose and brand name more often than adverse effects or usage. More competing demands (i.e., more topics discussed or more leading causes of disability addressed during the visit) were associated with less psychotropic medication discussions. Selected case scenarios illustrate the importance of acknowledging mental illness, prescribing psychotropic medications, explaining the medications, and/or referring patients to mental health providers to address their mental health complaints.

CONCLUSION

Competing demands may constrain discussions of psychotropic medications. Given the seriousness of mental illness in late life, system-level changes may be needed to correctly diagnose mental illness, take more proactive actions to improve mental health, and enhance information exchange concerning psychotropic medication in a manner that meets patients' needs.

Using baby books to increase new mothers' safety practices

OBJECTIVE

To determine whether educational baby books are an effective method for increasing low-income, first-time mothers' safety practices during their child's first 18 months.

METHODS

Primiparous women (n = 167) were randomly assigned to 1 of 3 groups: an educational book group, a noneducational book group, or a no-book group. Home visits and interviews measured safety practices when women were in their third trimester of pregnancy (baseline) and when their children were 2, 4, 6, 9, 12, and 18 months of age.

RESULTS

Women in the educational book group had fewer risks in their homes and exercised more safety practices than the no-book group (- 20% risk reduction; effect size = -.30). When the safety practices involved little time or expense (eg, putting away sharp objects), the educational book group was significantly more likely to engage in these behaviors than the no-book group (40% higher practices; effect size = 0.19) or noneducational book group (27% higher practices; effect size = 0.13). However, no differences were found between groups for behaviors that required high effort in time, money, or hassle (eg, installing latches on cabinets).

CONCLUSIONS

Educational baby books appear to be an easy and low-cost way to increase the safety practices of new mothers, especially if the practices involve little to no time, money, or hassle.

Profiles of disability among adults with bipolar spectrum disorders

BACKGROUND

Heterogeneous groups of patients with a spectrum of service needs are commonplace in mental health settings. Although comprehensive assessments are available to measure variations in service needs, numerous challenges still exist when confronting this heterogeneity and many assessments used in clinic settings are lengthy and have not been demonstrated to be consistent over time.

OBJECTIVE

The purpose of this study was to identify subgroups of persons with bipolar spectrum disorders, who have similar disability profiles, and to the extent to which the subgrouping is stable over time.

METHODS

Participants were recruited from the Continuous Improvement for Veterans in Care-Mood Disorders. Eligible patients (N = 435) were those who received inpatient or outpatient treatment for bipolar disorder at a large urban VA mental health facility in Western Pennsylvania from July 2004 through July 2006. This was a naturalistic cohort study of patients with bipolar spectrum disorders. Baseline and 1-year follow-up data were collected using face-to-face interviews and recorded abstraction. The World Health Organization Disability Assessment Scale was the primary measure used to identify subgroups within this sample.

RESULTS

Using a classification strategy called latent profile analysis, this study identified three unique subgroups that showed significant differences in various clinical measures at baseline and follow-up. The largest and most consistent subgroup differences were observed in the current bipolar symptomatology.

CONCLUSION

The classification of functional status in the present study can aid clinicians in the identification of bipolar patients, with specific impairment profiles, who may need additional intervention. Future research is needed to understand whether specific interventions targeted at these subgroups can improve the quality of care for this high-need and at-risk population.

Effects of exercise and physical activity on depression

INTRODUCTION

Depression is a very prevalent mental disorder affecting 340 million people globally and is projected to become the leading cause of disability and the second leading contributor to the global burden of disease by the year 2020.

AIM

In this paper, we review the evidence published to date in order to determine whether exercise and physical activity can be used as therapeutic means for acute and chronic depression. Topics covered include the definition, classification criteria and treatment of depression, the link between β-endorphin and exercise, the efficacy of exercise and physical activity as treatments for depression, properties of exercise stimuli used in intervention programs, as well as the efficacy of exercise and physical activity for treating depression in diseased individuals.

CONCLUSIONS

The presented evidence suggests that exercise and physical activity have beneficial effects on depression symptoms that are comparable to those of antidepressant treatments.

Depression and cancer mortality: a meta-analysis

BACKGROUND

The goal of the present study was to analyze associations between depression and mortality of cancer patients and to test whether these associations would vary by study characteristics.

METHOD

Meta-analysis was used for integrating the results of 105 samples derived from 76 prospective studies.

RESULTS

Depression diagnosis and higher levels of depressive symptoms predicted elevated mortality. This was true in studies that assessed depression before cancer diagnosis as well as in studies that assessed depression following cancer diagnosis. Associations between depression and mortality persisted after controlling for confounding medical variables. The depression-mortality association was weaker in studies that had longer intervals between assessments of depression and mortality, in younger samples and in studies that used the Beck Depression Inventory as compared with other depression scales.

CONCLUSIONS

Screening for depression should be routinely conducted in the cancer treatment setting. Referrals to mental health specialists should be considered. Research is needed on whether the treatment of depression could, beyond enhancing quality of life, extend survival of depressed cancer patients.

An Ethnic/Racial Comparison of Causal Beliefs and Treatment Preferences for the Symptoms of Depression Among Patients with Diabetes

Purpose

The purpose of the study was to explore African American, Latino, and Non-Hispanic White adult patients with type 2 diabetes cultural perceptions of symptoms of depression and factors that predict depression care treatment preferences between these groups.

Methods

A community sample of African Americans, Latinos, and White diabetic adults receiving services in 1 of 2 central Austin, Texas facilities participated in the study. Each participant was given a survey, which consisted of the following 5 components: (1) illness screener questions, (2) demographic questions, (3) Patient Health Questionnaire, (4) Depression Treatment Questionnaire, and (5) Illness Perception Questionnaire. A binary logistic regression was used to examine the relationship between cultural perceptions of symptoms and the predictor variables. A multinomial logistic regression analyses was used to examine the relationship between treatment and provider preferences for the symptoms of depression and ethnicity.

Results

The first research question addressed whether there were differences across ethnicity in how symptoms of depression are attributed among patients with diabetes. There were 7 causal beliefs that were associated with differences in cultural endorsements of the causes of depressive symptoms. In addition, culture was associated with treatment preferences but not with provider preferences.

Conclusions

The utility of assessing a patient’s understanding of symptoms of depression to determine how personal illness models impact treatment preferences and clinical implications of how knowledge of patient’s causal attributions can aid medical and behavioral health providers working in collaborative management of diabetes and depression are discussed.

Time to depression treatment in primary care among HIV-infected and uninfected veterans

BACKGROUND

Multiple factors, including patient characteristics, competing demands, and clinic type, impact delivery of depression treatment in primary care.

OBJECTIVE

Assess whether depression severity and HIV serostatus have a differential effect on time to depression treatment among depressed patients receiving primary care at Infectious Disease or General Medicine clinics.

DESIGN

Multicenter prospective cohort, (Veterans Aging Cohort Study), comparing HIV-infected to uninfected patients.

PARTICIPANTS AND MEASURES

The total cohort consisted of 3,239 HIV-infected and 3,227 uninfected patients. Study inclusion criteria were untreated depressive symptoms, based on a Patient Health Questionnaire (PHQ-9) score of greater than 9, and no antidepressants or mental health visits in the 90 days prior to PHQ-9 assessment. Treatment was defined as antidepressant receipt or mental health visit within 90 days following PHQ-9 assessment. Depression severity based on PHQ-9 scores was defined as mild-moderate (greater than 9 to 19) and severe (20 or greater). Kaplan-Meier curves were used to estimate time to treatment by depression severity and HIV serostatus. Cox proportional hazards methods adjusted for covariates were used.

KEY RESULTS

Overall, 718 (11%) of the cohort met inclusion criteria, 258 (36%) of whom received treatment. Median time to treatment was 7 days [95% confidence interval (CI) = 4, 13] and was shortest for severely depressed HIV-infected patients (0.5 days; 95% CI = 0.5, 6, p = 0.04). Compared to mildly-moderately depressed uninfected patients, severely depressed HIV-infected patients were significantly more likely to receive treatment [adjusted hazard ratio (HR) 1.67, 95% CI = 1.07, 2.60), whereas mildly-moderately depressed HIV-infected patients (adjusted HR 1.10, 95% CI = 0.79, 1.52) and severely depressed uninfected patients (adjusted HR 0.93, 95% CI = 0.60, 1.44) were not.

CONCLUSIONS

In this large cohort, time to primary care treatment of depression was shortest among severely depressed HIV-infected patients. Regardless of HIV serostatus, if depression was not treated on the assessment day, then it was unlikely to be treated within a 90-day period, leading to the majority of depression being untreated.