Investigation of the antiphase dynamics of the orthogonally polarized passively Q-switched Nd:YLF laser

The antiphase dynamics of Q-switched orthogonally polarized emissions have been thoroughly investigated. A Nd:YLF crystal with the anisotropic thermal lensing effect is used as the gain medium for achieving dual polarized laser. By using the Cr⁴⁺:YAG saturable absorber, the passively Q-switched output shows intriguing switching dynamics, where the number of pulses for both polarized components within one switching period is directly determined by the power ratio between the orthogonally polarized emissions. Experimental results reveal that the pulse energies of every single pulse for both orthogonally polarized states are equal with the maximum value of 223 μJ. The pulse durations for π- and σ-polarization are measured to be 15 ns and 11 ns and the corresponding peak power levels are up to 15.0 kW and 20.3 kW, respectively.

Evaluation of the impact of HIV serostatus, tobacco smoking and CD4 counts on epidermoid anal cancer survival

Tobacco smoking and HIV infection increase the risk of epidermoid anal cancer (EAC). No published studies have examined smoking and EAC outcomes, and the literature is discrepant regarding outcomes of HIV-positive patients with EAC. The goal of this study was to examine smoking history, HIV status and outcomes in EAC patients. We conducted a retrospective analysis of adults with invasive EAC treated in the University of Washington hospital system from 1 January 1994 to 31 December 2008. Sixty-three patients were included. Forty-seven patients (75%) had primary chemoradiation, of whom 42 (89%) completed therapy. Two patients (3%) received radiotherapy alone. Fourteen patients (22%) underwent primary surgery, of whom 11 (79%) underwent tumour excision and three (21%) abdominoperineal resection (APR). We analysed smoking history, HIV status and CD4 count (≥200 cells/μL/<200 cells/μL for HIV-positive patients) versus outcomes. Forty-five patients (71%) were in remission, and 44 (70%) were alive at last follow-up. Overall survival was significantly better for never-smokers than for ever-smokers. There were no differences in outcomes according to HIV status or CD4 counts. Patients with anal cancer who smoke have worse overall survival than non-smoking patients. HIV infection does not appear to affect anal cancer outcomes.

Regulation of expression of cd133, a colon cancer stem cell marker and other stemness genes/pathways, by celecoxib: Clues from clinical observations

e15065

Background: CD133 identifies intestinal stem cells and colon CSC, the putative culprit of cancer initiation, progression and resistance. Elevated CD133 levels at protein & mRNA levels predict poor outcomes in patients (pts) with colon cancer. Given that celecoxib reduces colon polyp and only maintenance capecitabine plus celecoxib lead to paradoxically high complete remission (CR) in colon cancer pts who had no resection or positive margin resection of metastases (ASCO 2007), we hypothesized that celecoxib could modulate CD133 and other stemness genes/signaling pathways. Methods: we studied the effects of celecoxib versus 5-FU on CD133, Wnt and other stemness genes/pathways using flow cytometry, immunoflurorescence, real time RT-PCR, western blot, TOP-Flash for Wnt, limiting dilution assay, and Affymetrix in colon cancer cell lines and primary colon cancer spheres. Results: Celecoxib or 5FU inhibited the growth of COX-2+ HT29 or COX-2- DLD1 that express CD133 at 80% and 30% respectively. Only celecoxib down-regulated CD133 expression at the mRNA, and protein levels in a dose and time dependent manner. This effect could not be rescued with PGE2 and may be due to Wnt inhibition. Microarray showed 4 folds down-regulation of CD133 and other stemness genes e.g. CD24, ABC transporters, and LGR4/5, findings of colon cancer sphere under differentiation. Celecoxib affected several key stem cells signaling pathway, restored RB and promote cell cycle progression (P < 0.05). In contrast, 5FU affected G2M transition but had no effects on stemness genes/pathways (p < 0.05). Celecoxib resulted in 6–10 folds reduction in colony size and number with 5.6–36 folds down-regulation of CD133 mRNA in primary colon cancer spheres. Pts with confirmed radiographic CR who had received >6 months of maintenance capecitabine and celecoxib reached 5-year survival > 90% comparable to pts who achieved pathological CR (12/19). Conclusions: Targeting colon CSC with capecitabine and celecoxib may lead to durable CR and survival and deserves further investigation.

No significant financial relationships to disclose.

Elevated stem cell marker CD133 mRNA in peripheral blood predicts colon cancer recurrence

10504

Background: CD133 is a specific stem cell marker that enriches cancer stem cells of many tumor types including colon cancer as well as circulating endothelial progenitors (CEP). CEP is vital in postnatal angiogenesis and elevated CEP is a proven favoable prognositic marker for heart disease but a potentially poor prognostic marker for cancer. We examined whether elevated CD133 mRNA expression levels in peripheral blood mononuclear cells (PBMC) predict recurrence in colon cancer patients. Methods: We developed and validated a semi-quantitative real-time RT-PCR to quantify CD133 mRNA levels relative to GADPH mRNA. Sixty-six colon cancer patients were enrolled between February 2002 and December 2003. The protocol excluded patients with history of cardiac disease or surgery < 4 weeks from the enrollment and were followed for recurrence for a median 30 months. A central statistician performed multivariate unconditional logistics regression analysis. Results: Among the patients without recurrence, 93% had a CD133 mRNA level < 4.79, whereas 7% had a CD133 mRNA value ≥ 4.79 (p = 0.029). Among patients with a CD133 mRNA value ≥ 4.79, 85% had experienced recurrence compared to 15% of the patient who had no recurrence (p = 0.03). Elevated CD133 mRNA levels at a cut-off point ≥ 4.79 versus < 4.79 were associated with an odd ratio of 22.6 for recurrence (95% CI, 1.7–291.2; p = 0.02); in comparison, the odds ratio for recurrence was 17.2 (95% CI, 1.8–164; p = 0.01) for stage IV patients versus stage I-III patients. No other predictive variables for recurrence were identified including age, race, sex, tumor differentiation, smoking, and diabetes etc. We also observed an trend of association with elevated carcinoma embryonic antigen (CEA) levels (p = 0.03, one sided) and a decreased survival (p = 0.035, one sided) with elevated CD133 mRNA level at a cutoff point ≥ 4.79. Conclusions: Elevated CD133 mRNA levels at a cutoff ≥ 4.79 in PBMC predict colon cancer recurrence independent of stage IV disease. The current assay has certain advantages over flow cytometry for wider clinical application. CD133+ cells measured by CD133 mRNA may contain both CEP and cancer stem cells, leading to increased risks of recurrence.

No significant financial relationships to disclose.

Quantitative real time-PCR of CD133 mRNA: A potential surrogate angiogenic marker of response for patients with metastatic sarcoma

20034

Background: CD133 antigen is a specific surface marker for circulating endothelial progenitor cells (CEPs), pivotal in post-natal angiogenesis. We hypothesize that changes in levels of the CD133 mRNA expression and vascular endothelial growth factor (VEGF) may correlate with tumor response. Methods: After informed consent, we obtained 48 peripheral blood samples from patients with metastatic sarcoma including gastrointestinal stroma tumors (GIST). There were 16-paired samples before and after treatment including chemotherapy, or surgery, or imatinib. Of 24 patients with metastatic GIST enrolled, seven were paired samples. We measured CD133 mRNA levels by method (Lin E et al AACR 2003# 5392) and VEGF levels by ELISA (Genzyme, MA). The measurements were done in duplicates in two experiments. Results: The mean CD133 levels and VEGF levels before and after treatment was in Table 1 . The treatment resulted in significant reduction of CD133 mRNA expression (p = 0.035) as well as the level of VEGF (p = 0.014). Three patients experienced increase in CD133 expression had progressive disease. Among the paired GIST patients, there was a trend of increased CD133 mRNA expression levels in patients with progressive disease, death, or tumor recurrence. CD133 mRNA levels appeared elevated among the imatinib naïve patients and imatinib appeared to reset CD133 mRNA levels among the responding GIST patients to that of healthy volunteers. Conclusion: CD133 mRNA expression levels in sarcoma patients measured by real time-PCR assay appeared to correlate with tumor response. Unpublished independent work with NASBA assay platform in other solid tumors supported our findings ( www.primagen.com ). Further work is needed to reduce assay variability, and to determine the sensitivity and specificity of assay comparing to flow cytometry and to test assay’s applicability in the antiangiogenic therapy of cancer and the angiogenic therapy of cardiovascular diseases.

[Table: see text]

No significant financial relationships to disclose.

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression

OBJECTIVE

The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management.

METHOD

Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data.

RESULTS

Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day.

CONCLUSIONS

A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Does physician education on depression management improve treatment in primary care?

OBJECTIVE

To assess the effect of physician training on management of depression.

DESIGN

Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial.

SETTING

One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States.

PATIENTS/PARTICIPANTS

Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians.

INTERVENTIONS

Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants.

MEASUREMENTS AND MAIN RESULTS

Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P =.95) or new prescription of antidepressant medicines (P =.10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P =.53) as measured by 12 weeks of continuous antidepressant treatment.

CONCLUSIONS

After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy.

Can depression treatment in primary care reduce disability? A stepped care approach

OBJECTIVE

To assess effects of stepped collaborative care depression intervention on disability.

DESIGN

Randomized controlled trial.

SETTING

Four primary care clinics of a large health maintenance organization.

PATIENTS

Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication.

INTERVENTION

Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes.

MAIN OUTCOME MEASURES

Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).

RESULTS

Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94).

CONCLUSIONS

Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058

Randomized trial of a depression management program in high utilizers of medical care

BACKGROUND

High utilizers of nonpsychiatric health care services have disproportionally high rates of undiagnosed or undertreated depression.

OBJECTIVE

To determine the impact of offering a systematic primary care-based depression treatment program to depressed "high utilizers" not in active treatment.

DESIGN

Randomized clinical trial.

SETTING

One hundred sixty-three primary care practices in 3 health maintenance organizations located in different geographic regions of the United States.

PATIENTS

A group of 1465 health maintenance organization members were identified as depressed high utilizers using a 2-stage telephone screening process. Eligibility criteria were met by 410 patients and 407 agreed to enroll: 218 in the depression management program (DMP) practices and 189 in the usual care (UC) group.

INTERVENTION

The DMP included patient education materials, physician education programs, telephone-based treatment coordination, and antidepressant pharmacotherapy initiated and managed by patients' primary care physicians.

MAIN OUTCOME MEASURES

Depression severity was measured using the Hamilton Depression Rating Scale (Ham-D) and functional status using the Medical Outcomes Study 20-item short form (SF-20) subscales. Outpatient visit and hospitalization rates were measured using the health plan's encounter data.

RESULTS

Based on an intent-to-treat analysis, at least 3 antidepressant prescriptions were filled in the first 6 months by 151 (69.3%) of 218 of DMP patients vs 35 (18.5%) of 189 in UC (P < .001). Improvements in Ham-D scores were significantly greater in the intervention group at 6 weeks (P = .04), 3 months (P = .02), 6 months (P < .001), and 12 months (P < .001). At 12 months, DMP intervention patients were more improved than UC patients on the mental health, social functioning, and general health perceptions scales of the SF-20 (P < .05 for all).

CONCLUSION

In depressed high utilizers not already in active treatment, a systematic primary care-based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity, and improve general health status compared with usual care.

Low-intensity treatment of depression in primary care: is it problematic?

The aim of this study was to examine patterns of care and outcomes of depressed patients under primary care during acute phase treatment. A cohort of depressed patients was assessed 6-8 weeks after starting pharmacotherapy in four large primary care clinics in a health maintenance organization. These patients (n = 1671) were receiving antidepressant treatment for a new episode of depression. To calculate main outcome measures, Structured Clinical Interview for Depression evaluated prior history and current depression status. Visit and pharmacy refill data described use of health services and antidepressant medication. Six to eight weeks after starting antidepressant therapy, 33.2% of patients had 0-3 depressive symptoms and no prior history of depression, an additional 42.3% also reported 0-3 symptoms but were at high risk of relapse, and 24. 5% were persistently depressed with 4 or more depressive symptoms. In the initial 6 weeks of treatment, these three groups showed similar use of antidepressant medication and health services. About 50% in each group had no follow-up visit for depression and 32%-42% had not refilled their antidepressant prescription. In general, depressed patients under primary care obtained low-intensity pharmacotherapy and inconsistent follow-up visits during initial acute phase treatment. Six weeks after starting antidepressant medicine, many were still symptomatic or recovered but had a high risk of depression relapse. Patients with unfavorable outcomes did not receive more intensive management than the one-third who had favorable outcomes.

Cytochrome CYP sources of N-alkylprotoporphyrin IX after administration of porphyrinogenic xenobiotics to rats

Cytochrome P-450 (CYP) 3A2 and CYP2C11 are sources of 70 and 30%, respectively, of N-vinylprotoporphyrin IX (N-vinylPP) formation after administration of 3-[(arylthio)ethyl]sydnone (TTMS) to rats. Female rats receiving TTMS were pretreated with dexamethasone, which induces CYP3A1 preferentially to CYP3A2. The resulting 12-fold increase in N-vinylPP formation showed that CYP3A1 was also a source of N-vinylPP. Phenobarbital (PB) pretreatment, which induces CYP2B1/2 and 3A1/2 in male rats, increased N-vinylPP formation after TTMS administration. Troleandomycin, a selective CYP3A inhibitor, was unable to decrease TTMS-mediated N-vinylPP formation in PB-treated male rats, indicating that CYP2B1/2 were sources of N-vinylPP. This conclusion was supported by demonstrating a 15-fold increase in TTMSinduced N-vinylPP formation in female rats after CYP2B1/2 induction with PB pretreatment. Allylispropylacetamide (AIA) inactivates rat CYP2B1/2, 2C6, 2C7, 2C11, and 3A1/2. Troleandomycin was unable to decrease N-AIA protoporphyrin IX adduct (N-AIAPP) formation, showing that CYP3A1/2 were not susceptible to AIA-mediated N-alkylation. N-AIAPP formation in females was approximately 30% of that in males, and thus we attribute 30% of N-AIAPP formation in males to the non-gender-specific isozymes (CYP2C6, 2C7, and/or 2B1/2), whereas approximately 70% originates from CYP2C11. PB treatment in female rats resulted in a 5-fold increase in N-AIAPP formation, showing that CYP2B1/2 were also susceptible to N-alkylation mediated by AIA. 1-Aminobenzotriazole elicited formation of equivalent amounts of N'N-aryl bridged protoporphyrin IX in male and female rat liver, demonstrating that nonselective mechanism-based inactivation is accompanied by nonselective conversion of the CYP heme moieties to N'N-aryl bridged protoporphyrin IX.

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care

OBJECTIVE

The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted.

METHOD

They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy.

RESULTS

At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy.

CONCLUSIONS

Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

Diagnosis of depression by primary care physicians versus a structured diagnostic interview. Understanding discordance

In this paper, false-negative and false-positive cases of depressive illness are examined, differentiating levels of disagreement between a primary care physician's diagnosis and a standardized research diagnosis. Two stratified random samples of primary care patients in Seattle, USA (N = 373) and Groningen, The Netherlands (N = 340) were examined with the Composite International Diagnostic Interview-Primary Health Care Version (CIDI-PHC). Physician's severity ratings and diagnosis of psychological disorder were obtained. Three levels of disagreement between physician and CIDI diagnosis were distinguished: 1) complete disagreement about the presence of psychiatric symptoms (true false-negative and true false-positive patients); 2) disagreement over severity of recognized psychological illness (underestimated or overestimated); and 3) disagreement over the specific psychiatric diagnosis among those given a diagnosis (misdiagnosed or given another CIDI diagnosis). All three levels of disagreement were common. Only 27% of the false-negative cases were due to complete disagreement (true false-negatives), and 55% of the false-positives were due to complete disagreement (true false-positives). The true false-negative patients were younger, more often employed, rated their own health more favorably, visited their doctor for a somatic complaint and made fewer visits than the underestimated, misdiagnosed, and concordant positive patients. Complete disagreement in depressive diagnoses between the primary care physician and research interview is not as frequent as indicated by an undifferentiated false-negative/ false-positive analysis. Differentiating levels of disagreement does more justice to diagnostic practice in primary care and provides guidance on how to improve the diagnostic accuracy of primary care physicians.

Relapse of depression in primary care. Rate and clinical predictors

OBJECTIVE

To determine the clinical predictors and rate of relapse for major depression in primary care.

DESIGN

A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted.

SETTING

A large primary care clinic of a staff-model health maintenance organization.

PATIENTS

Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months.

MAIN OUTCOME MEASURES

Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist.

RESULTS

Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither.

CONCLUSIONS

The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression

OBJECTIVE

The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care.

STUDY DESIGN

Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trail (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management.

RESULTS

Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression. Collaborative Care was more costly and not more cost-effective than Usual Care.

CONCLUSIONS

Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.

Achieving guidelines for the treatment of depression in primary care: is physician education enough?

OBJECTIVES

The authors examine whether physician education has enduring effects on treatment of depression.

METHODS

Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes.

RESULTS

No lasting educational effect was observed consistently in any of the outcomes measured.

CONCLUSIONS

There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.

Outcomes of "inadequate" antidepressant treatment

OBJECTIVE

To examine outcomes of primary care patients receiving low levels of antidepressant treatment.

DESIGN

Cohort study comparing patients receiving anti-depressant treatment within and below the recommended dosing range.

SETTING

Primary care clinics of a staff-model health maintenance organization.

PATIENTS

Primary care patients initiating antidepressant treatment for depression.

MEASUREMENTS AND MAIN RESULTS

Of 88 patients beginning antidepressant treatment, 49 (56%) used "adequate" doses for 30 days or more. Likelihood of "adequate" pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using "adequate" pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square = 4.44; df = 1; p = 0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F = 1.45; df = 1.86; p = 0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square = 1.30; df = 1; p = 0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results.

CONCLUSIONS

While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving "inadequate" treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment.

Application of multivariable optimal discriminant analysis in general internal medicine

OBJECTIVE

To illustrate the use of multivariable optimal discriminant analysis (MultiODA).

DESIGN

Data from four previously published studies were reanalyzed using MultiODA. The original analysis was Fisher's linear discriminant analysis (FLDA) for two studies and logistic regression analysis (LRA) for two studies.

MEASUREMENTS AND MAIN RESULTS

In Study 1, FLDA achieved an overall percentage accuracy in classification (PAC) for the training sample of 69.9%, compared with 73.5% for MultiODA. In Study 2, the LRA model required three attributes to achieve a 76.1% overall PAC for the training sample and a 79.4% overall PAC for the hold-out sample. Using only two attributes, the MultiODA model achieved similar values. In Study 3, the FLDA model achieved an overall PAC of 82.5%, compared with 87.5% for the MultiODA model. In Study 4, MultiODA identified a two-attribute model that achieved a 93.3% overall training PAC, when an LRA model could not be developed.

CONCLUSIONS

MultiODA identified: a superior training model (Study 1); a more parsimonious model that achieved superior overall training and identical hold-out PAC (Study 2); a model that achieved a higher hold-out PAC (Study 3); and a two-attribute model that achieved a relatively high PAC when a multivariable LRA model could not be obtained (Study 4). These findings suggest that MultiODA has the potential to improve the accuracy of predictions made in general internal medicine research.

The role of the primary care physician in patients' adherence to antidepressant therapy

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages--1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants--were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

Disability and depression among high utilizers of health care. A longitudinal analysis

We evaluated, among depressed medical patients who are high utilizers of health care, whether improved vs unimproved depression is associated with differences in the course of functional disability. At baseline, 6 months, and 12 months, depression and disability were assessed among a sample of enrollees in health maintenance organizations (N = 145) in the top decile of users of ambulatory health care who exceeded the 70th percentile of health maintenance organization population norms for depression. Improved depression was defined as a reduction of at least one third in depressive symptoms averaged across the two follow-up times. At the 12-month follow-up, persons with severe-improved depression experienced a 36% reduction in disability days (79 days per year to 51 days per year) and a 45% reduction in disability score. Persons with moderate-improved depression experienced a 72% reduction in disability days (62 days per year to 18 days per year) and a 40% reduction in disability score. In contrast, persons with severe-unimproved depression reported 134 disability days per year at baseline, while persons with moderate-unimproved depression reported 77 disability days per year at baseline. Neither group with unimproved depression showed improvement in either disability days or disability score during the 1-year follow-up period. High utilizers of health care with severe-unimproved depression were more likely to have current major depression and to be unemployed. Improved (relative to unimproved) depression was associated with borderline differences in the severity of physical disease and in the percent married. We conclude that depression and disability showed synchrony in change over time. However, depression and disability may show synchrony in change with disability because both depression and disability are controlled by some other factor that influences the chronicity of depression (eg, chronic disease or personality disorder). The finding of synchronous change of depression and disability provides a rationale for randomized controlled trials of depression treatments among depressed and disabled medical patients to determine whether psychiatric intervention might improve functional status in such patients. Such research is needed to determine whether there is a causal relationship between depression offset and reductions in functional disability.

Frustrating patients: physician and patient perspectives among distressed high users of medical services

OBJECTIVE

To identify differences between patients viewed as frustrating by their physicians and those considered typical and satisfying.

DESIGN

This cross-sectional observational study focused on psychologically distressed high users of medical services. Frustrating patients were compared with typical and satisfying patients, using data from patient questionnaires, physician assessments, structured psychiatric interviews, and computerized utilization records.

SETTING

Group Health Cooperative of Puget Sound, a large health maintenance organization.

PATIENTS/PARTICIPANTS

Study patients were in the top decile for ambulatory visits, and bad elevated scores for anxiety, depression, and somatization. Among the 339 patients invited to participate in the study, 251 agreed, and 228 were rated by their physicians.

MAIN RESULTS

A substantial proportion (37%) of the high users were viewed as frustrating by their physicians. Physicians' ratings of physical disease severity did not differ among the groups, but frustrating patients rated their own health status less favorably and reported more somatic symptoms and disabilities. The frustrating group utilized more medical services than did other distressed high utilizers. All three groups had a high prevalence of mental disorders. However, frustrating patients had higher rates of somatization and generalized anxiety disorder.

CONCLUSIONS

Physicians and their frustrating patients had contrasting views of the patients' illnesses. The best predictors of physician frustration were somatization and increased medical service utilization. There is need for further research and clinical attention concerning optimal clinical management for patients with somatization.

Pessimistic explanatory style and response to illness

Previous studies have shown that a pessimistic explanatory style is a risk factor for illness, but the factors linking explanatory style and illness are unknown. One's characteristic response to poor health may mediate this relationship. Perhaps pessimistic individuals act helplessly in the face of their symptoms, thereby exacerbating disease. In the present study, we investigated this possibility by asking 96 young adults to complete measures of explanatory style, habitual response to illness, and ways of coping during their most recent episode of illness. Subjects who explain bad events pessimistically (with internal, stable, and global causes) reported more frequent illnesses during the past year and rated their overall health more poorly than those who habitually favor external, unstable, and specific explanations. When ill, the pessimistic subjects were less likely than their optimistic counterparts to take active steps to combat their illness. Our results suggest that one pathway leading from pessimistic explanatory style to poor health is mundane: passivity in the face of disease.

Identifying suicide potential in primary care

This research addresses two issues concerning the role of primary care physicians in suicide prevention: 1) Are there signals in a patient's medical record that identify patients at increased risk of suicide? 2) Is the pattern of utilization of suicides immediately prior to suicide different from those of other patients? To address these issues, medical records data for suicides and for symptomatically depressed and non-depressed enrollees of an HMO were compared. Suicidal ideation and behavior, selected psychiatric diagnoses, and interpersonal problems were associated with suicide. However, information recorded in the medical record did not reliably discriminate suicides from controls. There were no substantial differences in the use of general medical services between the suicides and the controls. Less than 20% of the suicides visited a primary care physician in the month prior to death. Only 39% of suicides received specialty mental health treatment in the 18 months prior to death.

Children in sheltered homeless families: reported health status and use of health services

Studies of the health status of homeless people have primarily focused on alcoholic men and have reported numerous excess health risks. To determine the health status of children in homeless families, we performed a population-based, cross-sectional survey of a probability sample of 82 homeless families having a total of 158 children 17 days to 17 years of age living in emergency shelters in King County, Washington. Heights and weights were also measured. Seventy-five percent of the children belonged to racial minorities, and 54% were less than 6 years old. Nearly half the children (49%) had a wide variety of reported acute and chronic health problems. Less than 10% of the children measured were short for their age or underweight, whereas 35% were greater than the 95th percentile for weight-for-height. When compared with the US general pediatric population, the proportion of homeless children reported to be in "fair" or "poor" health was four times higher (13% v 3.2%). Thirty-five percent of the children had no health insurance, and 59% of the children had no regular health care provider. The homeless children used emergency rooms at a rate that was two to three times higher than the US general pediatric population (480/1,000 homeless children for 6-month period v 254/1,000 US children for 12-month period), twice as likely to lack measles immunization (21% v 9.0%), and twice as likely to never have had a tuberculosis skin test (48% v 27%). The data suggest that children in homeless families have poorer reported health status and are not obtaining preventive medical care.

Evaluation of psychiatric consultation-liaison in primary care settings

This article considers eight methodologic issues in the evaluation of psychiatric consultation-liaison services in primary care settings. What should be evaluated--standardized treatment regimens administered to highly selected patient groups or individualized treatments administered to heterogeneous patient groups? How can patient groups be selected to test for generic outcomes resulting from individualized treatments? When should randomized designs be employed? Should patients or physicians be randomized? How should diagnostic classification of study subjects be accomplished? What outcomes should be measured? How can study design be accommodated to patient flow in clinical settings? What resources are required to establish a productive program of research in liaison psychiatry?

An exploration of somatization among Asian refugees and immigrants in primary care

The clinical records of Chinese, Filipino, Vietnamese, Laotian, and Mien patients in primary care were reviewed to determine the prevalence of somatization, its associated patient characteristics, and the manifested illness behavior. Patients in this study were generally poor, unemployed, and spoke little English. Somatization accounted for 35 per cent of illness visits. These visits were also more costly. Refugees had a higher rate of somatization (42.7 per cent) than immigrants (27.1 per cent). Although sociodemographic characteristics did not strongly differentiate patients with somatization from others, ethnicity and indicators of decreased resources such as large households with low income, households headed by single women, or a limited English proficiency were associated with somatization in certain ethnic groups. Somatization is thus an important health problem among Asian refugees and immigrants.

Depression among Vietnamese refugees in a primary care clinic

Refugees are at high risk for mental disorders and manifest cultural influences in their health behavior. The Vietnamese Depression Scale was administered to Vietnamese patients at a community clinic to assess the underlying prevalence of depression. The rate of accurate diagnosis and the manifestations of depression were also examined. A high prevalence of depression (52 percent) and a high level of underdiagnosis (56 percent) by primary care physicians were found. Ninety-five percent of these patients presented with physical symptoms. Compared with patients who had negative depression scores, those who had positive depression scores were more likely to be older and sought care at the clinic more frequently. These findings underscore the importance of depression as an urgent health problem among Vietnamese refugees in primary care. Accuracy in diagnosis can be improved by using the Vietnamese Depression Scale and constitutes the first step toward effective treatment.

Intraethnic characteristics and the patient-physician interaction: "cultural blind spot syndrome"

Ethnic variation in the beliefs, expectations, and illness behavior of patients has dominated cultural studies of medical care. A widespread supposition, referred to as "cultural blind spot syndrome," assumes that similarities in the ethnic backgrounds of patient and physician invariably enhance clinical communication, thereby resulting in improved outcomes. The author's experience as a Western-trained Chinese physician attending to a wide spectrum of Chinese patients challenged this simplistic assumption. The cultural identity of the Western-trained physician and intraethnic variation among people of a common cultural heritage emerged as two key considerations from this analysis of patient-physician interaction. Two cases representing extremes in patient-physician interaction were chosen and analyzed with respect to each of six essential elements of patient-physician interaction. Common ethnicity does not ensure a positive patient-physician interaction. A good match among intraethnic descriptors of patient and physician enhances communication and thereby may improve outcome. However, the match between the patient's explanatory model and expectations of the physician and the physician's actual persona and practice is equally important in determining outcome.