Assessing the Impact of Different Depression Treatment Success Metrics on Organizational Performance

Objective: The Patient Health Questionnaire-9 (PHQ-9) is commonly used to assess depression symptoms, but its associated treatment success criteria (i.e., metrics) are inconsistently defined. The authors aimed to analyze the impact of metric choice on outcomes and discuss implications for clinical practice and research. Methods: Analyses included three overlapping and nonexclusive time cohorts of adult patients with depression treated in 33 organizations between 2008 and 2018. Average depression improvement rates were calculated according to eight metrics. Organization-level rank orders defined by these metrics were calculated and correlated. Results: The 12-month cohort had higher rates of metrics indicating treatment success than did the 3- and 6-month cohorts; the degree of improvement varied by metric, although all organization-level rank orders were highly correlated. Conclusions: Different PHQ-9 treatment metrics are associated with disparate improvement rates. Organization-level rankings defined by different metrics are highly correlated. Consistency of metric use may be more important than specific metric choice.

Demographic-Specific Rates for Life Events in the Cardiovascular Health Study and Comparisons With Other Studies

Purpose of the Study

(1a) We use the Cardiovascular Health Study (CHS), a multi-site heterogeneous sample of Medicare enrollees (N = 5,849) to provide rates for specific life events experienced within 6 months; (1b) We present rates for 29 other studies of community-residing older adults (N = 41,308); (2) For the CHS, we provide demographic-specific rates and predicted probabilities for age [young-old (65-75) vs old-old (≥75)], gender, race, marital status, and education.

Design/Methods

The CHS sample is 57.6% women, 84.2% white (15.8% black), and 66.3% married. Mean age is 72.8 years (standard deviation [SD] = 5.6, range = 65-100) and education is 13.7 years (SD = 4.8). Life events were interviewer-assessed. Regressions estimated associations of life event rates with demographic groups (e.g., age), controlling for other demographic variables (e.g., gender, etc.).

Results

(1a) CHS rates ranged from 44.7% (death of someone close) to 1.1% (retirement/work changes). (1b) Most life event studies used total scores and only 5 that met our inclusion criteria used time intervals <1 year; longer intervals were associated with higher rates. (2) In the CHS, the life event for illnesses was related to 5 demographic variables (net the other 4 demographic variables), difficulties caregiving to 4, and worse relationships to 3 demographic variables. Race was related to 8 life events, marital status to 7, education to 6, and age to 4 events.

Implications

By identifying demographic groups at highest risk for life events, this research focuses on older adults at greatest risk for health problems. These data are necessary for translating research into interventions, practice, and policy.

Changes in Physical Activity Barriers among American Indian Elders: A Pilot Study​

The objective of the present study was to assess whether selfreported physical activity barriers could be reduced among American Indian elders who participated in a 6-week randomized physical activity trial that compared the use of a pedometer only to that of pedometers with step-count goal setting. Elders (N = 32) were compared on the Barriers to Being Physically Active Quiz after participating in a pilot physical activity trial. Elders were classified into high- and low-barrier groups at baseline and compared on self-reported physical activity, health-related quality of life, pedometer step counts, and 6-minute walk performance. At the conclusion of the 6-week trial, only the lack of willpower subscale significantly decreased. The low-barrier group reported significantly higher physical activity engagement and improved mental health quality of life than the high-barrier group. The groups did not differ on daily step counts or 6-minute walk performance. Additional research is needed with a larger sample to understand relevant activity barriers in this population and assess whether they can be modified through participation in structured physical activity and exercise programs.

Technology Use, Preferences, and Capacity in Injured Patients at Risk for Posttraumatic Stress Disorder

OBJECTIVE

This investigation comprehensively assessed the technology use, preferences, and capacity of diverse injured trauma survivors with posttraumatic stress disorder (PTSD) symptoms.

METHOD

A total of 121 patients participating in a randomized clinical trial (RCT) of stepped collaborative care targeting PTSD symptoms were administered baseline one-, three-, and six-month interviews that assessed technology use. Longitudinal data about the instability of patient cell phone ownership and phone numbers were collected from follow-up interviews. PTSD symptoms were also assessed over the course of the six months after injury. Regression analyses explored the associations between cell phone instability and PTSD symptoms.

RESULTS

At baseline, 71.9% (n = 87) of patients reported current cell phone ownership, and over half (58.2%, n = 46) of these patients possessed basic cell phones. Only 19.0% (n = 23) of patients had no change in cell phone number or physical phone over the course of the six months postinjury. In regression models that adjusted for relevant clinical and demographic characteristics, cell phone instability was associated with higher six-month postinjury PTSD symptom levels (p < 0.001).

CONCLUSIONS

Diverse injured patients at risk for the development of PTSD have unique technology use patterns, including high rates of cell phone instability. These observations should be strongly considered when developing technology-supported interventions for injured patients with PTSD.

A Randomized Trial of Collaborative Care for Perinatal Depression in Socioeconomically Disadvantaged Women: The Impact of Comorbid Posttraumatic Stress Disorder

OBJECTIVE

The comorbidity of posttraumatic stress disorder (PTSD) with antenatal depression poses increased risks for postpartum depression and may delay or diminish response to evidence-based depression care. In a secondary analysis of an 18-month study of collaborative care for perinatal depression, the authors hypothesized that pregnant, depressed, socioeconomically disadvantaged women with comorbid PTSD would show more improvement in the MOMCare intervention providing Brief Interpersonal Psychotherapy and/or antidepressants, compared to intensive public health Maternity Support Services (MSS-Plus).

METHODS

A multisite randomized controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System, July 2009-January 2014. Pregnant women were recruited who met criteria for a probable diagnosis of major depressive disorder (MDD) on the Patient Health Questionnaire-9 and/or dysthymia on the MINI-International Neuropsychiatric Interview (5.0.0). The primary outcome was depression severity at 3-, 6-, 12-and 18-month follow-ups; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care.

RESULTS

Sixty-five percent of the sample of 164 met criteria for probable comorbid PTSD. The treatment effect was significantly associated with PTSD status in a group-by-PTSD severity interaction, controlling for baseline depression severity (Wald χ²₁ = 4.52, P = .03). Over the 18-month follow-up, those with comorbid PTSD in MOMCare (n = 48), versus MSS-Plus (n = 58), showed greater improvement in depression severity (Wald χ²₁ = 8.51, P < .004), PTSD severity (Wald χ²₁ = 5.55, P < .02), and functioning (Wald χ²₁ = 4.40, P < .04); higher rates of depression response (Wald χ²₁ = 4.13, P < .04) and remission (Wald χ²₁ = 5.17, P < .02); and increased use of mental health services (Wald χ²₁ = 39.87, P < .0001) and antidepressant medication (Wald χ²₁ = 8.07, P < .005). Participants without comorbid PTSD in MOMCare (n = 33) and MSS-Plus (n = 25) showed equivalent improvement on these outcomes.

CONCLUSIONS

Collaborative depression care had a greater impact on perinatal depressive outcomes for socioeconomically disadvantaged women with comorbid PTSD than for those without PTSD. Findings suggest that a stepped care treatment model for high-risk pregnant women with both MDD and PTSD could be integrated into public health systems in the United States.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01045655.

Barriers to Cancer Care among American Indians and Alaska Natives

INTRODUCTION

Cancer is among the leading causes of death in American Indians and Alaska Natives (AI/ANs), with rates increasing over the last two decades. Barriers in accessing cancer screening and treatment likely contribute to this situation.

METHODS

We administered structured clinical interviews and conducted descriptive and multiple linear regression analyses of demographic, health, spiritual, and treatment factors associated with self-reported barriers to cancer care among 143 adult AI/AN oncology patients.

RESULTS

High levels of satisfaction with cancer care, older age, positive mental health quality of life, and positive physical health quality of life were all significantly associated with lower scores for cancer care barriers, explaining 27% of the total model variance.

CONCLUSION

Addressing barriers to cancer care might help to reduce health disparities among AI/AN oncology patients. Future research should determine whether reducing barriers improves engagement with cancer treatment and overall health outcomes.

COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL

BACKGROUND

Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression care. The authors evaluated whether "MOMCare,"a culturally relevant, collaborative care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus).

METHODS

A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care.

RESULTS

All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ(2) = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ(2) = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ(2) = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ(2) = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ(2) = 10.00, df = 1, P < .01).

CONCLUSION

Compared to MSS-Plus, MOMCare showed significant improvement in quality of care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression care can be integrated into the services of a county public health system in the United States.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.govNCT01045655.

Genetic polymorphisms affecting susceptibility to mercury neurotoxicity in children: summary findings from the Casa Pia Children's Amalgam clinical trial

Mercury (Hg) is neurotoxic, and children may be particularly susceptible to this effect. A current major challenge is identification of children who may be uniquely susceptible to Hg toxicity because of genetic predisposition. We examined the possibility that common genetic variants that are known to affect neurologic functions or Hg handling in adults would modify the adverse neurobehavioral effects of Hg exposure in children. Three hundred thirty subjects who participated as children in the recently completed Casa Pia Clinical Trial of Dental Amalgams in Children were genotyped for 27 variants of 13 genes that are reported to affect neurologic functions and/or Hg disposition in adults. Urinary Hg concentrations, reflecting Hg exposure from any source, served as the Hg exposure index. Regression modeling strategies were employed to evaluate potential associations between allelic status for individual genes or combinations of genes, Hg exposure, and neurobehavioral test outcomes assessed at baseline and for 7 subsequent years during the clinical trial. Among boys, significant modification of Hg effects on neurobehavioral outcomes over a broad range of neurologic domains was observed with variant genotypes for 4 of 13 genes evaluated. Modification of Hg effects on a more limited number of neurobehavioral outcomes was also observed for variants of another 8 genes. Cluster analyses suggested some genes interacting in common processes to affect Hg neurotoxicity. In contrast, significant modification of Hg effects on neurobehavioral functions among girls with the same genotypes was substantially more limited. These observations suggest increased susceptibility to the adverse neurobehavioral effects of Hg among children, particularly boys, with genetic variants that are relatively common to the general human population. These findings advance public health goals to identify factors underlying susceptibility to Hg toxicity and may contribute to strategies for preventing adverse health risks associated with Hg exposure.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study

BACKGROUND

Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS).

METHODS

Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum).

BASELINE RESULTS

168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy.

CONCLUSIONS

A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription

OBJECTIVE

Increasing rates of opioid use disorders (OUDs) (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident OUDs among individuals with a new episode of a chronic noncancer pain (CNCP) condition.

METHODS

We utilized claims data from the HealthCore Database for 2000 to 2005. The dataset included all individuals aged 18 and over with a new CNCP episode (no diagnosis in the prior 6 mo), and no opioid use or OUD in the prior 6 months (n=568,640). We constructed a single multinomial variable describing prescription on opioid days supply (none, acute, and chronic) and average daily dose (none, low dose, medium dose, and high dose), and examined the association between this variable and an incident OUD diagnosis.

RESULTS

Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared with those not prescribed opioids. Effects varied by average daily dose and days supply: low dose, acute (odds ratio [OR]=3.03; 95% confidence interval [CI], 2.32, 3.95); low dose, chronic (OR=14.92; 95% CI, 10.38, 21.46); medium dose, acute (OR=2.80; 95% CI, 2.12, 3.71); medium dose, chronic (OR=28.69; 95% CI, 20.02, 41.13); high dose, acute (OR=3.10; 95% CI, 1.67, 5.77); and high dose, chronic (OR=122.45; 95% CI, 72.79, 205.99).

CONCLUSIONS

Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk.

Genetic polymorphisms of catechol-O-methyltransferase modify the neurobehavioral effects of mercury in children

Mercury (Hg) is neurotoxic and children may be particularly susceptible to this effect. A current major challenge is identification of children who may be uniquely susceptible to Hg toxicity because of genetic disposition. This study examined the hypothesis that genetic variants of catechol-O-methyltransferase (COMT) that are reported to alter neurobehavioral functions that are also affected by Hg in adults might modify the adverse neurobehavioral effects of Hg exposure in children. Five hundred and seven children, 8-12 yr of age at baseline, participated in a clinical trial to evaluate the neurobehavioral effects of Hg from dental amalgam tooth fillings. Subjects were evaluated at baseline and at seven subsequent annual intervals for neurobehavioral performance and urinary Hg levels. Following the clinical trial, genotyping assays were performed for single-nucleotide polymorphisms (SNPs) of COMT rs4680, rs4633, rs4818, and rs6269 on biological samples provided by 330 of the trial participants. Regression-modeling strategies were employed to evaluate associations between allelic status, Hg exposure, and neurobehavioral test outcomes. Similar analysis was performed using haplotypes of COMT SNPs. Among girls, few interactions for Hg exposure and COMT variants were found. In contrast, among boys, numerous gene-Hg interactions were observed between individual COMT SNPs, as well as with a common COMT haplotype affecting multiple domains of neurobehavioral function. These findings suggest increased susceptibility to the adverse neurobehavioral effects of Hg among children with common genetic variants of COMT, and may have important implications for strategies aimed at protecting children from the potential health risks associated with Hg exposure.

Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care

BACKGROUND

Women have higher rates of depression and often experience depression symptoms during critical reproductive periods, including adolescence, pregnancy, postpartum, and menopause. Collaborative care intervention models for mood disorders in patients receiving care in an OB-GYN clinic setting have not been evaluated. Study design and methodology for a randomized controlled trial of collaborative care depression management versus usual care in OB-GYN clinics and the details of the adapted collaborative care intervention and model implementation are described in this paper.

METHODS

Women over age 18 years with clinically significant symptoms of depression, as measured by a Patient Health Questionnaire-9 (PHQ-9) score ≥10 and a clinical diagnosis of major depression or dysthymia, were randomized to the study intervention or to usual care and were followed for 18 months. The primary outcome assessed was change over time in the SCL-20 depression scale between baseline and 12 months.

BASELINE RESULTS

Two hundred five women were randomized: 57% white, 20% African American, 9% Asian or Pacific Islander, 7% Hispanic, and 6% Native American. Mean age was 39 years. 4.6% were pregnant and 7.5% were within 12 months postpartum. The majority were single (52%), and 95% had at least the equivalent of a high school diploma. Almost all patients met DSM IV criteria for major depression (99%) and approximately 33% met criteria for dysthymia.

CONCLUSIONS

An OB-GYN collaborative care team, including a social worker, a psychiatrist, and an OB-GYN physician, who met weekly and used an electronic tracking system for patients was the essential element of the proposed depression care treatment model described here. Further study of models that improve quality of depression care that are adapted to the unique OB-GYN setting is needed.

Modification of neurobehavioral effects of mercury by genetic polymorphisms of metallothionein in children

Mercury (Hg) is neurotoxic, and children may be particularly susceptible to this effect. A current major challenge is the identification of children who may be uniquely susceptible to Hg toxicity because of genetic disposition. We examined the hypothesis that genetic variants of metallothionein (MT) that are reported to affect Hg toxicokinetics in adults would modify the neurotoxic effects of Hg in children. Five hundred seven children, 8-12 years of age at baseline, participated in a clinical trial to evaluate the neurobehavioral effects of Hg from dental amalgam tooth fillings. Subjects were evaluated at baseline and at 7 subsequent annual intervals for neurobehavioral performance and urinary Hg levels. Following the completion of the clinical trial, we performed genotyping assays for variants of MT isoforms MT1M (rs2270837) and MT2A (rs10636) on biological samples provided by 330 of the trial participants. Regression modeling strategies were employed to evaluate associations between allelic status, Hg exposure, and neurobehavioral test outcomes. Among girls, few significant interactions or independent main effects for Hg exposure and either of the MT gene variants were observed. In contrast, among boys, numerous significant interaction effects between variants of MT1M and MT2A, alone and combined, with Hg exposure were observed spanning multiple domains of neurobehavioral function. All dose-response associations between Hg exposure and test performance were restricted to boys and were in the direction of impaired performance. These findings suggest increased susceptibility to the adverse neurobehavioral effects of Hg among children with relatively common genetic variants of MT, and may have important public health implications for future strategies aimed at protecting children and adolescents from the potential health risks associated with Hg exposure. We note that because urinary Hg reflects a composite exposure index that cannot be attributed to a specific source, these findings do not support an association between Hg in dental amalgams specifically and the adverse neurobehavioral outcomes observed.

Influence of framing and graphic format on comprehension of risk information among American Indian tribal college students

We evaluated methods for presenting risk information by administering six versions of an anonymous survey to 489 American Indian tribal college students. All surveys presented identical numeric information, but framing varied. Half expressed prevention benefits as relative risk reduction, half as absolute risk reduction. One third of surveys used text to describe prevention benefits; one third used text plus bar graph; one third used text plus modified bar graph incorporating a culturally tailored image. The odds ratio (OR) for correct risk interpretation for absolute risk framing vs. relative risk framing was 1.40 (95 % CI = 1.01, 1.93). The OR for correct interpretation of text plus bar graph vs. text only was 2.16 (95 % CI = 1.46, 3.19); OR for text plus culturally tailored bar graph vs. text only was 1.72 (95 % CI = 1.14, 2.60). Risk information including a bar graph was better understood than text-only information; a culturally tailored graph was no more effective than a standard graph.

Modification of neurobehavioral effects of mercury by a genetic polymorphism of coproporphyrinogen oxidase in children

Mercury (Hg) is neurotoxic, and children may be particularly susceptible to this effect. A current major challenge is the identification of children who may be uniquely susceptible to Hg toxicity because of genetic disposition. We examined the hypothesis that CPOX4, a genetic variant of the heme pathway enzyme coproporphyrinogen oxidase (CPOX) that affects susceptibility to mercury toxicity in adults, also modifies the neurotoxic effects of Hg in children. Five hundred seven children, 8-12 years of age at baseline, participated in a clinical trial to evaluate the neurobehavioral effects of Hg from dental amalgam tooth fillings in children. Subjects were evaluated at baseline and at 7 subsequent annual intervals for neurobehavioral performance and urinary mercury levels. Following the completion of the clinical trial, genotyping assays for CPOX4 allelic status were performed on biological samples provided by 330 of the trial participants. Regression modeling strategies were employed to evaluate associations between CPOX4 status, Hg exposure, and neurobehavioral test outcomes. Among girls, few significant CPOX4-Hg interactions or independent main effects for Hg or CPOX4 were observed. In contrast, among boys, numerous significant interaction effects between CPOX4 and Hg were observed spanning all 5 domains of neurobehavioral performance. All underlying dose-response associations between Hg exposure and test performance were restricted to boys with the CPOX4 variant, and all of these associations were in the expected direction where increased exposure to Hg decreased performance. These findings are the first to demonstrate genetic susceptibility to the adverse neurobehavioral effects of Hg exposure in children. The paucity of responses among same-age girls with comparable Hg exposure provides evidence of sexual dimorphism in genetic susceptibility to the adverse neurobehavioral effects of Hg in children and adolescents.

Mental health disorders and long-term opioid use among adolescents and young adults with chronic pain

PURPOSE

The purpose of this study was to examine the association between mental health disorders and subsequent risk for long-term opioid use among adolescents and young adults presenting with common chronic pain complaints (back pain, neck pain, headache, and arthritis/joint pain).

METHODS

Using claims data from January 1, 2001 to June 30, 2008, we conducted a longitudinal analysis of opioid use patterns among 13-24-year-old subjects presenting with a new episode of chronic pain. Long-term opioid use was defined as receiving >90 days of opioids within a 6-month period with no gap of >30 days in use of opioids in the 18 months after the first qualifying pain diagnosis. Mental health disorders were identified from claims in the 6 months before the first qualifying pain diagnosis.

RESULTS

Fifty-nine thousand seventy-seven youth met criteria for a new episode of chronic pain. Among these youth, 321 (.5%) met criteria for long-term opioid use, and 16,172 (27.4%) had some opioid use. After controlling for demographic and clinical factors, youth with preexisting mental health diagnoses had a 2.4-fold increased risk of subsequently receiving long-term opioids versus no opioids (odds ratio = 2.36, 95% confidence interval = 1.73-3.23) and a 1.8-fold increased likelihood of receiving long-term opioids versus some opioids (odds ratio = 1.83, 95% confidence interval = 1.34-2.50).

CONCLUSIONS

Mental health disorders are associated with increased risk for long-term opioid use among adolescents and emerging young adults. Further study is warranted to examine risks and benefits of long-term opioid use in this population.

The association between intensive care unit admission and subsequent depression in patients with diabetes

OBJECTIVE

To examine whether intensive care unit (ICU) admission is independently associated with increased risk of major depression in patients with diabetes.

METHODS

This prospective cohort study included 3596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study, of whom 193 had at least one ICU admission over a 3-year period. We controlled for baseline depressive symptoms, demographics, and clinical characteristics. We examined associations between ICU admission and subsequent major depression using logistic regression.

RESULTS

There were 2624 eligible patients who survived to complete follow-up; 98 had at least one ICU admission. Follow-up assessments occurred at a mean of 16.4 months post-ICU for those who had an ICU admission. At baseline, patients who had an ICU admission tended to be depressed, older, had greater medical comorbidity, and had more diabetic complications. At follow-up, the point prevalence of probable major depression among patients who had an ICU admission was 14% versus 6% among patients without an ICU admission. After multivariate adjustment, ICU admission was independently associated with subsequent probable major depression (Odds Ratio 2.07, 95% confidence interval (1.06-4.06)). Additionally, baseline probable major depression was significantly associated with post-ICU probable major depression.

CONCLUSIONS

ICU admission in patients with diabetes is independently associated with subsequent probable major depression. Additional research is needed to identify at-risk patients and potentially modifiable ICU exposures in order to inform future interventional studies with the goal of decreasing the burden of comorbid depression in older patients with diabetes who survive critical illnesses.

Depression in pregnancy is associated with preexisting but not pregnancy-induced hypertension

BACKGROUND

The aim was to examine whether depression is associated with preexisting hypertension or pregnancy-induced hypertension in a large sample of women attending a university-based obstetrics clinic.

METHODS

In this prospective study, participants were 2398 women receiving ongoing prenatal care at a university-based obstetrics clinic from January 2004 through January 2009. Prevalence of depression was measured using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria based on the Patient Health Questionnaire-9 as well as the self-reported use of antidepressant medication. Evidence of preexisting hypertension, pregnancy-induced hypertension and preeclampsia/eclampsia was determined by obstetrician International Classification of Diseases, Ninth Revision codes. Logistic regression was used to quantify the association between hypertension in pregnancy and antenatal depression.

RESULTS

After adjusting for sociodemographic variables, chronic medical conditions, smoking and prior pregnancy complications, women with preexisting hypertension had an increased risk of any depression (minor, major, use of antidepressants) [odds ratio (OR)=1.55, 95% confidence interval (CI) 1.08-2.23) and major depression and/or use of antidepressants (OR=1.65, 95% CI 1.10-2.48) compared to women without hypertension. No differences were seen in risk of depression in women with pregnancy-induced hypertension or preeclampsia/eclampsia compared to those without hypertension.

CONCLUSION

Women with preexisting hypertension, but not pregnancy-induced hypertension, are more likely to meet criteria for an antenatal depressive disorder and/or to be treated with antidepressants and could be targeted by obstetricians for screening for depression and enhanced treatment.

Does pedometer goal setting improve physical activity among Native elders? Results from a randomized pilot study

We examined if step-count goal setting resulted in increases in physical activity and walking compared to only monitoring step counts with pedometers among American Indian/Alaska Native elders. Outcomes included step counts, self-reported physical activity and well-being, and performance on the 6-minute walk test. Although no significant between-group differences were found, within-group analyses indicated that elders significantly improved on the majority of step count, physical activity, health-related quality of life, and 6-minute walk outcomes.

The association of comorbid depression with intensive care unit admission in patients with diabetes: a prospective cohort study

BACKGROUND

It is unknown if comorbid depression in patients with diabetes mellitus increases the risk of intensive care unit (ICU) admission.

OBJECTIVE

This study examined whether comorbid depression in patients with diabetes increased risk of ICU admission, coronary care unit (CCU) admission, and general medical-surgical unit hospitalization, as well as total days hospitalized, after controlling for demographics, clinical characteristics, and health risk behaviors.

METHOD

This prospective cohort study included 3,596 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study. We assessed baseline depression with the Patient Health Questionnaire-9. We controlled for baseline demographics, smoking, BMI, exercise, hemoglobin A(1c), medical comorbidities, diabetes complications, type 1 diabetes, diabetes duration, and insulin treatment. We assessed time to any ICU, CCU, and/or general medical-surgical unit admission using Cox proportional-hazards regression. We used Poisson regression with robust standard errors to examine associations between depression and total days hospitalized.

RESULTS

Unadjusted analyses revealed that baseline probable major depression was associated with increased risk of ICU admission [hazard ratio (HR) 1.94, 95% confidence interval (95% CI)(1.34-2.81)], but was not associated with CCU or general medical-surgical unit admission. Fully adjusted analyses revealed probable major depression remained associated with increased risk of ICU admission [HR 2.23, 95% CI(1.45-3.45)]. Probable major depression was also associated with more total days hospitalized (Incremental Relative Risk 1.64, 95%CI(1.26-2.12)).

CONCLUSIONS

Patients with diabetes and comorbid depression have a greater risk of ICU admission. Improving depression treatment in patients with diabetes could potentially prevent hospitalizations for critical illnesses and lower healthcare costs.

Barriers and facilitators to walking and physical activity among American Indian elders

INTRODUCTION

Physical inactivity is common among older American Indians. Several barriers impede the establishment and maintenance of routine exercise. We examined personal and built-environment barriers and facilitators to walking and physical activity and their relationship with health-related quality of life in American Indian elders.

METHODS

We used descriptive statistics to report barriers and facilitators to walking and physical activity among a sample of 75 American Indians aged 50 to 74 years. Pearson correlation coefficients were used to examine the relationship between health-related quality of life and barriers to walking and physical activity after adjusting for caloric expenditure and total frequency of all exercise activities.

RESULTS

Lack of willpower was the most commonly reported barrier. Elders were more likely to report personal as opposed to built-environment reasons for physical inactivity. Better health and being closer to interesting places were common walking facilitators. Health-related quality of life was inversely related to physical activity barriers, and poor mental health quality of life was more strongly associated with total barriers than poor physical health.

CONCLUSION

We identified a variety of barriers and facilitators that may influence walking and physical activity among American Indian elders. More research is needed to determine if interventions to reduce barriers and promote facilitators can lead to objective, functional health outcomes.

Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents

OBJECTIVE

The purpose of this study was to examine the performance characteristics and validity of the Patient Health Questionnaire-9 Item (PHQ-9) as a screening tool for depression among adolescents.

METHODS

The PHQ-9 was completed by 442 youth (aged 13-17 years) who were enrolled in a large health care-delivery system and participated in a study on depression outcomes. Criterion validity and performance characteristics were assessed against an independent structured mental health interview (the Child Diagnostic Interview Schedule [DISC-IV]). Construct validity was tested by examining associations between the PHQ-9 and a self-report measure of functional impairment, as well as parental reports of child psychosocial impairment and internalizing symptoms.

RESULTS

A PHQ-9 score of 11 or more had a sensitivity of 89.5% and a specificity of 77.5% for detecting youth who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression on the DISC-IV. Receiver-operator-curve analysis revealed that the PHQ-9 had an area under the curve of 0.88 (95% confidence interval: 0.82-0.94), and the cut point of 11 was optimal for maximizing sensitivity without loss of specificity. Increasing PHQ-9 scores were significantly correlated with increasing levels of functional impairment, as well as parental report of internalizing symptoms and psychosocial problems.

CONCLUSIONS

Although the optimal cut point is higher among adolescents, the sensitivity and specificity of the PHQ-9 are similar to those of adult populations. The brief nature and ease of scoring of this instrument make this tool an excellent choice for providers and researchers seeking to implement depression screening in primary care settings.

Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents

OBJECTIVE

To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents.

METHODS

After completing a brief depression screen, 499 youth (aged 13-17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment.

RESULTS

A PHQ-2 score of > or =3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75-0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of > or =3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3.

CONCLUSIONS

The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

The relationship between changes in depression symptoms and changes in health risk behaviors in patients with diabetes

BACKGROUND

This longitudinal study of patients with diabetes examined the relationship between changes in depressive symptoms and changes in diabetes self-care behaviors over 5 years.

DESIGN, PATIENTS AND MEASUREMENTS

A total of 2759 patients with diabetes enrolled in a large HMO were followed over a 5-year period. Patients filled out a baseline mail survey and participated in a telephone interview 5 years later. Depression was measured with the Patient Health Questionnaire (PHQ-9) and diabetes self-care was measured with the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. Baseline and longitudinal evidence of diabetes and medical disease severity and complications were measured using ICD-9 and CPT codes and verified by chart review.

RESULTS

At the 5-year follow-up, patients with diabetes with either persistent or worsening depressive symptoms compared to those in the no depression group had significantly fewer days per week of following a healthy diet or participating in > or = 30 min of exercise. At 5-year follow-up, patients with clinical improvement in depression symptoms showed no differences compared to the no depression group on number of days per week of adherence to diet but showed deterioration in adherence to exercise on some, but not all, measures.

CONCLUSIONS

Patients with diabetes with persistent or worsening depressive symptoms over 5 years had significantly worse adherence to dietary and exercise regimens than patients in the no depression group. These results emphasize the need to further develop and test interventions to improve both quality of care for depression and self-care in diabetes patients.

Factors associated with detection and receipt of treatment for youth with depression and anxiety disorders

OBJECTIVE

Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth.

METHODS

Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11-17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months.

RESULTS

Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment.

CONCLUSIONS

The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications.

How does change in depressive symptomatology influence weight change in patients with diabetes? Observational results from the Pathways longitudinal cohort

BACKGROUND

Little is known about how change in depressive symptoms over time is associated with change in weight.

METHODS

Longitudinal associations between change in depression (Patient Health Questionnaire-9 [PHQ-9]) and weight (self-reported and chart abstracted) were examined in 2,600 patients with type 2 diabetes (mean age 62, SD = 11.6) who were surveyed by telephone in 2001-2002 and 5 years later as part of the Pathways study. Mixed effects regression analyses compared a) patients with persistently low depression symptoms with those whose depression worsened (increased at least 5 points on PHQ-9) over 5 years and b) patients with persistently high depression symptoms with those who improved (decreased at least 5 points on PHQ-9) over 5 years.

RESULTS

Those who worsened in comparison to those with persistently low depression symptoms did not differ in their pattern of weight change (z = 1.54, p = .12). Both groups weighed approximately 92 kg at baseline and lost approximately 2 kg. A significantly different pattern of change over time was observed for those with persistently high depression symptoms in comparison to those whose depression improved (z = 1.98, p = .04). Although the groups had almost identical weight at baseline (approximately 100 kg), at the 5-year assessment, those with persistently high depression symptoms had about half the weight loss (M = -1.71, SD = 9.08) in comparison to those whose depression improved (M = -3.62, SD = 19.93).

CONCLUSION

In persons with diabetes who have clinically significant levels of depressive symptoms, improvement in depression is accompanied by significantly greater, clinically significant weight loss.

Methamphetamine Users in the Psychiatric Emergency Services: A Case-Control Study

The purpose of this study is to examine the sociodemographic, clinical, and service use characteristics of patients with positive methamphetamine (MA) urine toxicology and compare with non-MA users seen in an urban Psychiatric Emergency Services (PES). One hundred twenty patient charts were extracted for demographics, mode of arrival, clinical information, medication treatment of MA-intoxication, and disposition. Compared with non-MA patients, MA patients were significantly younger, male, referred by police, with cardiac symptoms, psychosis, dysphoria, past substance use, and were less likely to have a diagnosis of Schizophrenia, a past psychiatric history/hospitalization, and a history of suicide attempts. Subsequent hospitalization rates did not differ. MA patients treated with medications more readily accepted the referral to chemical dependency treatment. This study shows that hypertension and tachycardia upon arrival to the PES, symptoms of dysphoria and psychosis, past substance use and not having the diagnosis of Schizophrenia are all related to methamphetamine use.

Understanding Why Patients Delay Seeking Care for Acute Coronary Syndromes

Background— Better insight into the psychosocial factors associated with prehospital delays in seeking care for acute coronary syndromes is needed to inform the design of future interventions. Delay in presenting for care after the onset of symptoms is common, limits the potential benefit of acute reperfusion, and has not been reduced by interventions tested thus far.

Methods and Results— Seven hundred ninety-six patients with suspected ischemic heart disease scheduled for clinically indicated imaging stress tests completed questionnaires concerning psychological distress and attachment styles (worthiness to receive care, trustworthiness of others to provide care). The primary dependent variable for this study was response to a question from the rapid early action for coronary treatment trial concerning intention to “wait until very sure” before seeking care for a possible “heart attack.” Responses to this question were strongly associated with actual emergency department-reported and self-reported care delay in the rapid early action for coronary treatment trial. In multivariable ordinal regression models, a more negative view of the trustworthiness of others, greater physical limitations from angina, and no previous revascularization were independently associated with increased intention to wait to seek care for a myocardial infarction. Intention to wait was not associated with inducible ischemia or self-perceived risk of myocardial infarction.

Conclusions— Intention to delay seeking care for acute coronary syndromes is associated with a patient’s view of the trustworthiness of others, previous experience with revascularization, and functional limitations, even after adjustment for objective and perceived acute coronary syndromes risk. These findings provide insight into novel factors contributing to longer delay times and may inform future interventions to reduce delay time.

Angina pectoris during daily activities and exercise stress testing: The role of inducible myocardial ischemia and psychological distress

Physicians often consider angina pectoris to be synonymous with myocardial ischemia. However, the relationship between angina and myocardial ischemia is highly variable and we have little insight into the sources of this variability. We investigated the relationship of inducible myocardial ischemia on SPECT stress perfusion imaging to angina reported with routine daily activities during the previous four weeks (N=788) and to angina reported during an exercise stress test (N=371) in individuals with confirmed or suspected coronary disease referred for clinical testing. We found that angina experienced during daily life is more strongly and consistently associated with psychological distress and the personal threat associated with angina than with inducible myocardial ischemia. In multivariable models, the presence of any angina during routine activities over the prior month was significantly associated with age, perceived risk of myocardial infarction, and anxiety when compared to those with no reported angina in the past month. Angina during daily life was not significantly associated with inducible myocardial ischemia on stress perfusion imaging in bivariate or multivariable models. In contrast, angina experienced during exercise stress testing was significantly related to image and ECG ischemia, though it was also significantly associated with anxiety. These results suggest that angina frequency over the previous four weeks is more strongly associated with personal threat and psychosocial distress than with inducible myocardial ischemia. These results lend support to angina treatment strategies that aim to reduce threat and distress as well as to reduce myocardial ischemia.

Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes

OBJECTIVE

The purpose of this study was to examine the 5-year effects on total health care costs of the Pathways depression intervention program for patients with diabetes and comorbid depression compared with usual primary care.

RESEARCH DESIGN AND METHODS

The Pathways Study was conducted in nine primary care practices of a large HMO and enrolled 329 patients with diabetes and comorbid major depression. The current study analyzed the differences in long-term medical costs between intervention and usual care patients. Participants were randomly assigned to a nurse depression intervention (n = 164) or to usual primary care (n = 165). The intervention included education about depression, behavioral activation, and a choice of either starting with support of antidepressant medication treatment by the primary care doctor or problem-solving therapy in primary care. Interventions were provided for up to 12 months, and the main outcome measures are health costs over a 5-year period.

RESULTS

Patients in the intervention arm of the study had improved depression outcomes and trends for reduced 5-year mean total medical costs of -$3,907 (95% CI -$15,454 less to $7,640 more) compared with usual care patients. A sensitivity analysis found that these cost differences were largely explained by the patients with depression and the most severe medical comorbidity.

CONCLUSIONS

The Pathways depression collaborative care program improved depression outcomes compared with usual care with no evidence of greater long-term costs and with trends for reduced costs among the more severely medically ill patients with diabetes.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma

OBJECTIVE

To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone.

METHODS

A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs.

RESULTS

Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures.

CONCLUSIONS

Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Agreement between parents and children regarding anxiety and depression diagnoses in children with asthma

This study examined parent-child agreement regarding anxiety and depressive disorders in youth with asthma and evaluated key demographic and health differences associated with parent-child agreement. Of 756 outpatient youth with asthma, 122 (16.0%) were diagnosed with a DSM-IV anxiety or depression disorder using the Diagnostic Interview Schedule for Children (C-DISC). Parents reported on internalizing symptoms using the Child Behavior Checklist (CBCL). Logistic regression analyses were used to examine factors related to parent- and child-reported symptom agreement. Low rates of agreement (48.9%) between youth and parents regarding diagnosis of a DSM-IV anxiety or depressive disorder were found among youth with asthma. Increased agreement was associated with higher externalizing behavior score on the CBCL and more anxiety and depressive symptoms on the C-DISC. Children without behavioral problems and with less severe anxiety and depression were recognized significantly less often by their parents.

Summary health status measures in advanced heart failure: relationship to clinical variables and outcome

BACKGROUND

Patient-centered health status measures are important because they capture the patient's perspective on their heart failure, but it is unclear which of these have independent prognostic significance.

METHODS AND RESULTS

A total of 142 consecutive subjects from a specialty heart failure clinic were assessed at baseline with a broad array of clinical, laboratory, and self-report measures including four summary measures of health status. The relationships between these measures and their association with the combined end point of transplantation or death over a mean follow-up of 3 years were examined. In unadjusted analyses, the Kansas City Cardiomyopathy Questionnaire (KCCQ) summary score had the strongest association with the combined end point (HR [for each unit score difference] = 0.98 [0.96-0.99], P = .002). In the adjusted Cox proportional hazards model including all 4 summary measures, the Seattle Heart Failure Score, V0(2,) systolic blood pressure, and medical comorbidity, only the Standard Gamble utility remained significantly associated with time to the combined end point (HR [for each 0.01 utility score difference] = 0.98 [0.97-0.99], P = .007).

CONCLUSIONS

Our study suggests that summary health status measures are simple and significant indicators of prognosis in advanced heart failure patients. The KCCQ summary score summarizes a wide range of clinical variables from the patient's point of view, whereas the standard gamble utility contains important prognostic information not captured in usual clinical variables.

Clinical factors associated with relapse in primary care patients with chronic or recurrent depression

BACKGROUND

Because in most patients depression is a relapsing/remitting disorder, finding clinical factors associated with risk of relapse is important. The majority of patients with depression are treated in primary care settings, but few previous studies have examined predictors of relapse in primary care patients with recurrent or chronic depression.

METHODS

Data from a cohort of 386 primary care patients in a clinical trial were analyzed for clinical and demographic predictors of relapse over a one-year post-study observational period. Patients were selected for a high risk of relapse, based on a history of either 3 previous depressive episodes or dysthymia, and enrolled in a randomized trial of relapse prevention.

RESULTS

Factors found to be associated with significantly higher risk of relapse included poorer medication adherence in the 30 days prior to the trial, lower self-efficacy to manage depression, and higher scores on the Child Trauma Questionnaire.

LIMITATIONS

Use of a sample of limited diversity taken from a clinical trial, and use of retrospective information from patients with potential for recall bias.

CONCLUSIONS

The findings of this report suggest specific risk factors to be targeted in depression relapse prevention interventions. It is encouraging that two of the factors associated with increased risk of relapse, self-efficacy and medication adherence have been seen to improve with the intervention utilized in the primary care trial from which the studied cohort was drawn.

Depression and health status in elderly patients with heart failure: a 6-month prospective study in primary care

To determine the prevalence and effects of depression on health status among elderly outpatients with heart failure, the authors conducted a 6-month prospective cohort study of 139 older outpatients with heart failure managed in primary care and 80 of their spouses. Primary care heart failure diagnosis was confirmed through chart review. The Primary Care Evaluation of Mental Disorders psychiatric diagnostic interview and Hamilton Depression Rating Scale were administered by phone. EQ-5D feeling thermometer, Medical Outcomes Study Short Form 36-Item Questionnaire, Kansas City Cardiomyopathy Questionnaire, and heart failure symptom severity questionnaires were administered by self-report. Depression diagnoses at baseline were: major depression and/or dysthymia (n=12, 9%), minor depression (n=14, 10%), and no depression (n=113, 81%). After adjusting for age, gender, and medical comorbidity, these depression groups differed by repeated measures analysis of covariance on most health status measures including the EQ-5D feeling thermometer; Medical Outcomes Study Short Form 36-Item Questionnaire general health and physical role function subscales; Kansas City Cardiomyopathy Questionnaire total score, symptom total, physical limitations, and quality of life subscales; as well as severity of chest pain and fatigue. Depression has significant and persistent effects on health status of elderly patients with heart failure, including heart failure symptoms, physical and role function, and quality of life. This may help explain why depression has been associated with increased health care utilization and costs in this population.

The Association of Patient Relationship Style and Outcomes in Collaborative Care Treatment for Depression in Patients With Diabetes

PURPOSE

We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes.

METHODS

From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes.

RESULTS

Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style.

CONCLUSION

Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style.

Using relationship styles based on attachment theory to improve understanding of specialty choice in medicine

BACKGROUND

Patient-provider relationships in primary care are characterized by greater continuity and depth than in non-primary care specialties. We hypothesized that relationship styles of medical students based on attachment theory are associated with specialty choice factors and that such factors will mediate the association between relationship style and ultimately matching in a primary care specialty.

METHODS

We determined the relationship styles, demographic characteristics and resident specialty match of 106 fourth-year medical students. We assessed the associations between 1) relationship style and specialty choice factors; 2) specialty choice factors and specialty match, and 3) relationship style and specialty match. We also conducted mediation analyses to determine if factors examined in a specialty choice questionnaire mediate the association between relationship style and ultimately matching in a primary care specialty.

RESULTS

Prevalence of attachment styles was similar to that found in the general population and other medical school settings with 59% of students rating themselves as having a secure relationship style. Patient centeredness was directly associated, and career rewards inversely associated with matching in a primary care specialty. Students with a self-reliant relationship style were significantly more likely to match in a non-primary care specialty as compared to students with secure relationship style (OR = 5.3, 95% CI 1.8, 15.6). There was full mediation of the association between relationship style and specialty match by the specialty choice factor characterized by patient centeredness.

CONCLUSION

Assessing relationship styles based on attachment theory may be a potentially useful way to improve understanding and counsel medical students about specialty choice.

Beliefs about psychotropic medication and psychotherapy among primary care patients with anxiety disorders

Primary health care clinics are increasingly providing psychiatric/psychological treatment of anxiety disorders, particularly for patients who do not have adequate access to specialty mental health services. Adequate treatment requires knowledge of and attention to patients' beliefs about available treatment options. The current investigation examined beliefs about psychotropic medications and psychotherapy among a sample of primary care patients with anxiety disorders. The influence of key demographic variables on strength of these beliefs was also explored. The presence of specific anxiety disorders was not found to impact strength of beliefs about either type of treatment. In contrast, there was a trend for the presence of depression to relate to more favorable attitudes toward psychotropic medication. Consistent with previous studies, ethnic minority patients reported less favorable attitudes toward both psychotropic medications and psychotherapy. These findings underscore the importance of assessing patient beliefs prior to the initiation of either psychotropic medications or psychotherapy across diagnostic and demographic groups. Practitioners should be particularly alert to the possibility that patients with anxiety disorders and members of ethnic minority groups may have less favorable attitudes toward treatment options. Treatment adherence may therefore be increased by addressing these beliefs directly.

Assessment of beliefs about psychotropic medication and psychotherapy: development of a measure for patients with anxiety disorders

OBJECTIVE

This study presents the psychometric properties of a brief measure to assess beliefs about psychotropic medications and psychotherapy among patients with anxiety disorders.

METHOD

Data were collected on a large sample of primary care patients with a range of anxiety disorders, as part of the Collaborative Care for Anxiety and Panic study. Factor analyses using principal axis factoring with Varimax rotations were used to determine the factor structure of the beliefs scale. Internal consistency, concurrent validity and predictive validity of the resulting subscales were examined.

RESULTS

Two subscales emerged, one reflecting beliefs about psychotropic medications and the other assessing beliefs about psychotherapy. Both showed strong internal consistency and concurrent validity. The beliefs about psychotropic medication demonstrated strong predictive validity.

CONCLUSIONS

This measure may be a useful tool for assessing treatment beliefs among patients with anxiety disorders toward the provision of more quality treatment for this population. Its brevity may make it particularly useful in primary health care settings.

The association of depression and perceptions of interpersonal relationships in patients with diabetes

OBJECTIVE

Using an instrument assessing interpersonal relationships in patients with diabetes, we hypothesized that a change in depression would be associated with a change in patients' perceptions of themselves and others in relationships.

METHODS

Instruments assessing attachment, depression, and demographics were administered twice to 367 patients with diabetes in an HMO primary care setting, 10 months apart. We assessed change in capacity to rely on others (model of other) and to feel worthy of attention (model of self) according to depression change categories (unchanged, decreased, and increased depression).

RESULTS

The degree to which patients reported being able to rely on others increased with a reduction in depressive symptoms (P = .02). The degree to which patients endorsed a sense that they were not worthy of attention in relationships increased with an increase in depressive symptoms (P = .02).

CONCLUSION

A change in depressive symptoms is associated with a change in perception of interpersonal relationships in patients with diabetes.

Usefulness of depression to predict time to combined end point of transplant or death for outpatients with advanced heart failure

In a prospective cohort study of 142 outpatients with advanced heart failure followed for a mean of 3 years, 29% of subjects with a depression diagnosis at baseline were significantly more likely to experience the combined end point of death or transplantation (hazard ratio 2.54, 95% confidence interval 1.16 to 5.55). After adjustment for a range of sociodemographic and clinical characteristics, patients with depressive disorders were still significantly more likely to reach the combined end point (hazard ratio 2.41, 95% confidence interval 1.24 to 4.68). Depressed patients also had more heart failure related hospitalizations (1.5 +/- 1.8 vs 0.6 +/- 1.4, p = 0.04) and clinic visits (2.4 +/- 1.7 vs 1.7 +/- 1.8, p = 0.04) over the first year of follow-up.

Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients

BACKGROUND

Suicide is a major risk for those with bipolar disorder, a risk amplified by comorbid substance abuse in some, but not all, previous studies. To further explore the relationships of substance abuse, suicide, and bipolarity as they present in clinical practice, we analyzed standardized clinical data from a large acute psychiatric inpatient service.

METHODS

Standardized clinical evaluations of 7819 patients with diagnoses of bipolar depression (n=990), bipolar mania (n=948), unipolar depressive episode (n=3626), or schizophrenia-schizoaffective disorders (n=2255) were analyzed to evaluate the relationship between current substance-use problems, substance-induced symptoms, and a current suicide crisis, as well as lifetime suicide attempts, with logistic regressions adjusting for age, gender, and ethnicity.

RESULTS

Across the combined groups, current substance-use problems were significantly associated with a lifetime suicide attempt (odds ratios [ORs] 1.6-2.5) and to a lesser degree to the admission suicide crisis (ORs 1-2.2). Among bipolar (depressed/manic) patients, but not other diagnostic groups, those with both current substance-use problems and substance-induced symptoms had even higher rates of a recent suicide crisis (ORs 1.5-3.1) and of a lifetime attempt (ORs 2.5-3.4).

CONCLUSIONS

In bipolar patients, substance use disorder doubled and substance use disorder plus substance-induced symptoms tripled the suicidal risk. Implications for future research are discussed.

Geriatric Patients Improve as Much as Younger Patients from Hospitalization on General Psychiatric Units

OBJECTIVES

To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission.

DESIGN

Cohort study.

SETTING

Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999.

PARTICIPANTS

A total of 5,929 inpatients.

MEASUREMENTS

Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses.

RESULTS

Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients.

CONCLUSION

Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Depression and health status in patients with advanced heart failure: a prospective study in tertiary care

BACKGROUND

Depression impairs health status among patients with coronary disease. The effect of depression on patients with heart failure has been studied to date only in hospitalized patients.

METHODS AND RESULTS

Prospective cohort study of 113 outpatients with advanced heart failure. At baseline, 19% (n = 21) had major depression or dysthymia, 9% (n = 10) had minor depression, and 72% (n = 82) had no current depression diagnosis. Repeated measures analyses of covariance adjusting for demographic and clinical differences demonstrated that the depression groups differed on observed function (6-minute walk distance [F = 4.8, P = .01]), and self-reported generic (SF-36) and disease-specific (Kansas City Cardiomyopathy Questionnaire) health status. Depression groups also differed in severity of self-reported breathlessness, chest pain, and fatigue. Subject- and spouse-reported role function also differed between the groups. Partial correlation (controlling for the same covariates) between baseline Hamilton Depression Scale scores and these outcomes was highly significant at baseline and follow-up.

CONCLUSIONS

Depression is prospectively associated with poorer health status in patients with advanced heart failure. Physical and role function, symptom severity, and quality of life are all significantly affected.

Adult health status of women HMO members with posttraumatic stress disorder symptoms

Posttraumatic stress disorder (PTSD) is associated with high numbers of self-reported physical symptoms and functional disability in clinical samples, but little is known about the magnitude of these associations in population samples and using actual physician-coded diagnoses. We administered a 22-page survey to 1225 female HMO enrollees randomly selected from the current membership of a large, staff model HMO in Seattle, Washington. Using the PTSD Checklist (internally validated against a subset of clinical interviews) we compared women with low, moderate, and high scores with respect to differences in self-reported physical health status, functional disability (36-item short form health survey), numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. Compared to women with low PTSD symptom severity, those with moderate or high severity reported significantly higher functional disability (P<.001), rates of abuse and neglect (P<.01 to P<.001), health risk behavior scores (P<0.05), as well as higher mean numbers of common physical symptoms (P<.05). Compared to women with low PTSD symptom severity those with moderate or high severity had significantly higher adjusted odds ratios for aversive physical symptoms (range, 1.7-10.1). The mean number of physician-coded ICD-9 diagnoses was also significantly higher in the both the moderate and high severity groups. Among female HMO members, PTSD symptoms are associated with a wide range of both self-reported and physician-coded adverse physical health outcomes.