Predicting posttraumatic stress symptoms longitudinally in a representative sample of hospitalized injured adolescents

OBJECTIVE

Adolescents constitute a high-risk population for traumatic physical injury, yet few longitudinal investigations have assessed the development of posttraumatic stress disorder (PTSD) symptoms over time in representative samples.

METHOD

Between July 2002 and August 2003, 108 randomly selected injured adolescent patients ages 12 to 18 and their parents were interviewed at baseline and again 2, 5, and 12 months postinjury. Initially, participants were screened for PTSD symptoms with the PTSD Reaction Index (PTSD-RI) and depressive symptoms with the Center for Epidemiologic Studies Depression Scale, as well as preinjury trauma. Random-coefficient regression was used to assess the association between baseline clinical, injury, and demographic characteristics and the development and maintenance of PTSD symptoms longitudinally.

RESULTS

Between 19% and 32% of adolescents screened positive for PTSD (i.e., had PTSD-RI scores of > or =38) during the course of the 12 months after the injury. Higher initial adolescent PTSD and depressive symptoms, higher emergency department heart rate, greater objective event severity, and greater parental preinjury trauma were significant independent predictors of higher adolescent PTSD symptoms.

CONCLUSIONS

For a substantive minority of hospitalized adolescents, high PTSD symptom levels persist during the 12 months after injury. Clinical characteristics readily identifiable after the acute injury predict the development of PTSD symptoms over time. Real-world clinical trials that test screening and intervention procedures for representative samples of at-risk youths are warranted.

Reducing Suicidal Ideation in Depressed Older Primary Care Patients

OBJECTIVES

To determine the effect of a primary care-based collaborative care program for depression on suicidal ideation in older adults.

DESIGN

Randomized, controlled trial.

SETTING

Eighteen diverse primary care clinics.

PARTICIPANTS

One thousand eight hundred one adults aged 60 and older with major depression or dysthymia.

INTERVENTION

Participants randomized to collaborative care had access to a depression care manager who supported antidepressant medication management prescribed by their primary care physician and offered a course of Problem Solving Treatment in Primary Care for 12 months. Participants in the control arm received care as usual.

MEASUREMENTS

Participants had independent assessments of depression and suicidal ideation at baseline and 3, 6, 12, 18, and 24 months. Depression was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Suicidal ideation was determined using the SCID and the Hopkins Symptoms Checklist.

RESULTS

At baseline, 139 (15.3%) intervention subjects and 119 (13.3%) controls reported thoughts of suicide. Intervention subjects had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. Information on suicide attempts or hospitalization for suicidal ideation was not available.

CONCLUSION

Primary care-based collaborative care programs for depression represent one strategy to reduce suicidal ideation and potentially the risk of suicide in older primary care patients.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms

OBJECTIVE

The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma.

METHODS

We conducted a telephone survey of 767 youth with asthma (aged 11-17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity.

RESULTS

After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with > or = 1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire.

CONCLUSIONS

The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Depression treatment preferences in older primary care patients

PURPOSE

For depressed older primary care patients, this study aimed to examine (a) characteristics associated with depression treatment preferences; (b) predictors of receiving preferred treatment; and (c) whether receiving preferred treatment predicted satisfaction and depression outcomes.

DESIGN AND METHODS

Data are from 1,602 depressed older primary care patients who participated in a multisite, randomized clinical trial comparing usual care to collaborative care, which offered medication and counseling for up to 12 months. Baseline assessment included demographics, depression, health information, prior depression treatment, potential barriers, and treatment preferences (medication, counseling). At 12 months, services received, satisfaction, and depression outcomes were assessed.

RESULTS

More patients preferred counseling (57%) than medication (43%). Previous experience with a treatment type was the strongest predictor of preference. In addition, medication preference was predicted by male gender and diagnosis of major depression (vs dysthymia). The collaborative care model greatly improved access to preferred treatment, especially for counseling (74% vs 33% in usual care). Receipt of preferred treatment did not predict satisfaction or depression outcomes; these outcomes were most strongly impacted by treatment condition.

IMPLICATIONS

Many depressed older primary care patients desire counseling, which is infrequently available in usual primary care. Discussion of treatment preferences should include an assessment of prior treatment experiences. A collaborative care model that increases collaboration between primary care and mental health professionals can increase access to preferred treatment. If preferred treatment is not available, collaborative care still results in good satisfaction and depression outcomes.

Health care discussions and treatment for urinary incontinence in U.S. women

OBJECTIVE

The objective of the study was to determine the proportions of women with urinary incontinence who had discussed their condition with a health care provider or received treatment and to identify factors associated with seeking health care.

STUDY DESIGN

The study was a population-based, age-stratified postal survey of 6000 women aged 30 to 90 years enrolled in a large health maintenance organization in Washington state.

RESULTS

The response rate was 64% (n = 3536) after applying exclusion criteria. Eighty percent (n = 1160) of women with urinary incontinence completed a detailed set of questions on care seeking and treatments. Fifty percent had discussed their incontinence with a health care provider, 21% reported receiving surgery or prescription medication, 10% reported performing Kegel exercises, and 48% reported wearing a pad to absorb urine daily or weekly. The following factors were significantly associated with odds of discussing urinary incontinence with a health care provider: age (50 to 69 years, adjusted odds ratio 1.5 [1.1 to 2.0]; 70 to 89 years, adjusted odds ratio 1.9 [1.4, 2.7]); duration of urinary incontinence (2 to 5 years, adjusted odds ratio 1.9 [1.3 to 2.8]; more than 5 years, adjusted odds ratio 2.8 [2.0,4.1]); severe urinary incontinence (adjusted odds ratio 1.7 [1.2 to 2.6]); and greater effect on daily activities (adjusted odds ratio 2.7 [1.9,3.8]).

CONCLUSION

Among women with urinary incontinence, one half have discussed their incontinence with a health care provider and one third have received any form of treatment.

Incremental cost-effectiveness of a collaborative care intervention for panic disorder

BACKGROUND

Panic disorder is a prevalent, often disabling, disorder among primary-care patients, but there are large gaps in quality of treatment in primary care. This study describes the incremental cost-effectiveness of a combined cognitive behavioral therapy (CBT) and pharmacotherapy intervention for patients with panic disorder versus usual primary-care treatment.

METHOD

This randomized control trial recruited 232 primary-care patients meeting DSM-IV criteria for panic disorder from March 2000 to March 2002 from six primary-care clinics from university-affiliated clinics at the University of Washington (Seattle) and University of California (Los Angeles and San Diego). Patients were randomly assigned to receive either treatment as usual or a combined CBT and pharmacotherapy intervention for panic disorder delivered in primary care by a mental health therapist. Intervention patients had up to six sessions of CBT modified for the primary-care setting in the first 12 weeks, and up to six telephone follow-ups over the next 9 months. The primary outcome variables were total out-patient costs, anxiety-free days (AFDs) and quality adjusted life-years (QALYs).

RESULTS

Relative to usual care, intervention patients experienced 60.4 [95% confidence interval (CI) 42.9-77.9] more AFDs over a 12-month period. Total incremental out-patient costs were 492 US dollars higher (95% CI 236-747 US dollars ) in intervention versus usual care patients with a cost per additional AFD of 8.40 US dollars (95% CI 2.80-14.0 US dollars ) and a cost per QALY ranging from 14,158 US dollars (95% CI 6,791-21,496 US dollars ) to 24,776 US dollars (95% CI 11,885-37,618 US dollars ). The cost per QALY estimate is well within the range of other commonly accepted medical interventions such as statin use and treatment of hypertension.

CONCLUSIONS

The combined CBT and pharmacotherapy intervention was associated with a robust clinical improvement compared to usual care with a moderate increase in ambulatory costs.

Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care

OBJECTIVE

To determine the long term effectiveness of collaborative care management for depression in late life.

DESIGN

Two arm, randomised, clinical trial; intervention one year and follow-up two years.

SETTING

18 primary care clinics in eight US healthcare organisations. Patients 1801 primary care patients aged 60 and older with major depression, dysthymia, or both.

INTERVENTION

Patients were randomly assigned to a 12 month collaborative care intervention (IMPACT) or usual care for depression. Teams including a depression care manager, primary care doctor, and psychiatrist offered education, behavioural activation, antidepressants, a brief, behaviour based psychotherapy (problem solving treatment), and relapse prevention geared to each patient's needs and preferences.

MAIN OUTCOME MEASURES

Interviewers, blinded to treatment assignment, conducted interviews in person at baseline and by telephone at each subsequent follow up. They measured depression (SCL-20), overall functional impairment and quality of life (SF-12), physical functioning (PCS-12), depression treatment, and satisfaction with care.

RESULTS

IMPACT patients fared significantly (P < 0.05) better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. One year after IMPACT resources were withdrawn, a significant difference in SCL-20 scores (0.23, P < 0.0001) favouring IMPACT patients remained.

CONCLUSIONS

Tailored collaborative care actively engages older adults in treatment for depression and delivers substantial and persistent long term benefits. Benefits include less depression, better physical functioning, and an enhanced quality of life. The IMPACT model may show the way to less depression and healthier lives for older adults.

Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression

OBJECTIVE

To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression.

RESEARCH DESIGN AND METHODS

This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care.

RESULTS

Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found.

CONCLUSIONS

The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care.

Where is the patient? The association of psychosocial factors and missed primary care appointments in patients with diabetes

OBJECTIVE

Missed appointments are associated with poorer health outcomes. We predicted that compared to secure attachment style, fearful and dismissing attachment styles would be associated with greater number of missed primary care visits in patients with diabetes.

METHODS

In patients with diabetes from nine health maintenance organization primary care clinics, we collected data on attachment style and major depression status, and determined the number of missed primary care appointments from automated data. We used Poisson and logistic regression analyses to determine if attachment style was associated with the number of missed primary care same day appointments, scheduled office visits and scheduled preventive care visits, after adjusting for demographics, clinical characteristics, appointment frequency and clustering by clinic. We included major depression as a potential effect modifier.

RESULTS

Among 3,923 patients with diabetes, prevalence rates of attachment styles were 43.9% for secure, 35.8% for dismissing, 8.1% for preoccupied and 12.2% for fearful attachment style. Major depression was present in 12.4% of patients. Among patients without major depression, there were more missed scheduled office visits (RR=1.46, 95% CI=1.18-1.81) among those with dismissing compared to secure attachment style. The likelihood of having missed same day appointments was lower for those with fearful attachment style relative to those with secure attachment style in nondepressed patients compared to patients with fearful and secure attachment style with major depression (P < .01).

CONCLUSIONS

Attachment styles characterized by low levels of collaboration are associated with more missed primary care appointments compared to secure attachment style in patients with diabetes. These associations are moderated by depression status.

Effects of enhanced depression treatment on diabetes self-care

PURPOSE

Among patients with diabetes, major depression is associated with more diabetic complications, lower medication adherence, and poorer self-care of diabetes. We reported earlier that enhanced depression care reduces depression symptoms but not hemoglobin A1c level. This study examined effects of depression interventions on self-management among depressed diabetic patients.

METHODS

A total of 329 patients in 9 primary care clinics were randomized to an evidence-based collaborative depression treatment (pharmacotherapy, problem-solving treatment, or both in combination) or usual primary care (routine medical services). Outcome measures included the Summary of Diabetes Self-Care Activities (SDSCA), reported at baseline and 3, 6, and 12 months, and medication non-adherence as assessed by automated pharmacy refill data of oral hypoglycemic agents, lipid-lowering agents, and angiotensin-converting enzyme inhibitors. We used mixed regression models adjusted for baseline differences to compare the intervention with usual care groups at follow-up assessments.

RESULTS

During the 12-month intervention period, enhanced depression care and outcomes were not associated with improved diabetes self-care behaviors (healthy nutrition, physical activity, or smoking cessation). Relative to the usual care group, the intervention group reported a small decrease in body mass index (mean difference = 0.70 kg/m2, 95% CI, 0.17 to 1.24 kg/m2) and a higher rate of nonadherence to oral hypoglycemic agents (mean difference = -6.3%, 95% CI, -11.91% to -0.71%). Adherence to lipid-lowering agents and to antihypertensive medicines was similar for the 2 groups.

CONCLUSIONS

In general, diabetes self-management did not improve among the enhanced depression treatment group during a 12-month period, except for small between-group differences of limited clinical importance. Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes.

Socioeconomic status, depression disparities, and financial strain: what lies behind the income-depression relationship?

Prior studies have consistently found the incidence and persistence of depression to be higher among persons with low incomes, but causal mechanisms for this relationship are not well understood. This study uses the National Longitudinal Survey of Youth 1979 cohort to test several hypotheses about the robustness of the depression-income relationship among adults. In regressions of depression symptoms on income and sociodemographic variables, income is significantly associated with depression. However, when controls for other economic variables are included, the effect of income is considerably reduced, and generally not significant. Employment status and the ratio of debts-to-assets are both highly significant for men and for women both above and below the median income. Fixed-effects estimates suggest that employment status and financial strain are causally related to depression, but income is not. Instrumental variable estimates suggest that financial strain may not lead to depression.

Functional Impact and Health Utility of Anxiety Disorders in Primary Care Outpatients

OBJECTIVE

The objective of this study was to examine the relative impact of anxiety disorders and major depression on functional status and health-related quality of life of primary care outpatients.

METHOD

Four hundred eighty adult outpatients at an index visit to their primary care provider were classified by structured diagnostic interview as having anxiety disorders (panic disorder with or without agoraphobia, social phobia, and posttraumatic stress disorder; generalized anxiety disorder was also assessed in a subset) with or without major depression. Functional status, sick days from work, and health-related quality of life (including a preference-based measure) were assessed using standardized measures adjusting for the impact of comorbid medical illnesses. Relative impact of the various anxiety disorders and major depression on these indices was evaluated.

RESULTS

In multivariate regression analyses simultaneously adjusting for age, sex, number of chronic medical conditions, education, and/or poverty status, each of major depression, panic disorder, posttraumatic stress disorder, and social phobia contributed independently and relatively equally to the prediction of disability and functional outcomes. Generalized anxiety disorder had relatively little impact on these indices when the effects of comorbid major depression were considered. Overall, anxiety disorders were associated with substantial decrements in preference-based health states.

CONCLUSIONS

These observations demonstrate that the presence of each of 3 common anxiety disorders (ie, panic disorder, posttraumatic stress disorder, and social phobia)-over and above the impact of chronic physical illness, major depression, and other socioeconomic factors-contributes in an approximately additive fashion to the prediction of poor functioning, reduced health-related quality of life, and more sick days from work. Greater awareness of the deleterious impact of anxiety disorders in primary care is warranted.

Impact of Antidepressant Drug Adherence on Comorbid Medication Use and Resource Utilization

BACKGROUND

Patients with depression are often nonadherent to therapy for depression and chronic comorbid conditions.

METHODS

To determine whether improved antidepressant medication adherence is associated with an increased likelihood of chronic comorbid disease medication adherence and reduced medical costs, we conducted a retrospective study of patients initiating antidepressant drug therapy with evidence of dyslipidemia, coronary artery disease (CAD), or both; diabetes mellitus (DM); or CAD/dyslipidemia and DM identified from a claims database. Measures included antidepressant medication adherence, measured by medication possession ratio during 180 days without a 15-day gap before 90 days of therapy; comorbid medication adherence, measured by medication possession ratio during 1 year; and the association between improved antidepressant drug adherence and disease-specific and total medical costs.

RESULTS

Of 8040 patients meeting the study criteria, those adherent to antidepressant medication were more likely to be adherent to comorbid therapy vs those nonadherent to antidepressant drug therapy (CAD/dyslipidemia: odds ratio [OR], 2.13; DM: OR, 1.82; and CAD/dyslipidemia/DM: OR, 1.45; P<.001 for all). Patients adherent to antidepressant drug therapy also had significantly lower disease-specific charges vs nonadherent patients (17% lower in CAD/dyslipidemia, P = .02; 8% lower in DM, P = .39; and 14% lower in CAD/dyslipidemia/DM, P = .38). These patients also incurred lower total medical charges (6.4% lower in CAD/dyslipidemia, P = .048; 11.8% lower in DM, P = .04; and 19.8% lower in CAD/dyslipidemia/DM, P = .03).

CONCLUSIONS

Antidepressant drug adherence was associated with increased comorbid disease medication adherence and reduced total medical costs for CAD/dyslipidemia, DM, and CAD/dyslipidemia/DM. Future studies should investigate the relationship between increased adherence and costs beyond 1 year.

Bullying, psychosocial adjustment, and academic performance in elementary school

BACKGROUND

Over the past decade, concerns about bullying and its role in school violence, depression, and health concerns have grown. However, no large studies in the United States have examined the prevalence of bullying during elementary school or its association with objective measures of school attendance and achievement.

OBJECTIVE

To determine the prevalence of bullying during elementary school and its association with school attendance, academic achievement, disciplinary actions, and self-reported feelings of sadness, safety, and belonging.

DESIGN

Cross-sectional study using 2001-2002 school data.

SETTING

Urban, West Coast public school district.

PARTICIPANTS

Three thousand five hundred thirty (91.4%) third, fourth, and fifth grade students.

MAIN OUTCOME MEASURE

Self-reported involvement in bullying.

RESULTS

Twenty-two percent of children surveyed were involved in bullying either as a victim, bully, or both. Victims and bully-victims were more likely to have low achievement than bystanders (odds ratios [ORs], 0.8 [95% confidence interval (CI), 0.7-0.9] and 0.8 [95% CI, 0.6-1.0], respectively). All 3 bullying-involved groups were significantly more likely than bystanders to feel unsafe at school (victims, OR, 2.1 [95% CI, 1.1-4.2]; bullies, OR, 2.5 [95% CI, 1.5-4.1]; bully-victims, OR, 5.0 [95% CI, 1.9-13.6]). Victims and bully-victims were more likely to report feeling that they don't belong at school (ORs, 4.1 [95% CI, 2.6-6.5] and 3.1 [95% CI, 1.3-7.2], respectively). Bullies and victims were more likely than bystanders to feel sad most days (ORs 1.5 [95% CI, 1.2-1.9] and 1.8 [95% CI, 1.2-2.8], respectively). Bullies and bully-victims were more likely to be male (ORs, 1.5 [95% CI, 1.2-1.9] and 3.0 [95% CI, 1.3-7.0], respectively).

CONCLUSIONS

The prevalence of frequent bullying among elementary school children is substantial. Associations between bullying involvement and school problems indicate this is a serious issue for elementary schools. The research presented herein demonstrates the need for evidence-based antibullying curricula in the elementary grades.

Incontinence severity and major depression in incontinent women

OBJECTIVE

Research has shown an association between urinary incontinence and depression. Studies that use community-based samples and major depressive disorder diagnostic criteria are needed. The objective of this study was to estimate the prevalence of and factors associated with major depression in women with urinary incontinence.

METHODS

We conducted an age-stratified postal survey of 6,000 women aged 30-90 years. Subjects were randomly selected from enrollees in a large health maintenance organization in Washington state. Main outcome measures were prevalence of current major depression and adjusted odds ratios for factors associated with major depression in women with urinary incontinence.

RESULTS

The response rate was 64% (n = 3,536) after applying exclusion criteria. The prevalence of urinary incontinence was 42% (n = 1,458). The prevalence of major depression was 3.7% (n = 129), with 2.2% in those without incontinence versus 6.1% in those with incontinence. Among women with incontinence, major depression prevalence rates differed by incontinence severity (2.1% in mild, 5.7% in moderate, and 8.3% in severe) and incontinence type (4.7% in stress, 6.6% in urge/mixed). Obesity (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3-4.0), current smoking (OR 2.7, 95% CI 1.5-4.9), lower educational attainment (OR 2.0, 95% CI 1.2-3.3), moderate incontinence (OR 2.7, 95% CI 1.1-6.6), and severe incontinence (OR 3.8, 95% CI 1.6-9.1) were each associated with increased odds of major depression in women with urinary incontinence, controlling for age and medical comorbidity. Compared with women with incontinence alone, women with comorbid incontinence and major depression had significantly greater decrements in quality of life and functional status and increased incontinence symptom burden.

CONCLUSION

Women with moderate-to-severe urinary incontinence should be screened for comorbid major depression and offered treatment if depression is present.

LEVEL OF EVIDENCE

II-2.

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

OBJECTIVE

This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program.

METHOD

Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model.

RESULTS

Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model.

CONCLUSIONS

Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.

Making the case for caregiver research in geriatric psychiatry

Research on caregiver health has seen a groundswell of interest in the last few years. Unfortunately, most of this literature has appeared in venues not usually seen by psychiatrist-geriatricians. In this article, the authors argue that caregiver research is not only relevant to the geriatric mental health community, but it is especially important to geriatric psychiatry. To do this, they focus on five areas: 1) an overview of caregiver outcomes and metaanalysis of relationships of caregiver distress/psychiatric morbidity with physiological/physical indices; 2) definitions and examples of moderators and mediators of relationships of caregiver status with health indices, including comorbidity of caregiving with psychiatric/medical illnesses; 3) caregiver/care-recipient trajectories and reciprocal relationships among dyads; 4) prospective studies; and, 5) areas to consider in caregiver interventions. Great strides have been made in caregiver research, but much more needs to be done. Psychiatric geriatricians are well placed to advance caregiver research because of their unique training in medicine, psychotherapy, pharmacology, and aging. They hope the discussion of this research will encourage work in this important area.

Medical illness and response to treatment in primary care panic disorder

OBJECTIVE

Although studies have suggested that comorbid medical illness can affect the outcome of patients with depression, little is known about whether medical illness comorbidity affects treatment outcome in patients with anxiety.

METHOD

Primary care patients with panic disorder (n=232), participating in a randomized collaborative care intervention of CBT and pharmacology, were divided into those above (n=125) and below (n=107) the median for burden of chronic medical illness and assessed at 3, 6, 9 and 12 months.

RESULTS

Subjects with a greater burden of medical illness were more psychiatrically ill at baseline, with greater anxiety symptom severity, greater disability and more psychiatric comorbidity. The intervention produced significant and similar increases in amount of evidence-based care, and reductions in clinical symptoms and disability that were comparable in the more and less medically ill groups.

CONCLUSIONS

The comparable response of individuals with more severe medical illness suggests that CBT and pharmacotherapy for panic disorder work equally well regardless of medical illness comorbidity. However, the more severe psychiatric illness both at baseline and follow-up in these same individuals suggest that treatment programs may need to be extended in time to optimize treatment outcome.

Work disability among individuals with diabetes

OBJECTIVE

Diabetes is rapidly increasing in prevalence among working-age adults, but little is known about the clinical characteristics that predict work disability in this population. This study assessed clinical predictors of work disability among working-age individuals with diabetes.

RESEARCH DESIGN AND METHODS

In a cohort of diabetic individuals (n = 1,642) enrolled in a large health maintenance organization, excluding homemakers and retirees, we assessed the relation of diabetes severity, chronic disease comorbidity, depressive illness, and behavioral risk factors with work disability. Three indicators of work disability were assessed: being unable to work or otherwise being unemployed; missing > or =5 days from work in the prior month; and having severe difficulty with work tasks.

RESULTS

In the study population, 19% had significant work disability: 12% were unemployed, 7% of employed subjects had missed > or =5 days from work in the prior month, and 4% of employed subjects reported having had severe difficulty with work tasks. Depressive illness, chronic disease comorbidity, and diabetes symptoms were associated with all three types of work disability. Diabetes complications predicted unemployment and overall work disability status, whereas obesity and sedentary lifestyle did not predict work disability. Among subjects experiencing both major depression and three or more diabetes complications, >50% were unemployed; of those with significant work disability, half met the criteria for major or minor depression.

CONCLUSIONS

Depressive illness was strongly associated with unemployment and problems with work performance. Disease severity indicators, including complications and chronic disease comorbidity, were associated with unemployment and overall work disability status. Effective management of work disability among diabetic patients may need to address both physical and psychological impairments.

An audiotaped mental health evaluation tool for Hispanic immigrants with a range of literacy levels

Debilitating mental illness is treatable if found. There is no validated self-administered mental illness evaluation tool for immigrant Hispanic farm workers with variable literacy levels. This study tested sensitivity and specificity of an audiotaped survey developed for low literacy levels compared with standard interview instruments. Subjects from 11 migrant camps completed a self-administered audiotaped survey in Spanish to diagnose major depression, substance abuse, panic and generalized anxiety, and domestic violence. Primary care clinics assisted in finding camps and provided follow-up treatment. For 154 men and 156 women, the audio tool was most sensitive for major depression and specific for anxiety disorder, alcohol abuse, and domestic violence. Seventy percent of those diagnosed with major depression received appropriate treatment. This study validated an inexpensive, self-administered audio tool to evaluate the mental health of immigrant Hispanic farm workers with a wide range of literacy levels.

Early cognitive stimulation, emotional support, and television watching as predictors of subsequent bullying among grade-school children

BACKGROUND

Bullying is a major public health issue, the risk factors for which are poorly understood.

OBJECTIVE

To determine whether cognitive stimulation, emotional support, and television viewing at age 4 years are independently associated with being a bully at ages 6 through 11 years.

METHODS

We used multivariate logistic regression, using data from the National Longitudinal Survey of Youth, to adjust for multiple confounding factors.

RESULTS

Parental cognitive stimulation and emotional support at age 4 years were each independently protective against bullying, with a significant odds ratio of 0.67 for both variables associated with a 1-SD increase (95% confidence interval, 0.54-0.82 for cognitive stimulation and 0.54-0.84 for emotional support). Each hour of television viewed per day at age 4 years was associated with a significant odds ratio of 1.06 (95% confidence interval, 1.02-1.11) for subsequent bullying. These findings persisted when we controlled for bullying behavior at age 4 years in a subsample of children for whom this measure was available.

CONCLUSION

The early home environment, including cognitive stimulation, emotional support, and exposure to television, has a significant impact on bullying in grade school.

Urinary incontinence in US women: a population-based study

BACKGROUND

Urinary incontinence (UI) is a common disorder that is increasingly important as our population ages. Less is known about UI in younger women, and few large surveys have been able to determine risk factors by linking their data to patients' medical findings.

METHODS

We conducted a population-based, age-stratified postal survey of 6000 women aged between 30 and 90 years who were enrolled in a large health maintenance organization in Washington State.

RESULTS

The response rate was 64% (n = 3536) after exclusion criteria were applied. The population-based prevalence of UI was 45%. Prevalence increased with age, from 28% for 30- to 39-year-old women to 55% for 80- to 90-year-old women. Eighteen percent of respondents reported severe UI. The prevalence of severe UI also increased notably with age, from 8% for 30- to 39-year-old women to 33% for 80- to 90-year-old women. Older age, higher body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), greater medical comorbidity, current major depression, a history of hysterectomy, and parity increased the odds of having UI. Not being white and having had only cesarean deliveries decreased the odds of having UI. Major depression (odds ratio, 2.48; 95% confidence interval, 1.65-3.72) and obesity, defined as having a BMI of 30 or greater (odds ratio, 2.39; 95% confidence interval, 1.99-2.87), had the strongest association with UI. Among women with UI, age, BMI, medical comorbidity, current major depression, diabetes, a history of hysterectomy, and having had only cesarean deliveries were significantly associated with severe UI.

CONCLUSIONS

Urinary incontinence is highly prevalent in women across their adult life span, and its severity increases linearly with age. Age, BMI, race, medical comorbidity, current major depression, a history of hysterectomy, parity, and having only had cesarean deliveries are each independent factors significantly associated with the likelihood of having UI.

A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder

BACKGROUND

Panic disorder is a prevalent, often disabling condition among patients in the primary care setting. Although numerous studies have assessed the effectiveness of treatments for depression in primary care, few such studies have been conducted for panic disorder.

OBJECTIVE

To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting.

DESIGN

Randomized, controlled study comparing intervention to treatment as usual.

SETTING

Six primary care clinics associated with 3 university medical schools, serving an ethnically and socioeconomically diverse patient population.

PARTICIPANTS

Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder. Comorbid mental and physical disorders were permitted, provided these did not contraindicate the treatment to be provided and were not acutely life threatening.

INTERVENTION

Patients were randomized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions (across 12 weeks) of cognitive-behavioral therapy (CBT) modified for the primary care setting, with up to 6 follow-up telephone contacts during the next 9 months, and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist. Behavioral health specialists, the majority inexperienced in CBT for panic disorder, were trained to deliver the CBT and coordinated overall care, including pharmacotherapy.

MAIN OUTCOMES MEASURES

Proportion of subjects remitted (no panic attacks in the past month, minimal anticipatory anxiety, and agoraphobia subscale score <10 on Fear Questionnaire) and responding (Anxiety Sensitivity Index score <20) and change over time in World Health Organization Disability Scale and short form 12 scores.

RESULTS

The combined cognitive-behavioral and pharmacotherapeutic intervention resulted in sustained and gradually increasing improvement relative to treatment as usual, with significantly higher rates at all points of both the proportion of subjects remitted (3 months, 20% vs 12%; 12 months, 29% vs 16%) and responding (3 months, 46% vs 27%; 12 months, 63% vs 38%) and significantly greater improvements in World Health Organization Disability Scale (all points) and short form 12 mental health functioning (3 and 6 months) scores. These effects were obtained in spite of similar rates of delivery of guideline-concordant pharmacotherapy to the 2 groups.

CONCLUSION

Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naive, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder.

Psychiatric distress amplifies symptoms after surgery for chronic rhinosinusitis

BACKGROUND

Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress.

METHODS

This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed before surgery; CT scans were reviewed, and questionnaires were completed about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively.

RESULTS

Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared with those without somatization ( P < 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression ( P < 0.05). The presence of somatization preoperatively was also independently associated with worse symptom severity 12-months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. In addition, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12-months after surgery than subjects without psychiatric distress.

CONCLUSIONS

Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared with those without distress.

CLINICAL SIGNIFICANCE

Psychiatric distress should be considered in patients with persistent symptoms after surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system.