Psychosocial interest, medical interviews, and the recognition of depression

Effects of Primary Care Provider Characteristics on Changes in Behavioral Health Delivery During a Collaborative Care Trial

OBJECTIVE

Pediatric primary care providers (PCPs) are increasingly expected to deliver behavioral health (BH) services, yet PCP characteristics that facilitate or hinder BH service delivery are poorly understood. This study examined how PCP characteristics and collaborative care participation influenced changes in BH-related effort and competency over time.

METHODS

Pediatric PCPs (N = 74) participating in a cluster randomized trial (8 practices) of a collaborative care intervention for disruptive behavior problems completed self-report measures at 0, 6, 12, and 18 months. Latent growth curve models tested the impact of PCP characteristics (ie, age, gender, negative BH beliefs, BH burden, BH competency) on changes in identification/treatment of disruptive behavior disorders and competency over the course of the trial.

RESULTS

Participation in collaborative care was associated with increases in identification/treatment, with no evidence that PCP characteristics moderated changes in identification/treatment. For competency, however, older PCPs (>50 years) in collaborative care exhibited steep increases over time, while older PCPs in the comparison condition exhibited steep decreases, suggesting differential benefits of collaborative care participation by PCP age. In both conditions, PCPs with more negative BH beliefs reported less identification/treatment over time. Baseline competency was positively associated with identification/treatment and associations weakened over time. Gender and perceived burden had little impact.

CONCLUSIONS

PCP characteristics are associated with changes in PCPs' BH-related effort and competency over time. Participation in a collaborative care model appears to be especially beneficial for older PCPs. Implementation of collaborative care can promote growth in BH-related effort and competency for PCPs.

Mental Health Consultation Among Ontario's Immigrant Populations

To determine the prevalence rates and characteristics of past-year mental health consultation for Ontario's adult (18 + years old) immigrant populations. The Canadian Community Health Survey (CCHS) 2012 was used to calculate the prevalence rates of past-year mental health consultation by service provider type. Characteristics associated with mental health consultation were determined by carrying out multivariable logistic regression analysis on merged CCHS 2008-2012 data. Adult immigrant populations in Ontario (n = 3995) had lower estimated prevalence rates of past-year mental health consultation across all service provider types compared to Canadian-born populations (n = 14,644). Amongst those who reported past-year mental health consultation, 57.89% of Ontario immigrants contacted their primary care physician, which was significantly higher than the proportion who consulted their family doctor from Canadian-born populations (45.31%). The factors of gender, age, racial/ethnic background, education level, working status, food insecurity status, self-perceived health status, smoking status, alcohol drinking status, years since immigration, and age at time of immigration were significantly associated with past-year mental health consultation for immigrant populations. Ontario's adult immigrant populations most commonly consult their family doctor for mental health care. Potential exists for expanding the mental health care role of primary care physicians as well as efforts to increase accessibility of specialized mental health services. Integrated, coordinated care where primary care physicians, specialized mental health professionals, social workers, and community educators, etc. working together in a sort of "one-stop-shop" may be the most effective way to mitigate gaps in the mental health care system. In order to effectively tailor mental health policy, programming, and promotion to suit the needs of immigrant populations initiatives that focus on the connection between physical and mental health and migration variables such as length of stay in Canada, years since immigration, and other important migration variables (beyond the scope of the CCHS which require further study) need to be developed. Examination of the social determinants of mental health is critical to understand how we can best serve the mental health needs of Ontario's immigrant populations.

Which medical interview skills are associated with patients' verbal indications of undisclosed feelings of anxiety and depressive feelings?

BACKGROUND

In medical practice, obtaining information regarding patients' undisclosed "feelings of anxiety" or "depressive feelings" is important. The purpose of this study was to determine which interview skills are best suited for eliciting verbal indications of undisclosed feelings, for example anxiety or depressive feelings in patients.

METHODS

Our group videotaped 159 medical interviews at an outpatient department of the Department of Family Medicine, Mie University Hospital (Mie, Japan). Physicians' medical interview skills were evaluated using a Medical Interview Evaluation System and Emotional Information Check Sheet for assessing indications of "feelings of anxiety" or "depressive feelings". We analyzed the relationship between the interview skills and patients' consequent emotional disclosure using generalized linear model (GLIM).

RESULTS

The usage of interview skills such as "open-ended questions" "asking the patient's ideas about the meaning of illness" "reflection" and "legitimization" were positively associated with the number of anxiety disclosure, whereas "close-ended questions" and "focused question" were negatively associated. On the other hand, only "respect" was positively associated with the number of depressive disclosures, whereas "surveying question" was negatively associated.

CONCLUSIONS

The results revealed that there are several interview skills that are effective in eliciting verbal indication of undisclosed "feelings of anxiety" or "depressive feelings".

The development of an evidence based assessment protocol for intimate partner violence in the U.S. Army

The importance of conducting evidence based assessment has been widely acknowledged by many professions, including social work. In this study, the U.S. Army, in partnership with University researchers, developed an evidence based assessment protocol to assist the individual social worker in conducting his/her assessment of intimate partner violence. The protocol development process involved posing answerable research questions about intimate partner violence assessment content and method and then adhering to the steps of evidence based practice to answer those questions. Key to the protocol development process was the partnership created between researchers and practitioners as part of an expert panel.

An ethnic/racial comparison of causal beliefs and treatment preferences for the symptoms of depression among patients with diabetes

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Barriers in recognising, diagnosing and managing depressive and anxiety disorders as experienced by Family Physicians; a focus group study

BACKGROUND

The recognition and treatment of depressive- and anxiety disorders is not always in line with current standards. The results of programs to improve the quality of care, are not encouraging. Perhaps these programs do not match with the problems experienced in family practice. This study aims to systematically explore how FPs perceive recognition, diagnosis and management of depressive and anxiety disorders.

METHODS

focus group discussions with FPs, qualitative analysis of transcriptions using thematic coding.

RESULTS

The FPs considered recognising, diagnosing and managing depressive- and anxiety disorders as an important task. They expressed serious doubts about the validity and usefulness of the DSM IV concept of depressive and anxiety disorders in family practice especially because of the high frequency of swift natural recovery. An important barrier was that many patients have difficulties in accepting the diagnosis and treatment with antidepressant drugs. FPs lacked guidance in the assessment of patients' burden. The FPs experienced they had too little time for patient education and counseling. The under capacity of specialised mental health care and its minimal collaboration with FPs were experienced as problematic. Valuable suggestions for solving the problems encountered were made

CONCLUSION

Next to serious doubts regarding the diagnostic concept of depressive- and anxiety disorders a number of factors were identified which serve as barriers for suitablemental health care by FPs. These doubts and barriers should be taken into account in future research and in the design of interventions to improve mental health care in family practice.

Physician and patient characteristics associated with discussion of psychosocial health during pediatric primary care visits

This study examined whether physical pain, mental health symptoms, and provider characteristics were associated with the discussion of children's behavior, mood, getting along with others, school performance, family stress, and parent stress during 800 pediatric primary care visits to 54 providers in 13 clinics. The discussion of psychosocial health was more common when the child demonstrated hyperactivity symptoms, the visit was for a mental health problem, and the provider was a woman or reported greater confidence in mental health treatment skills, but less common when the child demonstrated physical pain. Provider gender, psychosocial orientation, the reason for the visit, and the child's characteristics did not explain the inverse relationship between pain and discussion. This suggests that multilevel factors that describe the child and provider are associated with the discussion of psychosocial health, and that pain interferes with discussion during all types of visits and during visits with children who are impaired by mental health symptoms.

Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review

Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.

Identification of youth psychosocial problems during pediatric primary care visits

This investigation applied the Gateway Provider Model (GPM) of child mental health services to investigate whether characteristics of the child, family, visit, and provider were related to the identification of youth psychosocial problems during primary care visits. Data were gathered during 774 visits to 54 primary care providers (PCPs) at 13 clinics. Similar to previous investigations in primary care settings, 42% of youth demonstrated at least a sub-threshold clinical mental health problem. Most PCPs reported high job satisfaction and control, but reported varying access to mental health specialists. PCPs generally had positive attitudes and beliefs about treating psychosocial problems but many reported that doing so was burdensome. Identification was more likely when the visit was for a mental health problem, when issues related to psychosocial problems were discussed during the visit, when the youth demonstrated mental health symptoms, impairment, or burden to the family, and when the youth was older, uninsured, or received Medicaid. Identification was less likely when the PCP reported greater burden associated with treating psychosocial problems and when the PCP reported greater accessibility to mental health specialists. These results suggest that identification is associated with the interaction of multilevel factors and that the GPM is a useful model to investigate points of intervention for improving the identification of children's mental health problems in primary care settings.

Teaching Advanced Interviewing Skills to Residents: A Curriculum for Institutions with Limited Resources

Residency program directors currently face new requirements from the Accreditation Council for Graduate Medical Education (ACGME), including the mandate to demonstrate their residents' proficiency in communication skills. Such skills can be improved through an educational intervention, but few residencies specifically offer formal instruction in communication. Furthermore, the only formal instruction in communication skills described thus far for internal medicine residents requires hundreds of hours per month of faculty and resident time. This paper describes a time-efficient seminar series in communication skills for first-year internal medicine residents, which has been received well by faculty and learners as evidenced by post-seminar surveys and focus groups.

Conceptual models of treatment in depressed Hispanic patients

PURPOSE

Though patient variables are likely to play an important role in the undertreatment of depression, little is known of patients' perceptions of standard depression treatments. In an effort to understand their perspective, we investigated depressed Hispanic patients' perceptions of primary care treatments and the specific benefits associated with them.

METHODS

We undertook semistructured interviews with 121 depressed Hispanic medical patients waiting for their appointments. We developed and implemented a coding scheme using standard iterative procedures.

RESULTS

More than one half of the patients viewed physician consultation and medication as helpful. Almost all patients considered psychotherapy to be helpful. Supportive talk was the most commonly mentioned specific benefit of physician consultation. The most common benefit of medication was its anxiolytic, sedative effect; energizing effects were less common. The most common benefits associated with psychotherapy included support, advice, and catharsis. Patients currently taking medication for depression had a more favorable view of pharmacological treatment; differences by language of interview were noted.

CONCLUSIONS

Patients' perceptions of the specific efficacies of depression treatment did not match priorities implicit in current treatment guidelines. Such perceptions may play a key role in shaping patients' decisions to initiate and maintain treatment.

How to recognize and manage psychological distress in cancer patients

Psychological distress is common in cancer patients, however, it is often unrecognized and untreated. We aimed to identify barriers to cancer patients expressing their psychological concerns, and to recommend strategies to assist oncologists to elicit, recognize, and manage psychological distress in their patients. Medline, Psychlit, and the Cochrane databases were searched for articles relating to the detection of emotional distress in patients. Patients can provide verbal and non-verbal information about their emotional state. However, many patients may not reveal emotional issues as they believe it is not a doctor's role to help with their emotional concerns. Moreover, patients may normalize or somatize their feelings. Anxiety and depression can mimic physical symptoms of cancer or treatments, and consequently emotional distress may not be detected. Techniques such as active listening, using open questions and emotional words, responding appropriately to patients' emotional cues, and a patient-centred consulting style can assist in detection. Screening tools for psychological distress and patient question prompt sheets administered prior to the consultation can also be useful. In conclusion, the application of basic communication techniques enhances detection of patients' emotional concerns. Training oncologists in these techniques should improve the psychosocial care of cancer patients.

Training Latin American primary care physicians in the WPA module on depression: results of a multicenter trial

BACKGROUND

In order to improve care for people with depressive disorders and to reduce the increasing burden of depression, the American Regional Office of the World Health Organization has launched a major region-wide initiative. A central part of this effort was directed to the primary care system where the diagnosis and treatment of depression are deficient in many countries. This study evaluated the materials developed by the World Psychiatric Association in a training program on depression among primary care physicians by measuring changes in their knowledge, attitudes, and practice (KAP).

METHOD

One hundred and seven physicians and 6174 patients from five Latin American countries participated in the trial. KAP were assessed 1 month before and 1 month following the training program. In addition, the presence of depressive symptoms was measured in patients who visited the clinic during a typical week at both times using the Zung Depression Scale and a DSM-IV/ ICD-10 major depression checklist.

RESULTS

The program slightly improved knowledge about depression and modified some attitudes, but had limited impact on actual practice. There was no evidence that the diagnosis of depression was made more frequently, nor was there an improvement in psychopharmacological management. The post-training agreement between physician diagnosis and that based on patient self-report remained low. The physicians, however, seemed more confident in treating depressed patients after training, and referred fewer patients to psychiatrists.

CONCLUSIONS

Traditional means of training primary care physicians in depression have little impact on clinical practice regardless of the quality of the teaching materials.

Identifying physician-recognized depression from administrative data: consequences for quality measurement

BACKGROUND

Multiple factors limit identification of patients with depression from administrative data. However, administrative data drives many quality measurement systems, including the Health Plan Employer Data and Information Set (HEDIS).

METHODS

We investigated two algorithms for identification of physician-recognized depression. The study sample was drawn from primary care physician member panels of a large managed care organization. All members were continuously enrolled between January 1 and December 31, 1997. Algorithm 1 required at least two criteria in any combination: (1) an outpatient diagnosis of depression or (2) a pharmacy claim for an antidepressant Algorithm 2 included the same criteria as algorithm 1, but required a diagnosis of depression for all patients. With algorithm 1, we identified the medical records of a stratified, random subset of patients with and without depression (n = 465). We also identified patients of primary care physicians with a minimum of 10 depressed members by algorithm 1 (n = 32,819) and algorithm 2 (n = 6,837).

RESULTS

The sensitivity, specificity, and positive predictive values were: Algorithm 1: 95 percent, 65 percent, 49 percent; Algorithm 2: 52 percent, 88 percent, 60 percent. Compared to algorithm 1, profiles from algorithm 2 revealed higher rates of follow-up visits (43 percent, 55 percent) and appropriate antidepressant dosage acutely (82 percent, 90 percent) and chronically (83 percent, 91 percent) (p < 0.05 for all).

CONCLUSIONS

Both algorithms had high false positive rates. Denominator construction (algorithm 1 versus 2) contributed significantly to variability in measured quality. Our findings raise concern about interpreting depression quality reports based upon administrative data.

Primary care clinicians' use of standardized tools to assess child psychosocial problems

BACKGROUND AND OBJECTIVES

Children's psychosocial problems are prevalent but often inaccurately diagnosed. This study investigated primary care clinicians' (PCCs) use of standardized tools for psychosocial problems among children in whom they reported finding a problem.

METHODS

The data consisted of 21 065 unique visits by children ages 4 to 15 years in 204 practices. Parents completed questionnaires before seeing the PCCs, who completed a survey after the visit. This analysis included 3934 children who were recognized by PCCs as having one or more psychosocial problems. The primary outcome was the PCCs' usage of a tool to assess child psychosocial problems.

RESULTS

PCCs used a tool in 20.2% of visits where a psychosocial problem was recognized, whereas 50% of PCCs never used such tools. Tools were less likely to be used by female PCCs and family practitioners and were less likely to be used with girls and African American children. Tools were more frequently used with children with attention problems, during visits for psychosocial problems, and when the PCC knew about the problem before the visits.

CONCLUSIONS

PCCs use standardized tools infrequently to screen for, confirm, or monitor psychosocial problems.

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment

OBJECTIVE

This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options.

METHODS

In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability.

RESULTS

Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent).

CONCLUSIONS

In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.

Measuring the involvement of patients in shared decision-making: a systematic review of instruments

We wanted to determine whether research instruments exist which focus on measuring to what extent health professionals involve patients in treatment and management decisions. A systematic search and appraisal of the relevant literature was conducted by electronic searching techniques, snowball sampling and correspondence with field specialists. The instruments had to concentrate on assessing patient involvement in decision-making by observation techniques (either direct or using audio or videotaped data) and contain assessments of the core aspects of 'involvement', namely evidence of patients being involved (explicitly or implicitly) in decision-making processes, a portrayal of options and a decision-making or deferring stage. Eight instruments met the inclusion criteria. But we did not find any instruments that had been specifically designed to measure the concept of 'involving patients' in decisions. The results reveal that little attention has been given to a detailed assessment of the processes of patient involvement in decision-making. The existing instrumentation only includes these concepts as sub-units within broader assessments, and does not allow the construct of patient involvement to be measured accurately. Instruments developed to measure 'patient-centeredness' are unable to provide enough focus on 'involvement' because of their attempt to cover so many dimensions. The concept of patient involvement (shared decision-making; informed collaborative choice) is emerging in the literature and requires an accurate method of assessment.

Meeting the needs of primary care physicians: a guide to content for programs on depression

OBJECTIVE

The purpose of this article is to identify literature-based content for the design of educational programs on depression for practicing primary care physicians.

METHODS

A MEDLINE search was conducted of English-language medical literature published from 1982 through July 1997 for studies describing primary care physicians' knowledge, skills, practice patterns, and perceived barriers related to care of depressed patients. Studies focusing exclusively on residency training and those describing physician practices outside North America were excluded. Of 377 articles identified, forty met inclusion and exclusion criteria.

RESULTS

Recommendations for educational content were identified from the literature review. For recognition, educators should prioritize communication skills and strategies for the use of depression questionnaires. For diagnosis, practice interpreting symptoms in the medically ill, strategies for efficient diagnosis, and systematic approaches to assessing suicide risk should be emphasized. For treatment, greater attention to the therapeutic alliance, staged therapy, and strategies for improving medication adherence are indicated.

CONCLUSIONS

There is a moderately well developed literature describing self-perceived and observed gaps in the current care for depression in primary care. Addressing the entire list of needs would take more time than practicing physicians are likely to have. An important challenge for educators is to design flexible programs based on individualized needs assessment or, when not possible, to prioritize the most generalizable needs.

Predictors of patient satisfaction

Correlates of patient satisfaction at varying points in time were assessed using a survey with 2-week and 3-month follow-up in a general medicine walk-in clinic, in USA. Five hundred adults presenting with a physical symptom, seen by one of 38 participating clinicians were surveyed and the following measurements were taken into account: patient symptom characteristics, symptom-related expectations, functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), mental disorders (PRIME-MD), symptom resolution, unmet expectations, satisfaction (RAND 9-item survey), visit costs and health utilization. Physician perception of difficulty (Difficult Doctor Patient Relationship Questionnaire), and Physician Belief Scale. Immediately after the visit, 260 (52%) patients were fully satisfied with their care, increasing to 59% at 2 weeks and 63% by 3 months. Patients older than 65 and those with better functional status were more likely to be satisfied. At all time points, the presence of unmet expectations markedly decreased satisfaction: immediately post-visit (OR: 0.14, 95% CI: 0.07-0.30), 2-week (OR: 0.07, 95% CI: 0.04-0.13) and 3-month (OR: 0.05, 95% CI: 0.03-0.09). Other independent variables predicting immediate after visit satisfaction included receiving an explanation of the likely cause as well as expected duration of the presenting symptom. At 2 weeks and 3 months, experiencing symptomatic improvement increased satisfaction while additional visits (actual or anticipated) for the same symptom decreased satisfaction. A lack of unmet expectations was a powerful predictor of satisfaction at all time-points. Immediately post-visit, other predictors of satisfaction reflected aspects of patient doctor communication (receiving an explanation of the symptom cause, likely duration, lack of unmet expectations), while 2-week and 3-month satisfaction reflected aspects of symptom outcome (symptom resolution, need for repeat visits, functional status). Patient satisfaction surveys need to carefully consider the sampling time frame as well as adjust for pertinent patient characteristics.

Medical students' experience with psychiatric diagnoses in a family medicine clerkship

BACKGROUND

Many medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses encountered by the students.

PURPOSE

This study examines patients encountered with psychiatric diagnoses using quantitative data collected by students in a family practice clerkship.

METHODS

Over a 2-year period, 445 students completed 3,320 patient encounter forms for patients with a psychiatric diagnosis, noting their comfort level and responsibilities.

RESULTS

The patients' diagnoses reflect those seen in a typical family practice. Of the 71,869 presenting diagnoses, 3,548 were for a psychiatric condition, most commonly depression (37.1%) and neuroses (28.0%). Students reported a high level of comfort in diagnosing and treating patients with a psychiatric disorder. The students routinely discussed these cases with their preceptors.

CONCLUSIONS

By using a relatively simple computerized database, many curricular issues can be identified. For example, analysis of the database shows that the clerkship provides students with substantial practice in taking patient histories and performing initial patient examinations in patients presenting with a psychiatric problem. However, students infrequently provided patient education and counseling to patients with psychiatric disorders. Specific psychiatric diagnoses reflecting limited experience and lower levels of perceived competence include attention deficit disorder and senile and presenile organic psychotic disorders.

Do pediatricians recognize mothers with depressive symptoms?

OBJECTIVE

To determine whether pediatric health care providers recognize maternal depressive symptoms and to explore whether maternal, provider, and visit characteristics affect pediatric providers' ability to recognize inner-city mothers with depressive symptoms.

DESIGN

A cross-sectional study was conducted at a hospital-based, inner-city, general pediatric clinic. Two groups of participants completed questionnaires, each unaware of the other's responses: 1) mothers who brought their children ages 6 months to 3 years for health care maintenance or a minor acute illness and 2) pediatric health care providers (attending pediatricians, pediatric trainees, and nurse practitioners). The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Pediatric providers assessed child, maternal, and family functioning and documented maternal depressive symptoms. Criteria for positive identification of a mother by the pediatric health care provider were met if the provider reported one or more maternal symptoms (from a 10-item list of depressive symptoms), a rating of 4 or less on a scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression.

RESULTS

Of 338 mothers who completed the questionnaire, 214 (63%) were assessed by 1 of 60 pediatric providers. Seventy-seven percent of surveys were completed by the child's designated pediatric provider. The mean visit length was 23 minutes. Mothers primarily were single, were black or Hispanic, and had a mean age of 26 years (15-45 years). Almost 25% of mothers were living alone with their children. Eighty-six (40%) mothers scored >/=20 on the PSI, representing high symptom levels. Of these, 25 were identified by pediatric providers (sensitivity = 29%). A total of 104 of 128 mothers with a PSI score <20 were identified as such by providers (specificity = 81%). Pediatric providers were more likely to identify mothers who were <30 years old, living alone, and on public assistance. Also, mothers who were assessed by the child's own primary provider or by an attending pediatrician were more likely to be identified accurately than were mothers whose children were seen by a pediatric trainee or a nurse practitioner.

CONCLUSIONS

Pediatric health care providers did not recognize most mothers with high levels of self-reported depressive symptoms. Pediatricians may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for developing depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.

Patient-centredness: a conceptual framework and review of the empirical literature

A 'patient-centred' approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor-patient relationship encompassed by the concept of 'patient-centredness' and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; 'patient-as-person'; sharing power and responsibility; therapeutic alliance; and 'doctor-as-person'. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.

Suicide prevention in late life: directions for science and practice

Suicide among the elderly is a critical public health problem, yet there remains limited information on risk factors to target due to the few number of controlled studies that could help isolate and focus on the most potent risk factors. We suggest that because there are no proven, effective interventions showing reduced suicidal behaviors in older adults, the best current approach is to improve detection and treatment of later-life depression. This effort may be especially effective in primary care settings, where the majority of our nation's elderly seek and receive their mental health care. We review approaches to assessment and treatment of later life depression that seem most relevant for later life suicide prevention. Testing and determining whether these treatment approaches are effective is an immediate goal on the path to advancing the science and practice of late-life suicide prevention.

Awareness, diagnosis, and treatment of depression

OBJECTIVES

To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers.

DESIGN

MEDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized.

CONCLUSIONS

Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.

Gender differences in the recognition of depression in old age

OBJECTIVE

The study should answer the question of whether identical symptom presentations of depression in male and female patients leads to similar recognition rates in primary care.

METHOD

We performed a survey in primary care. Two written case vignettes were presented to 170 family physicians in a face-to-face interview which took place in their practices. The case vignettes described either a mildly depressed otherwise healthy old patient (case 1) or a severely depressed patient with somatic comorbidity (case 2). For each case different versions with regard to patients' gender were used: in case 1 only the gender of the patient varied; in case 2 both the gender and the anamnesis (stroke/hypothyroidism) varied. Afterwards the interviewers asked standardised open questions. The physicians were not aware of the mental health focus and the gender focus of the study.

RESULTS

The study is representative with a response rate of 77.6%. For primary diagnosis, the female versions were given the diagnosis of depression more often. There was a non-significant trend that female physicians considered depression more often.

CONCLUSION

The results show that gender-related experience and stereotypes on the physicians' side influence the diagnosis of (old age) depression in primary care. Further studies should elucidate the influence of the physicians' gender on the management of psychiatric disorders.

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.

Recognition and treatment of depressive disorders by internal medicine attendings and housestaff

Depression is underdiagnosed and undertreated by nonpsychiatric practitioners. Research suggests improvement is needed in the recognition and treatment of depressive disorders by primary care physicians. This study was undertaken to better understand internists' ability to recognize depressive disorders, choice of appropriate medications, dosage, and treatment patterns. Questionnaires were distributed to 45 internal medicine attendings, 45 internal medicine housestaff, and 32 adult psychiatry residents. Each questionnaire contained four vignettes: major depressive disorder (MDD), MDD with melancholic features, MDD with atypical features, and MDD with psychotic features. Eleven questions per case covered diagnoses, management, and treatment. Data analysis with intragroup comparisons on 20 internal medicine attendings, 33 internal medicine housestaff, and 32 psychiatry residents suggested that many internal medicine attendings and housestaff had difficulty in recognizing major depression and its subtypes. Although the findings indicated that internists would initiate pharmacological treatment, they frequently made incorrect or questionable pharmacological choices. Psychiatric referral or consultation was often endorsed. Our findings among internists are consistent with previous research examining other primary care physicians suggesting that depression is underdiagnosed and undertreated.

Using successful models of care to guide the teaching of psychiatry in primary care

The focus of efforts to improve primary care physicians' recognition and treatment of psychiatric conditions has been on enhancing the content of their education, with little attention paid to the choice of models through which the content is delivered. The authors believe that existing models of primary care delivery are analogous to Strain's six basic models of teaching psychiatry to primary care physicians. Each model is especially suited to a particular segment of the primary care physician's education; for example, the consultation model has relevance for teaching about better management of identified patients and the bridge model for enhancing recognition of unrecognized disorders. All six models have a place in both education and practice.

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

A considerable body of knowledge noe exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of "competing demands" derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated "domains," representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of "face validity" for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.

Major depression in primary medical care practice. Research trends and future priorities

This paper reviews recent developments in assessing and treating major depression in primary care practice and proposes needed research directions for the coming years. Topics warranting attention include the predictive validity of psychiatric nomenclatures specific to general medical settings; the impact of patient, clinician, and system factors on the physician's assessment of major depression; the relationship between diagnostic and treatment decisions; and the course of this disorder when treated in primary care facilities by generalists or specialists.