Treatment of Depression in Primary Care

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany

Background

The Psychiatry, Neurology, Psychosomatics and Psychotherapy (PNP) program of the German statutory health insurance AOK BW promotes coordinated and evidence-based specialist care with the aim of providing individualized, guideline-based outpatient care, strengthening the collaboration between health care providers, as well as reducing care costs. The purpose of this study was to evaluate its effectiveness regarding patient-reported outcomes compared to the less specialized general practitioner program (GP) and usual care (UC).

Materials and methods

AOK insured patients, who were on sick leave due to a mental disorder (affective disorder, anxiety disorder, adjustment disorder, somatoform disorder, alcohol abuse disorder, schizophrenia) or multiple sclerosis were included in the prospective non-randomized controlled study. All patients either participated in the PNP program (intervention group, IG-PNP), the general practitioner program (control group, CG-GP) or usual care (control group, CG-UC). Entropy balancing was used to adjust for baseline imbalance between groups. Primary outcome was health-related quality of life, assessed by the Short-form health survey (SF-36) 12 months after diagnosis. Secondary outcomes included symptom severity, functional health, and treatment satisfaction.

Results

Of the 14,483 insured patients who were contacted, 1,104 patients participated at baseline and 725 at follow-up. The adjusted mean differences of SF-36 sum score did not significantly differ between groups: -1.89 (95%-CI = -4.60; 0.81, p = 0.170) between IG-PNP and CG-GP, and -1.42 (95%-CI = -4.05; 1.22, p = 0.293) between PNP and CG-UC. The adjusted mean differences of secondary outcomes did not differ between groups, except for a slightly higher increase of functional health in CG-UC.

Conclusion

We found no evidence that the PNP program is superior to the GP program or to usual care in terms of patient-reported outcomes or treatment satisfaction. The results are limited by the low response rate. Accordingly, future studies should strive for more representative samples. To improve the program, an integration of further collaborative care elements and guideline recommendations might be useful.

Clinical trial registration

DRKS (German Clinical Trials Register https://drks.de/search/en); identifier (DRKS00013114).

Closing the Mental Health Access Gap Through Novel Analytics

Depression and anxiety are associated with substantial morbidity, including physical deterioration. Connecting individuals to timely care improves outcomes. Unfortunately, significant gaps remain between the demand for behavioral healthcare and the supply of care. Further, estimates of demand are based on retrospective and/or non-localized measures, which impedes planning. This poses an opportunity to rethink how to close this gap. Health systems are better positioned than ever to do so, given novel technologies, data, and community integration. By developing more localized, real-time models of depression and anxiety demand and healthcare supply, health systems can better prioritize resource deployment and partnerships to proactively meet patient needs.

COVID-19 and Depression: Prevalence and Risk Factors in Youth from Maharashtra, India

The COVID-19 pandemic and the ensuing lockdown have been a seismic shock for youth in India, elevating their risk of mental health problems like depression. This cross-sectional study sought to measure the point prevalence levels of depression in university students (ages 19–25 years) from Maharashtra, India, during the peak of the first wave of the pandemic and lockdown, through an online opt-in survey. The BDI-II was self-administered by 783 respondents (males = 243; females = 540). Results indicated overall mild levels of depression (mean BDI = 16.48) and high point prevalence, with 51.8% (n = 406) of the population being symptomatic, of which 16.3% had severe, 17.9% had moderate, and 17.8% had mild levels of depression. No association was found with age, gender, educational level of participants, period of hostel stay, education, and occupational level of parents. Overall percentages of symptomatic women were higher, suggesting the gendered effects of the pandemic. This study explored the symptomatology of depression wherein “sadness,” “changes in sleep patterns,” and “concentration difficulties” emerged as the most commonly experienced symptoms. Symptom expression was found to vary with intensity and gender. Symptomatic men experienced significantly more cognitive symptoms like self-criticalness, punishment feelings, thoughts about past failures, and changes in sleep patterns, while symptomatic women felt significantly high “loss of energy.” No significant gender differences were seen in the experience of cognitive-affective symptoms. Possible reasons are discussed. Further exploration of the experiences of youth is essential to understand the full gamut of the pandemic’s impact on them.

Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration

Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention's basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention's standard core functions and the forms adapted to local contexts' characteristics.

Collaborative mental health care program versus a general practitioner program and usual care for treatment of patients with mental or neurological disorders in Germany: protocol of a multiperspective evaluation study

BACKGROUND

German statutory health insurances are pursuing the goal of improving treatment of chronically ill people by promoting networks of health care providers and supporting treatments that reflect the current medical knowledge. The so-called PNP program is a collaborative care program developed by a German statutory health insurance, which defines specific rules on psychiatric, neurological, psychosomatic, and psychotherapeutic treatment. It aims to strengthen provision of guideline-based outpatient treatment and collaboration between different health care providers. It includes the general practitioners' program, which aims to strengthen the coordinating role of GPs. This study aims to evaluate the PNP program.

METHODS

To evaluate the effectiveness of the PNP program, we will conduct a prospective non-randomized controlled trial with primary data comparing patients enrolled in the PNP program and in the general practitioner program (intervention group) to patients enrolled only in the general practitioner program and patients who receive usual care (control groups). To evaluate costs and level of detail of diagnoses in care of patients with PNP program, we will use routinely collected secondary administrative health data in a retrospective quasi-experimental design. Patients who are at least 18 years old, insured by the statutory health insurance AOK, and on sick leave due to one of the mental or neurological diagnoses (affective, anxiety, somatoform or adjustment disorders, alcohol use disorders, schizophrenia, multiple sclerosis) will be included. We will collect data at baseline and at 12-months follow-up. Health-related quality of life (primary data) and direct costs (secondary data) caused by outpatient and inpatient service utilization and medication will be the primary outcomes. We will analyze data using (generalized) linear mixed models and exploratory analyses. We will use entropy balancing to control for possible differences between the groups. We will use an exploratory sequential design including qualitative and descriptive statistical analyses to assess the structure and process quality of the PNP program among health care providers.

DISCUSSION

The results will help to develop a comprehensive picture of collaborative care programs for mental and neurological health care from the perspective of patients, health care providers, and health insurance companies.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00013114.

Differences in Use of Government Subsidised Mental Health Services by Men and Women with Psychological Distress: A Study of 229,628 Australians Aged 45 Years and Over

This study examined factors associated with use of government subsidised mental health services by 229,628 men and women from the Sax Institute's 45 and Up Study. Logistical regression models assessed use of mental health services by gender and according to level of psychological distress. Approximately equal proportion of men and women had high psychological distress scores (approximately 7%) but only 7% of these men and 11% of these women used services. Use was associated with predisposing (younger age and higher education), enabling (private health insurance) and need factors (higher psychological distress scores). Associations were similar for men and women except urban area of residence, separated/divorced marital status, and smoking were associated with service use for women but not men. Results suggest some inequity in the use of services by those with higher levels of need and further efforts may be required to reach people with higher need but lower service use.

Guideline-based stepped and collaborative care for patients with depression in a cluster-randomised trial

Guidelines recommend stepped and collaborative care models (SCM) for depression. We aimed to evaluate the effectiveness of a complex guideline-based SCM for depressed patients. German primary care units were cluster-randomised into intervention (IG) or control group (CG) (3:1 ratio). Adult routine care patients with PHQ-9 ≥ 5 points could participate and received SCM in IG and treatment as usual (TAU) in CG. Primary outcome was change in PHQ-9 from baseline to 12 months (hypothesis: greater reduction in IG). A linear mixed model was calculated with group as fixed effect and practice as random effect, controlling for baseline PHQ-9 (intention-to-treat). 36 primary care units were randomised to IG and 13 to CG. 36 psychotherapists, 6 psychiatrists and 7 clinics participated in SCM. 737 patients were included (IG: n = 569 vs. CG: n = 168); data were available for 60% (IG) and 64% (CG) after 12 months. IG showed 2.4 points greater reduction [95% confidence interval (CI): -3.4 to -1.5, p < 0.001; Cohen's d = 0.45] (adjusted PHQ-9 mean change). Odds of response [odds ratio: 2.8; 95% CI: 1.6 to 4.7] and remission [odds ratio: 3.2; 95% CI: 1.58 to 6.26] were higher in IG. Guideline-based SCM can improve depression care.

Effectiveness and cost-effectiveness of a guideline-based stepped care model for patients with depression: study protocol of a cluster-randomized controlled trial in routine care

BACKGROUND

Depression is a widespread and serious disease often accompanied by a high degree of suffering and burden of disease. The lack of integration between different care providers impedes guideline-based treatment. This constitutes substantial challenges for the health care system and also causes considerable direct and indirect costs. To face these challenges, the aim of this project is the implementation and evaluation of a guideline-based stepped care model for depressed patients with six treatment options of varying intensity and setting, including low-intensity treatments using innovative technologies.

METHODS/DESIGN

The study is a randomized controlled intervention trial of a consecutive sample of depressive patients from primary care assessed with a prospective survey at four time-standardized measurement points within one year. A cluster randomization at the level of participating primary care units divides the general practitioners into two groups. In the intervention group patients (n = 660) are treated within the stepped care approach in a multiprofessional network consisting of general practitioners, psychotherapists, psychiatrists and inpatient care facilities, whereas patients in the control condition (n = 200) receive routine care. The main research question concerns the effectiveness of the stepped-care model from baseline to t3 (12 months). Primary outcome is the change in depressive symptoms measured by the PHQ-9; secondary outcomes include response, remission and relapse, functional quality of life (SF-12 and EQ-5D-3 L), other clinical and psychosocial variables, direct and indirect costs, and the incremental cost-effectiveness ratio. Furthermore feasibility and acceptance of the overall model as well as of the separate treatment components are assessed.

DISCUSSION

This stepped care model integrates all primary and secondary health care providers involved in the treatment of depression; it elaborates innovative and evidence-based treatment elements, follows a stratified approach and is implemented in routine care as opposed to standardized conditions. In case of positive results, its sustainable implementation as a collaborative care model may significantly improve the health care situation of depressive patients as well as the interaction and care delivery of different care providers on various levels.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov, number NCT01731717 (date of registration: 24 June 2013).

Predictors of postpartum depression

OBJECTIVE

To examine sociodemographic factors, pregnancy-associated psychosocial stress and depression, health risk behaviors, prepregnancy medical and psychiatric illness, pregnancy-related illnesses, and birth outcomes as risk factors for post-partum depression (PPD).

METHODS

A prospective cohort study screened women at 4 and 8 months of pregnancy and used hierarchical logistic regression analyses to examine predictors of PPD. The study sample include 1,423 pregnant women at a university-based high risk obstetrics clinic. A score of ≥10 on the Patient Health Questionnaire-9 (PHQ-9) indicated clinically significant depressive symptoms.

RESULTS

Compared with women without significant postpartum depressive symptoms, women with PPD were significantly younger (p<0.0001), more likely to be unemployed (p=0.04), had more pregnancy associated depressive symptoms (p<0.0001) and psychosocial stress (p<0.0001), were more likely to be smokers (p<0.0001), were more likely to be taking antidepressants (ADs) during pregnancy (p=0.002), were less likely to drink any alcohol during pregnancy (p=0.02), and were more likely to have prepregnancy medical illnesses, including diabetes (p=0.02) and neurologic conditions (p=0.02).

CONCLUSION

Specific sociodemographic and clinical risk factors for PPD were identified that could help physicians target depression case finding for pregnant women.

Routine versus ad hoc screening for acute stress following injury: who would benefit and what are the opportunities for prevention

Background

Screening for acute stress is not part of routine trauma care owing in part to high variability of acute stress symptoms in identifying later onset of posttraumatic stress disorder (PTSD). The objective of this pilot study was to assess the sensitivity, specificity, and power to predict onset of PTSD symptoms at 1 and 4 months using a routine screening program in comparison to current ad hoc referral practice.

Methods

Prospective cross-sectional observational study of a sample of hospitalized trauma patients over a four-month period from a level-I hospital in Canada. Baseline assessments of acute stress (ASD) and subsyndromal ASD (SASD) were measured using the Stanford Acute Stress Reaction Questionnaire (SASRQ). In-hospital psychiatric consultations were identified from patient discharge summaries. PTSD symptoms were measured using the PTSD Checklist-Specific (PCL-S). Post-discharge health status and health services utilization surveys were also collected.

Results

Routine screening using the ASD (0.43) and SASD (0.64) diagnoses were more sensitive to PTSD symptoms at one month in comparison to ad hoc referral (0.14) and also at four months (0.17, 0.33 versus 0.17). Ad hoc referral had greater positive predictive power in identifying PTSD caseness at 1 month (0.50) in comparison to the ASD (0.46) and SASD (0.43) diagnoses and also at 4 months (0.67 versus 0.25 and 0.29).

Conclusions

Ad hoc psychiatric referral process for acute stress is a more conservative approach than employing routine screening for identifying persons who are at risk of psychological morbidity following injury. Despite known limitations of available measures, routine patient screening would increase identification of trauma survivors at risk of mental health sequelae and better position trauma centers to respond to the circumstances that affect mental health during recovery.

Making the case for primary care and mandated suicide prevention education

During its 2012 legislative session, Washington State passed ESHB 2366, otherwise known as the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012. ESHB 2366 is a significant legislative achievement as it is the first law in the country to require certain health professionals to obtain continuing education in the assessment, treatment, and management of suicide risk as a requirement to obtain and maintain licensure. However, ESHB 2366 does not apply to primary care providers, an important next step for legislation that has as its goal "to help lower the suicide rate in Washington." This commentary addresses objections raised against the law and potential responses as Washington considers strengthening its own law to include primary care providers and as other states consider similar legislation.

The role of social structural factors in treatment of mental health disorder

BACKGROUND

Mental disorder implies a biopsychosocial condition, so adequate mental health treatment involves not just medical and pharmacological care but also psychotherapy or counseling.

AIMS

The present study determined how social structural factors might explain accessing of primary care providers and specialty care providers in response to mental disorder, hypothesizing that the two broad types of care differ as to the likelihood of offering minimally adequate treatment.

METHOD

We analyzed data from the cross-sectional study called "2000-2001 Healthcare for Communities", employing five imputed data sets to handle missing data and defining minimally adequate treatment of mental disorder as "at least four counseling sessions at any provider and prescribed medication". Results While mental disorder can be treated in primary care or specialty facilities, our results show that minimally adequate treatment (as defined) is most likely to be obtained via specialty care.

CONCLUSION

For individuals with mental disorder, accessing only primary care creates social inequity, because care from specialty facilities is comparatively more adequate.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Primary care practice transformation is hard work: insights from a 15-year developmental program of research

BACKGROUND

Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.

METHODS

Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change.

RESULTS

A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice.

CONCLUSIONS

It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.

Yield of practice-based depression screening in VA primary care settings

BACKGROUND

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.

OBJECTIVE

We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.

DESIGN

Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.

PARTICIPANTS

Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.

MEASUREMENTS

PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.

RESULTS

Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).

CONCLUSIONS

Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Meeting the mental health needs of low-income immigrants in primary care: a community adaptation of an evidence-based model

Low-income, uninsured immigrants are burdened by poverty and a high prevalence of trauma exposure and thus are vulnerable to mental health problems. Disparities in access to mental health services highlight the importance of adapting evidence-based interventions in primary care settings that serve this population. In 2005, the Montgomery Cares Behavioral Health Program began adapting and implementing a collaborative care model for the treatment of depression and anxiety disorders in a network of primary care clinics that serve low-income, uninsured residents of Montgomery County, Maryland, the majority of whom are immigrants. In its 6th year now, the program has generated much needed knowledge about the adaptation of this evidence-based model. The current article describes the adaptations to the traditional collaborative care model that were necessitated by patient characteristics and the clinic environment.

Complications among colorectal cancer survivors: SF-6D preference-weighted quality of life scores

BACKGROUND

Societal preference-weighted health-related quality of life (HRQOL) scores enable comparing multidimensional health states across diseases and treatments for research and policy.

OBJECTIVE

To assess the effects of living with a permanent intestinal stoma, compared with a major bowel resection, among colorectal cancer (CRC) survivors.

RESEARCH DESIGN

Cross-sectional multivariate linear regression analysis to explain preference-weighted HRQOL scores.

SUBJECTS

In all, 640 CRC survivors (≥ 5 years) from 3 group model health maintenance organizations; ostomates and nonostomates with colorectal resections for CRC were matched on gender, age (± 5 years), time since diagnosis, and tumor site (rectum vs. colon).

MEASURES

SF-6D scoring system was applied to Medical Outcomes Study Short Form-36 version 2 (SF-36v2); City of Hope Quality of Life-Ostomy; and Charlson-Deyo comorbidity index.

METHODS

Survey of CRC survivors linked to respondents' clinical data extracted from health maintenance organization files.

RESULTS

Response rate was 52%. Ostomates and nonostomates had similar sociodemographic characteristics. Mean SF-6D score was 0.69 for ostomates, compared with 0.73 for nonostomates (P < 0.001), but other factors explained this difference. Complications of initial cancer surgery, and previous year comorbidity burden, and hospital use were negatively associated with SF-6D scores, whereas household income was positively associated.

CONCLUSIONS

CRC survivors' SF-6D scores were not associated with living with a permanent ostomy after other factors were taken into account. Surgical complications, comorbidities, and metastatic disease lowered the preference-weighted HRQOL of CRC survivors with and without ostomies. Further research to understand and reduce late complications from CRC surgeries as well as associated depression is warranted.

The role of psychosomatic medicine in global health care

This article reviews the principles and skills involved with psychosomatic medicine and their potential ability to improve global health care. New awareness of the escalating global public health impact of noncommunicable diseases, including chronic medical conditions and mental disorders, has stimulated interest in determining how best to organize health services. Home to the biopsychosocial model, the field of psychosomatic medicine is well-suited to inform such efforts by virtue of its emphasis on cross-disciplinary collaboration and specialized knowledge at the interface of medicine and psychiatry that takes into account individual and contextual influences on health. Consistent with the principles of psychosomatic medicine, promising strategies to improve global health care include integrating mental health care into primary care, applying the chronic care model in programs aimed at enhancing disease self-management, and using innovative models such as Internet-based therapy and telemedicine to increase access to quality care.

Gender differences in depression and PTSD symptoms following combat exposure

BACKGROUND

This research examined gender as a moderator of the association between combat exposure (CE) and depression as well as CE and PTSD symptoms among a nonclinical sample of Soldiers following deployment in support of operations in Afghanistan and Iraq.

METHODS

Cases included 6,943 (516 women, 6,427 men) active duty Soldiers that were retrospectively analyzed from a pre- and post-deployment screening database at a large Army installation.

RESULTS

Gender moderated the association between CE and depressive and PTSD symptoms such that higher levels of CE were more strongly associated with depression and PTSD symptoms in women compared to men. Female Soldiers also reported higher severity of depressive symptoms compared to male Soldiers, whereas men reported higher levels of CE and a greater number of previous deployments compared to women.

CONCLUSIONS

CE was a stronger predictor of post-deployment depression and PTSD symptoms for women compared to men. These results provide evidence for gender-based differences in depression and PTSD risk. Screening for degree of CE in addition to symptoms associated with depression and PTSD can help with the care for service members who are returning from deployments to combat zones.

Long-term clinical outcomes of care management for chronically depressed primary care patients: a report from the depression in primary care project

PURPOSE

Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.

METHODS

The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.

RESULTS

DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P = .012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.

CONCLUSIONS

The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.

Collaborative care: evidence-based models that improve primary care depressive outcomes

The 2001 Institute of Medicine Report “Crossing the Quality Chasm,” summarized the current care of chronic illness in the United States by emphasizing “Between the health care we have and the health care we could have lies not just a gap, but a chasm.” Across multiple chronic illnesses within primary and specialty care systems, this summary statement illustrates that clinicians and other health professionals are not adequately providing patients guideline levels of treatment–levels that can lower the risk for complications of those illnesses.

Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management

While there has been a great deal of speculation over the years on the importance of emotional factors in inflammatory bowel disease (IBD), it is only in the last decade or so that studies with stronger designs have been available to clarify the nature of this relationship. This review considers recent evidence on the prevalence of anxiety and depressive disorders in IBD, the role of these disorders as a risk factor for IBD onset, the degree to which they affect the course of the IBD, and the contribution of corticosteroid treatment to psychiatric symptom onset. There is evidence that anxiety and depression are more common in patients with IBD and that the symptoms of these conditions are more severe during periods of active disease. The few studies that address the issue of anxiety and depression as risk factors for IBD do not yet provide enough information to support definite conclusions. There is evidence, however, that the course of the disease is worse in depressed patients. Treatment with corticosteroids can induce mood disorders or other psychiatric symptoms. The second part of the review focuses on patient management issues for those with comorbid anxiety or depression. Practical approaches to screening are discussed, and are recommended for routine use in the IBD clinic, especially during periods of active disease. We review evidence-based pharmacological and psychological treatments for anxiety and depression and discuss practical considerations in treating these conditions in the context of IBD to facilitate overall management of the IBD patient.

Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention

BACKGROUND

Current interventions to enhance patient self-efficacy, a key mediator of health behavior, have limited primary care application.

OBJECTIVE

To explore the effectiveness of an office-based intervention for training resident physicians to use self-efficacy-enhancing interviewing techniques (SEE IT).

DESIGN

Randomized controlled trial.

PARTICIPANTS

Family medicine and internal medicine resident physicians (N = 64) at an academic medical center.

MEASUREMENTS

Resident use of SEE IT (a count of ten possible behaviors) was coded from audio recordings of the physician-patient portion of two standardized patient (SP) instructor training visits and two unannounced post-training SP visits, all involving common physical and mental health conditions and behavior change issues. One post-training SP visit involved health conditions similar to those experienced in training, while the other involved new conditions.

RESULTS

Experimental group residents demonstrated significantly greater use of SEE IT than controls, starting after the first training visit and sustained through the final post-training visit. The mean effect of the intervention was significant [adjusted incidence rate ratio for increased use of SEE IT = 1.94 (95% confidence interval = 1.34, 2.79; p < 0.001)]. There were no significant effects of resident gender, race/ethnicity, specialty, training level, or SP health conditions.

CONCLUSIONS

SP instructors can teach resident physicians to apply SEE IT during SP office visits, and the effects extend to health conditions beyond those used for training. Future studies should explore the effects of the intervention on practicing physicians, physician use of SEE IT during actual patient visits, and its influence on patient health behaviors and outcomes.

Relationship between the presence of practice systems and the quality of care for depression

A valid measure of practice systems for improving chronic disease care is needed as a guide for both improvement and public accountability. We tested whether a new survey measure of the presence of practice systems (the PPC-R) is associated with performance measure rates for depression among 40 medical groups in Minnesota. These PPC-R scores were compared with standardized medical group measures of antidepressant persistence. Only 54% of potentially important systems were present, and there was high variability. However, there was a positive correlation between systems and quality on the 90-day measure of antidepressant persistence, both overall (r = .33, P = .04) and for the Chronic Care Model domains of decision support (r = .38, P = .02) and delivery system redesign (r = .31, P = .05). Thus, practice systems overall and several domains of the Chronic Care Model appear to be associated with higher quality care for depression. This questionnaire may help practices identify particular systems to improve.

The health value and cost of care for major depression

BACKGROUND

Trade-offs between costs and outcomes are a reality of health-care decisions. Cost-effectiveness analyses can guide choices toward interventions with the most health benefit for the least cost but are limited because generic measures of health value are infrequently available in the literature and are expensive to collect.

OBJECTIVE

We report on the application of a new approach to estimate the health value of alternative treatment patterns. We apply this approach to common treatment patterns for major depression, and we generate estimates of the change in health value that is attributable to a particular treatment. We also obtain estimates of treatment costs and report cost/health value ratios. We used a modified expert panel approach to estimate the change in health value attributable to different patterns of treatment. We used claims and pharmacy data to define usual care treatment patterns and estimate costs.

RESULTS

The lowest cost and most frequent treatment, 1 to 3 psychotherapy visits, produces minimal improvement. Treatments that include an antidepressant medication provide more health benefit per unit cost than all other treatments and adding a medication follow-up visit provides a lot of benefit for minimal cost.

CONCLUSIONS

We demonstrate the application of a new approach to estimate the health value of common depression treatment practices in the United States. Our results suggest cost-effective targets for quality improvement efforts by identifying ways in which treatment for depression could cost less to get to a given outcome. Because our approach uses a generic health outcome measure, it can be applied to other conditions, permitting comparisons of benefit across diseases.

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Physical symptoms that predict psychiatric disorders in rural primary care adults

RATIONALE, AIMS AND OBJECTIVES

There is a robust association between physical symptoms and mental distress, but recognition rates of psychiatric disorders by primary care doctors are low. We investigated patient-reported physical symptoms as predictors of concurrent psychiatric disorders in rural primary care adult outpatients.

METHOD

A convenience sample of 1092 patients were assessed with a two-stage diagnostic system consisting of a brief screening questionnaire and a clinician-administered semi-structured interview that linked common physical symptoms with the concurrent presence of psychiatric disorders.

RESULTS

Somatoform physical symptoms were highly predictive of the concurrent presence of a psychiatric disorder, with odds ratios ranging from 10.4 (fainting spells) to 54.6 (shortness of breath). Aggregate analysis of somatoform and non-somatoform symptoms relative to no physical symptom produced odds ratios of 3.0 or higher for headaches, chest pain, dizziness, sleep problem, shortness of breath, tired or low energy, and fainting spells. As the number of symptoms (especially somatoform) increased, the odds of a psychiatric disorder increased.

CONCLUSION

Although individual physical symptoms are valid triggers for suspecting a psychiatric disorder, the most powerful correlates are total number of physical complaints and somatoform symptom status.

Collaborative mental health and primary care for bipolar disorder

This article discusses the use of integrated care models, in particular, collaborative care, in the treatment of bipolar disorder. Dr. Williams first discusses how care delivered via a collaboration between primary care and psychiatric providers has the potential to improve both mental health and general medical outcomes for patients with bipolar disorder. He describes promising findings from studies of the use of collaborative care in the treatment of depression, an area where this model has received the most study. Dr. Williams then discusses how such collaborative care models might best be implemented in the treatment of bipolar disorder. In the second half of the article, Dr. Manning focuses on five key issues that are an especially appropriate focus for collaborative care for bipolar disorder and for which the STAndards for BipoLar Excellence (STABLE) Project developed quality improvement performance measures: assessment for risk of suicide, assessment for substance use/abuse, monitoring for extrapyramidal symptoms, monitoring of metabolic parameters (e.g., monitoring for weight gain, hyperglycemia, hyperlipidemia), and provision of bipolar-specific psychoeducation.

[Improving the management of depression in primary care: review and prospects]

BACKGROUND

Depression is a common disorder, associated with significant social and functional impairment, and whose natural course tends to chronicity. The majority of the patients suffering from this disorder are attended in primary health care settings. General practitioners represent the greatest part of the prescribers of antidepressants. Unfortunately, there are many barriers with detection and with the treatment of depression, thus only a minority of patients profits from a treatment with effective posology and with sufficient duration.

LITERATURE FINDINGS

Several programs of interventions directed by mental health professionals aim at improving the management of depression in primary care. There are single interventions consisting of an educational program to physicians or a single intervention to the patient. The assessments of an educational strategy find some contradictory results. Single interventions are not sufficient by themselves. On the other hand, programs associating several interventions are effective. These associations consist of an educational intervention to the physicians and an intervention or more to the patient treated by antidepressant. Interventions are generally carried out by nurses and supervised by a psychiatrist. Mental health professionals share their informations with general practitioners. Interventions can be telephone or in <<face to face>>. Telephone interventions have the advantage of a low cost and appear quite as relevant as interventions in <<face to face>>.

RESULTS

But the effectiveness of these programs grows blurred in time, unless the program itself does continue. Moreover, this effectiveness is variable according to the severity of symptomatology. Indeed, the interest of this type of programs for the patients suffering from minor depression is limited. These various programs can be supplemented by the contribution of tools of detection or assessment of the depressive symptomatology to general practitioners, like by the contribution of oral and/or written informations to the patient concerning the disorder from which he suffers. The setting-up of such programs represents a considerable cost but depression is itself responsible for an important cost for our society. Several estimates concerning the setting-up of these programs find a good cost-effectiveness ratio; it should facilitate their installation taking into account their effectiveness.

CONCLUSION

A close cooperation, based on the complementarity between general practitioners and mental health professionals is required to improve the management of depression.

Efficacy of paroxetine in treating major depressive disorder in persons with multiple sclerosis

OBJECTIVE

The objective of this study was to evaluate the efficacy of paroxetine in treating major depressive disorder (MDD) in persons with multiple sclerosis (MS).

METHOD

In this double-blind trial, 42 participants with MS and MDD were randomly assigned to one of two parallel 12-week treatment arms: paroxetine or placebo. The participants started at an initial dose of 10 mg/day paroxetine or placebo, titrated up to 40 mg daily based on symptoms response and side effects. The primary outcome measure was the Hamilton Rating Scale for Depression (HAM-D). Secondary outcomes included fatigue, anxiety and self-reported quality of life.

RESULTS

Intent-to-treat analyses revealed that both groups improved from pretreatment to posttreatment. Although the treatment group improved more than the control group on most measures, few differences were statistically significant. For the primary outcome, 57.1% of participants in the treatment arm had at least a 50% reduction in HAM-D score, compared with 40% in the control group (nonsignificant). Treatment effects were greater among the participants who completed the study; 78.6% of completers had a treatment response compared with 42.1% of controls (P=.073).

CONCLUSION

Although paroxetine may not be efficacious for all persons with MS and MDD, it appears to benefit some individuals.

Depression in public community long-term care: implications for intervention development

The objective of this paper is to increase understanding of geriatric depression in the public community long-term care system to guide intervention development. Protocols included screening 1,170 new clients of a public community long-term care agency and interviewing all clients with major, dysthymia, or subthreshold depression (n = 299) and a randomly selected subset of nondepressed older adults (n = 315) at baseline, 6-month, and 1 year. Six percent had major depression, one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the year observation period, 40% were persistently depressed; 32% were assessed as depressed only at the first observation; and the remainder was intermittently depressed. There were high levels of comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and clients reported attitudinal and other barriers to depression treatment. Findings suggest the need for universal screening for depression with some strategies for triaging the most severely and persistently depressed for treatment. Although there will be challenges to the development of depression interventions, the public community long-term care system has high potential to assist vulnerable older adults receive help with depression.

Psychiatric issues in multiple sclerosis

MDD and anxiety disorders are highly prevalent among persons who have MS and have been associated with decreased adherence to MS treatment and poorer functional status and quality of life. Effective treatment is available for MDD, but this disorder continues to be underdetected and undertreated by MS providers. Treatment with pharmacotherapy is particularly challenging in this patient population, given the somatic symptom overlap between MS and depression and the increased burden of side effects. Larger randomized, controlled trials are needed to elucidate further the effectiveness of pharmacotherapy and to identify subgroups of patients who would benefit from this type of treatment for depression. There have been few rigorous studies of the prevalence and impact of anxiety disorders, substance use disorders, or serious mental illness such as bipolar disorder or schizophrenia, in MS samples.

Receiving treatment and labor force activity in a community survey of people with anxiety and affective disorders

INTRODUCTION

Standard treatments for depression and anxiety disorders are generally expected to benefit individuals, employers, and the wider community through improvements in work-functioning and productivity. Although some evidence supports expectations of treatment benefits, these are rarely examined at a population level.

METHODS

We investigated receiving treatment, labor force activity, and self-reported work performance among people with ICD-10 affective and anxiety disorders. Data were collected by the Australian Bureau of Statistics using representative multistage sampling strategies. This large household probability sample consisted of 37,580 working age individuals. A secondary analysis was conducted using multiple binary logistic regression.

RESULTS

After statistically controlling for eight covariates: extent of employment restrictions; mental health status; age; sex; partner status; country of birth; age left school; and educational attainment; receiving treatment was consistently associated with non-participation in the labor force, and was negatively associated with work performance.

CONCLUSIONS

At a population level, receiving treatment for anxiety and depression was negatively associated with being employed or looking for work. This could be an unintended side effect of treatment, although other explanations are also possible. These results justify more specific longitudinal investigations into how different forms of mental health treatment influence labor force activity among working age community residents with anxiety and affective disorders.

Self-reported confidence and skills of general practitioners in management of mental health disorders

OBJECTIVE

To identify the predictors of self-reported confidence and skills of GPs in management of patients with mental health problems.

DESIGN

Cross-sectional survey, with questionnaire presented to 246 GPs working in 62 practices throughout Gippsland.

SETTING

Rural general practices in Gippsland.

PARTICIPANTS

One hundred and thirty-four GPs across Gippsland.

MAIN OUTCOME MEASURES

GPs completed a questionnaire assessing self-perception of knowledge and skills in recognition and management of common mental health problems.

RESULTS

Of 134 GPs, 45% reported that they have a specific interest in mental health, and 39% of GPs reported that they had previous mental health training. Only 22% of GPs describe having both an interest and prior training in mental health care. Age and years since graduation are not significantly related to self-reported confidence and skills.

CONCLUSIONS

The results of this study highlight that self-professed interest and prior training in mental health are associated. Self-professed interest in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health disorders. Similarly, prior training in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health problems. Self-professed interest in mental health issues is also associated with hours of participation in continuing medical education related to mental health care. Unfortunately, only a minority described having both interest and prior training in mental health care.

Effect of care setting on evidence-based depression treatment for veterans with COPD and comorbid depression

BACKGROUND

Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients.

OBJECTIVE

To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder.

MEASUREMENTS AND MAIN RESULTS

Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (> or = 3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only.

CONCLUSIONS

Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings.

Let's not talk about it: suicide inquiry in primary care

PURPOSE

The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests.

METHODS

Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality.

RESULTS

Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with rho = 0.57 (95% confidence interval, 0.45-0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression.

CONCLUSIONS

When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.

The impact of depressive symptoms in early Parkinson disease

BACKGROUND

Depressive disorders may affect up to 50% of patients with Parkinson disease (PD) and are associated with increased disability and reduced quality of life. No previous study has systematically examined the impact of depressive symptoms in early, untreated PD.

METHODS

We administered the 15-item Geriatric Depression Scale (GDS-15) as part of two NIH-sponsored phase II clinical trials in PD, enrolling 413 early, untreated PD subjects. We used linear mixed models to examine the relationship of depressive symptoms, measured by the GDS-15, with motor function and activities of daily living (ADLs), as measured by the Unified PD Rating Scale (UPDRS). A time-dependent Cox model was used to examine the effect of demographic and clinical outcome measures as predictors of investigator-determined time to need for symptomatic therapy for PD.

RESULTS

A total of 114 (27.6%) subjects screened positive for depression during the average 14.6 months of follow-up. Forty percent of these subjects were neither treated with antidepressants nor referred for further psychiatric evaluation. Depression, as assessed by the GDS-15, was a significant predictor of more impairment in ADLs (p < 0.0001) and increased need for symptomatic therapy of PD (hazard ratio = 1.86; 95% CI 1.29, 2.68).

CONCLUSIONS

Clinically important depressive symptoms are common in early Parkinson disease (PD), but are often not treated. Depressive symptoms are an important contributor to disability and the decision to start symptomatic therapy for motor-related impairment in early PD, highlighting the broad importance of identifying and treating depression in this population.

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.

Health service patterns indicate potential benefit of supported self-management for depression in primary care

OBJECTIVE

To examine health service delivery in a Canadian province (British Columbia) to consider how Canadian health care services might be developed to best address the large number of individuals with mildly to moderately severe depressive illnesses.

METHOD

We used provincial administrative data to describe patterns of medical services provided to individuals suffering from depression during 3 different time periods (1991-1992, 1995-1996, and 2000-2001) and to determine the frequency with which depression patients receive treatment from primary care physicians and psychiatrists. We then used these findings to consider the feasibility and potential applicability of the various approaches that have been described to decrease the burden of disease related to depression.

RESULTS

In the fiscal year 1991-1992, the "treated prevalence" rate was 7.7%; in 1995-1996, it was 8.7%; and in 2000-2001, it was 9.5%. In each cohort over the 10-year period, the proportion of individuals who received a diagnosis of depression and who were then treated by primary care physicians alone (no psychiatric services were provided) remained constant at 92%.

CONCLUSIONS

Supported self-management is identified as a promising intervention that could be integrated into primary health care within the context of the Canadian health care system. It constitutes a feasible and practical approach to enhance the role of family physicians in the delivery of services to individuals with milder forms of depression and promotes the active engagement of individuals in their recovery and in prevention of future episodes.

Perspectives on disparities in depression care

Depression is a major public health problem and a leading cause of disability worldwide. Compounding the high rates of morbidity and mortality and treatment challenges associated with depression are the tremendous disparities in quality of mental health care that exist between the majority of the population and those of racial and ethnic minorities. Although more study data are available on depression care for African Americans than for other groups, racial and ethnic minorities overall are less likely than whites to receive an accurate diagnosis, to receive care according to evidence-based guidelines, and to receive an antidepressant upon diagnosis. Multiple factors contribute to these disparities, among them socioeconomic and cultural issues and prejudices among patients and health care providers. Closing the gap that exists between what depression care is and what depression care could be begins with clinicians' recognizing the relevance of culture to care. Opportunities exist within the broader context of medical education, including continuing medical education (CME), to prepare health care professionals to address the myriad issues related to managing depression.

Work performance among Australians with depression and anxiety disorders: a population level second order analysis

At a population level, little is known about how anxiety and depression impact on work performance. We investigated the first and second order correlates of work accomplishment and care taken at work among people with International Statistical Classification of Diseases and Related Health Problems, 10th Revision, affective and anxiety disorders in comparison to healthy community residents. Australian Bureau of Statistics multistage sampling strategies obtained a household sample of 37,580 working age individuals. A secondary analysis was conducted using multiple binary logistic regression. The first order correlates of work performance were the extent of employment restrictions, mental health status, age, sex, and whether or not treatment was received. At the second order level, the effects of mental health status on work performance depended on age, sex, and receiving treatment. The effect of employment restrictions on work performance depended on age and sex only.

Do Patient Requests for Antidepressants Enhance or Hinder Physicians’ Evaluation of Depression?

OBJECTIVE

We sought to ascertain whether patients' requests for antidepressants affect visit duration or history taking by primary care physicians (PCPs) for patients with depressive symptoms and a coexisting musculoskeletal disorder and to determine whether more thorough history taking is associated with diagnostic accuracy or with provision of minimally acceptable initial care for major depression.

DESIGN

This was a randomized trial using standardized patients (SPs). Six roles involved 2 conditions (major depression and adjustment disorder, both with coexisting musculoskeletal conditions) and 3 patient request types (brand-specific, general, or none). We conducted the study in 152 PCP offices in Northern California and Rochester, New York. Physicians were assigned randomly to see 2 SPs with depression/wrist pain or adjustment disorder/back pain.

MAIN OUTCOME MEASURES

Physician history-taking for depression and the musculoskeletal condition; depression diagnosis in the medical record; antidepressant prescriptions/samples; referral/follow-up recommendations; visit duration; and provision of minimally acceptable initial depression care.

RESULTS

General antidepressant requests were associated with more depression history-taking (Adjusted Parameter Estimate = 0.80 more questions of 10 (95% confidence interval = 0.31-1.29, P < 0.001); brand-specific requests were marginally associated with more depression history-taking (Adjusted Parameter Estimate = 0.45, 95% confidence interval = -0.04-0.93, P = 0.07). Antidepressant medication requests were not related to musculo-skeletal question asking (P > 0.3) or visit length (P > 0.8). Depression history taking was directly associated with the likelihood of a chart diagnosis of depression and the provision of minimally acceptable initial depression care.

CONCLUSION

General antidepressant requests increase depression history taking, including screening for suicide. Patients' requests for medication do not appear to short-circuit history taking for depression or distract the physician's attention from coexisting musculoskeletal conditions.

[Depressive disorders. A diagnostic and therapeutic challenge also for primary care]

Diagnosis and treatment of depressive disorders play a major role in primary care. Due to their high prevalence in the general population with a pronounced psychiatric and somatic morbidity and a significant subsequent psychosocial disability, such disorders constitute a serious disease entity. This review provides basic knowledge on epidemiology, diagnosis, pharmacotherapy and psychotherapy to enable successful primary care of this important group of patients.

Dissemination of evidence-based mental health interventions: importance to the trauma field

Randomized controlled trials have established the efficacy of psychotherapy and medication treatments for posttraumatic stress disorder (PTSD). Despite these advancements, many individuals do not receive guideline-concordant PTSD care. In an effort to advance dissemination of evidence-based PTSD treatments, the authors review several examples of dissemination efforts of mental health interventions. The first examples describe the dissemination of multifaceted collaborative care interventions for patients with depressive disorders and evidence-based interventions for patients with severe mental illness. The final example explores evolving efforts to adapt and disseminate interventions to acutely injured trauma survivors. For each example, the authors describe the problem with prior clinical approaches, the program to be disseminated, the barriers and levers to implementation and the progress in overcoming these barriers.

Somatic symptoms in depression

Both painful and nonpainful somatic symptoms essentially characterize clinical states of depressive mood. So far, this well-established psychopathological knowledge has been appreciated only insufficiently by the official diagnostic sys-terms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IVTR) and the ICD-10 Classification of Mental and Behavioral Disorders. Clinical Descriptions and Diagnostic Guidelines (ICD-10). From a perspective of primary care services, this unmet diagnostic need is deplorable, as the main mode of presenting a depression is by reporting somatic symptoms. This somatic form of presentation, however, significantly contributes to low rates of recognition in primary care. A diagnostic challenge may be seen in the differentiation of a depression with prevailing somatic symptoms from anxiety, somatoform disorders, and medical conditions. When somatic symptoms, particularly painful physical conditions, accompany the already debilitating psychiatric and behavioral symptoms of depression, the course of the illness may be more severe, implying a higher risk of early relapse, chronicity suicide, or mortality due to other natural causes, the economic burden increases considerably, the functional status may be hampered heavily, and health-related quality of life may be lowered dramatically. The neurobiological underpinnings of somatic symptoms in depression may guide more promising treatment approaches.

Responsiveness of the PHQ-9 to Psychopharmacological Depression Treatment

This is the first study that investigates the responsiveness of the Patient Health Questionnaire-9 (PHQ-9), a standard 9-item self-report depression scale, to antidepressant medication. Authors analyzed data from 1,788 depressed outpatients (66.8% women; mean age, 50.3 years), participating in a prospective, open-label, non-interventional, observational study of sertraline. On the 0-27-point PHQ-9 scale, the total sample gained 10.3 points at 12 weeks, corresponding to a standardized effect size of -1.85. With reference to two independent criterion standards, the PHQ-9 change scores were considerably greater in therapy responders than in nonresponders. The PHQ-9 was equally responsive in men and women. Therefore, the PHQ-9 qualifies as a practical tool for gauging response to pharmacological treatment in depressed patients.

Medical patients' attitudes toward emotional problems and their treatment. What do they really want?

BACKGROUND

Understanding medical patients' attitudes toward emotional problems and their management is crucial to overcoming obstacles to efficient depression treatment.

OBJECTIVE

To investigate attitudes toward emotional problems, psychotherapy, antidepressants, alternative treatment approaches, and self-management techniques in depressed and nondepressed medical outpatients.

DESIGN

Cross-sectional interview study, including quantitative and qualitative methods.

PATIENTS

Eighty-seven depressed subjects (mean age, 41.0 years; 66% female) and 91 nondepressed subjects (mean age, 41.4 years; 67% female) from 7 internal medicine outpatient clinics and 12 family practices (participation rate, 91%).

MEASUREMENTS

Depression diagnoses were established using a structured diagnostic interview, and patient attitudes were investigated with open-ended interview questions regarding treatment preferences, factors improving and impairing emotional well-being, and patients' self-management to improve well-being.

RESULTS

Among the depressed patients, psychotherapy was the most frequently preferred treatment (29%) and the most common factor reported to improve emotional well-being (36%). Twenty-two percent of the depressed patients desired depression treatment within their current medical system, but requested substantially more time to communicate with their physician. Antidepressants were rarely mentioned as a preferred treatment (6%) or factor improving well-being (11%). Thirty-eight percent of the depressed patients attributed their impaired mood to health problems. Compared with the depressed patients, the nondepressed controls preferred significantly less frequent depression-specific therapies.

CONCLUSIONS

The vast majority of medical outpatients prefer treatment approaches for emotional problems that go beyond antidepressant medication therapy. Health care providers should consider providing sufficient time to communicate with their patients, the strong preference for psychotherapy, and an appropriate treatment of comorbid physical conditions.