The epidemiology of psychiatric disorders and the de facto mental health care system

Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study

BACKGROUND

A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression.

OBJECTIVE

To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression.

DESIGN

A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center.

PATIENTS

Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded.

INTERVENTION

Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening.

MAIN MEASURES

The primary outcome was the depression screening rate.

KEY RESULTS

The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001).

CONCLUSION

Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832283.

Behavioral Health in Primary Care: Brief Screening and Intervention Strategies for Pediatric Clinicians

Despite the high prevalence of behavioral health concerns presenting in pediatric primary care and the growing support for integrating behavioral health services into this setting, a majority of primary care providers do not have access to on-site behavioral health specialists. Fortunately, primary care providers can implement some services typically provided by behavioral health clinicians. This article outlines screening, brief intervention, and referral guidelines for prominent behavioral health problems seen in primary care. The evidence-based approaches have the potential to supplement typical management of behavioral health problems in primary care and provide a foundation for future integrated behavioral health practice.

Health Risk Behaviors and Resilience Among Low-Income, Black Primary Care Patients: Qualitative Findings From a Trauma-Informed Primary Care Intervention Study

This study describes an intervention with low-income, Black primary care patients and their experience in changing a health risk behavior. Participant themes, including behavioral coping, personal values, accomplishments and strengths, barriers and strategies, and social support, are understood in relationship to health behavior theories. Two structured interviews were conducted 1 month apart. Content analysis was used to analyze responses from 40 participants. Participants were well equipped with resilience-based coping, self-efficacies, and informal social networks despite economic and social disadvantages. Findings from this study have the potential to improve behavioral health coping and reduce racial inequities in health prevalent for this population.

Psychological interventions for posttraumatic stress disorder involving primary care physicians: systematic review and Meta-analysis of randomized controlled trials

Background

Evidence-based psychological interventions for posttraumatic stress disorder (PTSD) are available in specialized settings, but adequate care in primary care is often lacking.

The aim of this systematic review was to determine the effectiveness of psychological interventions for PTSD involving primary care physicians (PCPs) and to characterize these interventions as well as their providers.

Method

A systematic review and meta-analyses of randomized controlled trials (RCTs). Primary outcome were symptoms of PTSD.

Results

Four RCTs with a total of 774 patients suffering from PTSD symptoms were included, all applying cognitive behavioural based interventions. Three studies with psychological interventions being conducted by case managers were pooled in a meta-analysis. Interventions were not effective in the short term (0–6 months; SMD, − 0.1; 95% CI, − 0.24-0.04; I² = 0%). Only two studies contributed to the meta-analysis for long term (12–18 months) outcomes yielding a small effect (SMD, − 0.23; 95% CI, − 0.38- -0.08; I² = 0%).

Conclusions

Psychological interventions for PTSD in primary care settings may be effective in the long term but number and quality of included studies was limited so the results should be interpreted with caution.

Thrombotic thrombocytopenic purpura patients' attitudes toward depression management: A qualitative study

BACKGROUND AND AIMS

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder characterized by acute episodes of systemic microvascular thrombosis; TTP is more common in adults, women, and African-Americans (Blacks). Our Oklahoma TTP Registry documented that survivors have an increased prevalence of depression compared with the general population; however, many patients' depression remains untreated. Moreover, studies identifying attitudes toward depression management are lacking. The objective of this study was to identify TTP patients' attitudes towards pharmacotherapy. As a secondary question, we explored attitudes towards counseling.

METHODS

We interviewed TTP patients with major depression who had experience with different management strategies (previous/current pharmacotherapy treatment versus no pharmacotherapy treatment). Eligibility criteria included (a) age > 18 years, (b) ADAMTS13-deficient TTP, (c) enrolled in the Oklahoma Registry, and (d) moderate/major depression on either the Beck Depression Inventory II or Patient Health Questionnaire from 2004 to 2012. Qualitative purposive sampling was used to interview patients with a range of experiences with TTP and depression symptom management. Our study was based on the theoretical framework of the Theory of Reasoned Action. Patients were asked about their views on depression (attitudes), their family and friends' views (social norms), and ways they cope with depression.

RESULTS

Semi-structured interviews were conducted between June and October 2013. Data saturation was achieved after interviewing 16 patients (nine, pharmacotherapy and seven, no pharmacotherapy). The majority (88%) were women; 56% were Black, and the median age was 49 years. Patients in both groups believed TTP was life altering and traumatic and that counseling improved depressive symptoms. However, the pharmacologic group believed medication improved one's quality of life, whereas the no pharmacotherapy group was not sure pharmacotherapy was effective and expressed fears related to potential addiction and side effects. When asked about cultural views to depression management, many Black patients stated that in the Black community, a person is taught to deal with his/her emotional issues instead of asking strangers for help.

CONCLUSION

Ensuring effective depression management is a critical part of TTP care. Understanding attitudes toward management will assist in tailoring patient discussions.

Teaching residents mental health care

OBJECTIVE

We tested the hypothesis that trained medical faculty can train residents effectively in a mental health care model.

METHODS

After the authors trained medical faculty intensively for 15 months in primary care mental health, the newly trained faculty taught medical residents intensively. Residents were evaluated pre- and post-residency and compared to non-equivalent control residents in another city. Using ANOVA, the primary endpoint was residents' use of a mental health care model with simulated patients. Secondary endpoints were residents' skills using models for patient-centered interviewing and for informing and motivating patients.

RESULTS

For the mental health care model, there was a significant interaction between study site and time (F = 33.51, p < .001, Eta² = .34); mean pre-test and post-test control group scores were 8.15 and 8.79, respectively, compared to 7.44 and 15.0 for the intervention group. Findings were similarly positive for models of patient-centered interviewing and informing and motivating.

CONCLUSIONS

Training medical faculty to teach residents a mental health care model offers a new educational approach to the widespread problem of poor mental health care.

PRACTICE IMPLICATIONS

While the models tested here can provide guidance in conducting mental health care, further evaluation of the train-the-trainer program for preparing residents is needed.

Depression and survival outcomes after emergency department cancer pain visits

OBJECTIVES

Pain and depression frequently co-occur in patients with cancer. Although pain is a common reason for emergency department (ED) presentation by these patients, depression frequently goes unrecognised during an ED visit. In this study, we assessed the risk for depression in patients with cancer presenting to the ED for uncontrolled pain and assessed the extent to which the risk for depression was associated with survival in this population.

METHODS

Participants were consecutive patients with cancer taking Schedule II opioids (n=209) who presented to the ED of a tertiary cancer centre for uncontrolled pain. Risk for depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the somatic symptoms. Survival was calculated from date of ED visit to date of death/last follow-up.

RESULTS

The CES-D was completed by 197 of 209 participants (94.3%); of these, 81 of 197 (41.1%) had high risk for depression (CES-D ≥10). The mean survival time for the entire sample was 318 days (SD=33), with 84 deaths. Cox proportional hazards regression modeling showed that risk for depression and disease stage (CES-D ≥10: HR=1.75, 95% CI 1.11 to 2.78, p=0.016; disease stage: HR=2.52, 95% CI 1.20 to 5.30, p<0.001) were significant factors for survival.

CONCLUSIONS

Risk for depression was prevalent and associated with survival outcomes in patients with cancer presenting to the ED with uncontrolled pain. Screening for risk for depression in the ED may identify patients who need referral for clinical assessment of depression. Diagnosis and adequate treatment could improve health outcomes and survival rates for these patients.

Conceptualizing Culturally Infused Engagement and Its Measurement for Ethnic Minority and Immigrant Children and Families

Despite the central role culture plays in racial and ethnic disparities in mental health among ethnic minority and immigrant children and families, existing measures of engagement in mental health services have failed to integrate culturally specific factors that shape these families' engagement with mental health services. To illustrate this gap, the authors systematically review 119 existing instruments that measure the multi-dimensional and developmental process of engagement for ethnic minority and immigrant children and families. The review is anchored in a new integrated conceptualization of engagement, the culturally infused engagement model. The review assesses culturally relevant cognitive, attitudinal, and behavioral mechanisms of engagement from the stages of problem recognition and help seeking to treatment participation that can help illuminate the gaps. Existing measures examined four central domains pertinent to the process of engagement for ethnic minority and immigrant children and families: (a) expressions of mental distress and illness, (b) causal explanations of mental distress and illness, (c) beliefs about mental distress and illness, and (d) beliefs and experiences of seeking help. The findings highlight the variety of tools that are used to measure behavioral and attitudinal dimensions of engagement, showing the limitations of their application for ethnic minority and immigrant children and families. The review proposes directions for promising research methodologies to help intervention scientists and clinicians improve engagement and service delivery and reduce disparities among ethnic minority and immigrant children and families at large, and recommends practical applications for training, program planning, and policymaking.

Psychological Issues in Medically Underserved Patients

The US population has a subset of those that are underserved who are in need of primary care and also suffer from mental health disorders. In this article, categories of underserved populations are described. Each section defines the population being presented, identifies the mental health problems each is likely to encounter, explores the barriers that prevent access to care, and identifies potential methods to minimize such barriers. The ways in which psychiatric issues vary in underserved settings compared with the general population are differentiated. Recommendations are offered for primary care physicians to support improved recognition and management of psychosocial stressors and psychiatric illness among the underserved.

The struggle for schizophrenia treatment: A case study

Individual of legal age with schizophrenia presenting anosognosia was abandoned, as a result of a court decision. Close family members were not allowed to provide medical follow-up, treatment, protection regarding his vulnerability, and preserve the dignity of their loved one. The issue was the court's prioritization of the autonomy of the individual over his mental health status. The purpose of this case study was to identify the pitfalls of a court case seeking medical follow-up and treatment for a family member with schizophrenia and anosognosia. The method was qualitative and the design was descriptive and instrumental, linking the law to the life experience resulting from the procedures for its implementation. This study examined the difference between clinical and medical-legal evaluation of the examinee. The application of the Therapeutic Jurisprudence principles to the high number of schizophrenia cases with anosognosia, the abandonment of the mentally ill, and family crisis call healthcare providers and the Judiciary for an improvement action of the process of guardianship.

Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention

OBJECTIVE

Although depression is common among homeless mothers, little progress has been made in testing treatment strategies for this group. We describe pilot test results of an adapted collaborative care model for homeless mothers with depression.

METHOD

We conducted a pilot intervention study of mothers screening positive for depression in 2 randomly selected shelter-based primary care clinics in New York over 18 months in 2010-2012. Study participants completed a psychosocial, health, and mental health assessment at baseline, 3 months, and 6 months.

RESULTS

One-third of women screened positive for depression (123 of 328 women). Sixty-seven women (63.2% of the eligible sample) enrolled in the intervention. At 6 months, compared to usual-care women, intervention group women were more likely to be receiving depression treatment (40.0% vs 5.9%, P = .01) and antidepressant medication (73.3% vs 5.9%, P = .001, respectively) and had more primary care physician and care manager visits at both 3 months (74.3% vs 53.3%, P = .009 and 91.4% vs 26.7%, P < .001, respectively) and 6 months (46.7% vs 23.5%, P = .003 and 70% vs 17.7%, P = .001, respectively). More women in the intervention group compared to usual-care women reported ≥ 50% improvement in depression symptoms at 6 months (30% vs 5.9%, P = .07).

CONCLUSIONS

This pilot study found that implementing an adapted collaborative care intervention was feasible in a shelter-based primary care clinic and had promising results that require further testing.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02723058.

Anxiolytic and nootropic activity of Vetiveria zizanioides roots in mice

Background:

Vetiveria zizanioides (VZ) (family: Poaceae), an aromatic plant commonly known as “Vetiver” has been used for various ailments. Concerning the various ailments being listed as the traditional uses of VZ, no mention about anxiety and memory was found.

Objective:

The present study examined the anxiolytic and memory enhancing activity of ethanolic extract of V. zizanioides (EEVZ) dried roots in mice.

Materials and Methods:

Activity of EEVZ was assessed using models of anxiety (elevated plus-maze [EPM], light/dark test, hole board test, marble-burying test) and learning and memory (EPM, passive shock avoidance paradigm).

Results:

EEVZ at doses of 100, 200, and 300 mg/kg b.w. illustrated significant anxiolytic activity indicated by increase in time spent and number of entries in open arm, time spent in lightened area, number of head poking and number marble buried when compared to that of diazepam (1 mg/kg b.w.), a reference standard. The same treatment showed a significant decrease in transfer latency to reach open arm, shock-free zone, and number of mistakes when compared to that of scopolamine (0.3 mg/kg b.w.). EEVZ in all the doses (100, 200, and 300 mg/kg b.w.) significantly decreased mortality in sodium nitrite (250 mg/kg b.w.) induced hypoxia and also significantly increases contraction induced by acetylcholine on rat ileum preparation.

Conclusion:

The result emanated in the present investigation revealed EEVZ possesses significant anxiolytic and nootropic activity by possibly interplaying with neurotransmitters implicated in anxiety and learning and memory.

Lost in translation? Moving contingency management and cognitive behavioral therapy into clinical practice

In the treatment of addictions, the gap between the availability of evidence-based therapies and their limited implementation in practice has not yet been bridged. Two empirically validated behavioral therapies, contingency management (CM) and cognitive behavioral therapy (CBT), exemplify this challenge. Both have a relatively strong level of empirical support but each has weak and uneven adoption in clinical practice. This review highlights examples of how barriers to their implementation in practice have been addressed systematically, using the Stage Model of Behavioral Therapies Development as an organizing framework. For CM, barriers such as cost and ideology have been addressed through the development of lower-cost and other adaptations to make it more community friendly. For CBT, barriers such as relative complexity, lack of trained providers, and need for supervision have been addressed via conversion to standardized computer-assisted versions that can serve as clinician extenders. Although these and other modifications have rendered both interventions more disseminable, diffusion of innovation remains a complex, often unpredictable process. The existing specialty addiction-treatment system may require significant reforms to fully implement CBT and CM, particularly greater focus on definable treatment goals and performance-based outcomes.

Consulting psychiatry within an integrated primary care model

After implementation of an integrated consulting psychiatry model and psychology services within primary care at a federally qualified health center, patients have increased access to needed mental health services, and primary care clinicians receive the support and collaboration needed to meet the psychiatric needs of the population.

Psychosocial issues in patients with chronic hepatitis B and C

Psychosocial issues and the quality of life are important components at the patients diagnosed with chronic hepatitis B and C. In function of the severity of the infection with virus B or the patients who already have cirrhosis, the treatment and psychosocial education should be improved because they have bigger problems. The frequency of psychosocial disorders seems to be raised at the patients diagnosed with chronic hepatitis B. Factors as alcohol abuse and a low social support have a negatively impact above mental health of these patients. The prevalence rate of chronic hepatitis C infection at patients with severe mental illness can be nine times higher than in healthy population. Usually patients with chronic hepatitis B have a quality of life and a mental health better than patients with chronic hepatitis C. Patients with psychiatric affections (especially institutionalized people) have generally a higher risk of being infected with virus B in comparison with general population. Patients with chronic hepatitis B and C suggest a higher grade of stigmatization from society. Despite clinical challenges which treatment with interferon at patients with chronic hepatitis and comorbidities represents, recent studies indicate the fact that treatment can be administrated in safe conditions at patients with viral chronic hepatitis and psychiatric disorders.

Addressing mental health issues in primary care: an initial curriculum for medical residents

OBJECTIVE

Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems.

METHOD

We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base.

RESULTS

We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care.

CONCLUSION

Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve.

PRACTICE IMPLICATIONS

Training residents in mental health will lead to improved care for this very prevalent primary care population.

Psychiatric management of the hepatitis C patient

Patients with hepatitis C virus (HCV) infection have a higher prevalence of psychiatric illness compared with the general US population, and the prevalence of HCV infection in patients with severe mental illness ranges between 8% and 19%, which is four to nine times that of the general US population (1.8%). Given the association between HCV infection and psychiatric illness, gastroenterologists are on the front line of identifying comorbid psychiatric and substance use disorders and conducting a psychosocial pretreatment risk-benefit assessment for HCV infection. The use of interferon-alpha (IFN)-based therapies in combination with ribavirin (RBV) to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of both HCV patients with and those without a preexisting history of psychiatric illness. Consequently, gastroenterologists have been reluctant to engage patients with HCV and comorbid psychiatric illness in antiviral treatment due to concerns about exacerbating or precipitating neuropsychiatric symptoms. Despite the clinical challenge that HCV treatment of patients with comorbid HCV and psychiatric illness presents, recent research indicates that HCV treatments can be safely administered to patients with psychiatric illness provided that there is a comprehensive pretreatment assessment, a risk-benefit analysis, and ongoing follow-up of neuropsychiatric symptoms during antiviral therapy. The process of pretreatment assessment involves screening patients for psychiatric and substance use disorders, educating patients about the treatment process, and addressing available psychosocial support. Most psychotropic medications (antidepressants, mood stabilizers, antipsychotics, and neuroleptics) are thought to be safe to use in the management of patients with HCV and psychiatric illness and for the management of IFN- and RBV-induced neuropsychiatric adverse effects. Nonetheless, the prophylactic use of psychotropic medications to prevent IFN- and RBV-induced neuropsychiatric adverse effects remains a controversial topic. The use of IFN and RBV in patients with HCV and severe mental illness can be done safely with expert psychiatric follow-up. In this review, we discuss the process of pretreatment assessment of patients with HCV and psychiatric illness and specifically address IFN- and RBV-induced depression in patients receiving HCV treatment.

Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future

BACKGROUND

The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings.

METHODS

We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure.

RESULTS

The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research.

CONCLUSIONS

Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.

Diagnosis of depressed young people in primary health care--a validation of HSCL-10

BACKGROUND

According to the World Health Organization, depression ranks as a major contributor to the global burden of disease. A large proportion of adult depressions had their first appearance in adolescence.

AIM

Because primary health care professionals lack valid instruments for early identification of depression, we sought to validate HSCL-10. The design of study is a GP multicentre study conducted in Norway and Denmark. The setting of the study is adolescents (14-16 years) responded by answering a questionnaire and later completed a Composite International Diagnostic Interview, which was used as the gold standard. Depression was defined by International Classification of Diseases-10 (ICD-10). Both internal and external validity were examined, the likelihood between pretest and posttest measured and a cut-off point for depression calculated by using the Youden index.

RESULTS

The Hopkins Symptom Checklist-10 test (HSCL-10) met the criteria for external and internal validity. When analysed separately, the criteria were met both in Denmark and in Norway and both for paper and web. The optimal cut-off point for the HSCL-10 test was 16 (HSCL-10 = 16/10 items = 1.6), with no gender differences. For girls and boys, respectively, it yielded a sensitivity of 87.5% and 87.5%, specificity of 72.4% and 87.9% and likelihood of 3.2 and 7.2.

CONCLUSION

HSCL-10 is a suitable and valid instrument for detecting depression in young people in primary care.

Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence

BACKGROUND

Posttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease.

PURPOSE

The purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes.

METHODS

A systematic literature search in the period of 2002-2009 for PTSD, cardiovascular disease, and metabolic disease was conducted.

RESULTS

The literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers.

CONCLUSIONS

Although the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research.

Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development

OBJECTIVE

To assess the message preferences of individuals affected by depression as part of a project that will evaluate interventions to encourage at-risk patients to talk to their physicians about depression.

METHODS

Adaptive Conjoint Analysis (ACA) of 32 messages defined by 10 message attributes. Messages were developed based on input from three focus groups comprised of individuals with a personal and/or family history of depression, then tested using volunteers from an Internet health community. In an online conjoint survey, 249 respondents with depression rated their liking of the messages constructed for each attribute. They were then presented with two message sets and rated their preferences. Preference utilities were generated using hierarchical Bayes estimation.

RESULTS

The optimal communication approach described both psychological and physical symptoms of depression, recognized multiple treatment options, offered lifetime prevalence data, noted that depression can affect anyone, and acknowledged that finding an effective treatment can take time.

CONCLUSION

Individuals with depression respond differently to depression care messages, underscoring the need for careful message development and evaluation.

PRACTICE IMPLICATIONS

ACA, used in conjunction with focus groups, is a promising approach for developing and testing messages in the formative research stage of intervention development.

Psychiatric care of the patient with hepatitis C: a review of the literature

CONTEXT

Approximately 1.8% of the US population is chronically infected with the hepatitis C virus (HCV). The prevalence rates of psychiatric illness in patients with HCV infection are higher than those rates in the general US population, and the prevalence of HCV infection in patients with severe mental illness may be as high as 9 times that of the general US population. Primary care physicians and psychiatrists are on the forefront of identifying patients with psychiatric illness who are at risk for HCV infection and can screen for HCV infection. This review summarizes the psychiatric implications of HCV infection and strategies for the management of interferon alfa-induced neuropsychiatric adverse effects.

EVIDENCE ACQUISITION

English-language studies were identified by computerized searches using the term hepatitis C psychiatric between 1972 and 2009, and further references were obtained from bibliographies of the reviewed articles. Relevant references were reviewed by the authors and included the basis of significance and applicability to practicing psychiatrists and internists.

RESULTS

Since primary care physicians and psychiatrists are sometimes the only medical link for patients with psychiatric illness, they are expected to provide posttest counseling for their patients with HCV and psychiatric illness. The task of conducting a psychiatric and psychosocial pretreatment risk-benefit assessment to determine whether or not to treat HCV infection is increasingly delegated to primary care providers as well as psychiatrists. The use of interferon alfa-based therapies to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of HCV patients with and without a preexisting history of psychiatric illness. Primary care physicians and psychiatrists are frequently asked to assist in the management of these neuropsychiatric adverse effects and evaluate the risks and benefits of using prophylactic psychotropics.

CONCLUSIONS

Despite the clinical challenge that interferon alfa treatment for patients with comorbid HCV and psychiatric illness presents, recent research indicates that interferon alfa can be safely administered to HCV-infected patients with psychiatric disorders provided there is a comprehensive pretreatment assessment, a risk-benefit analysis, and intensive ongoing medical and psychiatric follow-up.

The content of substance abuse and mental health counseling reported by patients in a national survey

This study examined counseling content reported by a national sample of persons receiving care for alcohol, drug or mental health (ADM) problems in a year. The sample included 2,722 individuals over 18 who reported past year mental health or substance abuse care or assessments in a nationally representative survey conducted in 2000-2001. Counseling domains approximating commonly practiced or evidence-based approaches for depression, anxiety, or substance abuse were assessed. Patient self-report may be one useful way of tracking whether components of standard therapies are implemented in practice.

Mental health and emergency medicine: a research agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

Evaluating a community-based participatory research project for elderly mental healthcare in rural America

The purpose of this evaluation was to explore the collaborative nature of partners in a rural mental health program for the elderly, and to test an adapted method of assessing the collaborative process. Sixteen collaborative partners were interviewed to explore ratings of collaboration across 6 domains identified as critical to participatory research. Results indicate that the context of rural Missouri and uniqueness of the program necessitated an approach to collaboration that began with a top-down approach, but greater community responsibility developed over time. Partners recognized the efforts of the program’s directors to seek input. Most were satisfied with their roles and the degree of success achieved by the program, although several wanted to have more input in the future in some domains, but not in others. Interviews revealed numerous barriers to achieving sustainability. Methods to improve the assessment of collaboration are discussed and areas for improvement are offered.

Characterizing emergency department discussions about depression

BACKGROUND

The reality of emergency health care in the United States today requires new approaches to mental health in the emergency department (ED). Major depression is a disabling condition that disproportionately affects women.

OBJECTIVES

To characterize ED provider-patient discussions about depression.

METHODS

This was a secondary analysis of a database of audiotaped ED visits with women patients collected during a clinical trial of computer screening for domestic violence and other psychosocial risks. Nonemergent female patients, ages 18-65 years, were enrolled from two socioeconomically diverse academic EDs. All audio files with two or more relevant comments were identified as "significant depression discussions" and independently coded using a structured coding form.

RESULTS

Of 871 audiorecorded ED visits, 70 (8%) included discussions containing any reference to depression and 20 (2%) constituted significant depression discussions. Qualitative analysis of the 20 significant discussions found that 16 (80%) required less than 90 seconds to complete. Ten included less than optimal provider communication characteristics. Despite the brevity or quality of the communication, 15 of the 20 yielded high patient satisfaction with their ED treatment.

CONCLUSIONS

ED providers rarely addressed depression. Qualitative analysis of significant patient-provider interactions regarding depression found that screening for depression in the ED can be accomplished with minimal expenditure of provider time and effort. Attention to psychosocial risk factors has the potential to improve the quality of ED care and patient satisfaction.

A vision of the next generation of behavioral therapies research in the addictions

Whither, or wither, empirically supported therapies? Increasingly rigorous research in behavioral therapies has yielded a large number of effective therapies, but comparatively little work, demonstrating that integrating empirically supported therapies (ESTs) into standard practice results in meaningful improvements in patient outcomes. Methodology and strategies for evaluating ESTs and their effectiveness in clinical practice is a fairly recent innovation, and a host of unanswered questions remain regarding issues such as selection among different ESTs and what type of ESTs should be emphasized in dissemination efforts, what type of clinicians should be trained in what type of ESTs, the most effective training strategies for various types of clinicians, the need for ongoing supervision to maintain minimum levels of treatment fidelity and skill. In this review, we call for broader use of new research strategies and methods relevant to dissemination of ESTs; these may include adaptive designs, identification of mechanisms of action to foster greater emphasis on effective change principles, training and adoption trials, as well as novel implementation strategies including computer-assisted therapy and computer-assisted training.

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.

Treatment adherence among patients with schizophrenia treated with atypical and typical antipsychotics

This study evaluated treatment adherence among patients with schizophrenia receiving atypical and typical antipsychotics. Claims data for 7017 treatment episodes of commercially insured patients with schizophrenia (ICD-9-CM) receiving antipsychotics, covering the period from January 1999 through August 2003, were assessed. Overall adherence was evaluated by adherence intensity (medication possession ratio) and treatment duration (length of treatment episode). Pair-wise comparisons of the individual atypicals and a combined group of leading typical antipsychotics were undertaken using multiple regression, adjusting for differing patient characteristics. Each atypical antipsychotic demonstrated a significantly higher adherence intensity than the combined typicals, while quetiapine demonstrated a significantly greater adherence intensity than risperidone and olanzapine. None of the atypicals showed treatment durations significantly different from the typicals. While the small improvements in adherence intensity among atypical agents do not appear to be clinically important, they may reflect an underlying, stronger tendency to use filled prescriptions.

Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes

The objectives of this study were to explore age and gender differences in attitudes toward seeking professional psychological help, and to examine whether attitudes negatively influence intentions to seek help among older adults and men, whose mental health needs are underserved. To achieve these objectives 206 community-dwelling adults completed questionnaires measuring help-seeking attitudes, psychiatric symptomatology, prior help-seeking, and intentions to seek help. Older age and female gender were associated with more positive help-seeking attitudes in this sample, although age and gender interacted with marital status and education, and had varying influences on different attitude components. Age and gender also influenced intentions to seek professional psychological help. Women exhibited more favourable intentions to seek help from mental health professionals than men, likely due to their positive attitudes concerning psychological openness. Older adults exhibited more favourable intentions to seek help from primary care physicians than younger adults, a finding that was not explained by age differences in attitudes. Results from this study suggest that negative attitudes related to psychological openness might contribute to men's underutilization of mental health services. Help-seeking attitudes do not appear to be a barrier to seeking professional help among older adults, although their intentions to visit primary care physicians might be. These findings suggest the need for education to improve men's help-seeking attitudes and to enhance older adults' willingness to seek specialty mental health services.

Pharmacotherapy of delusional disorders in the context of offending and the potential for compulsory treatment

Delusional disorder is an uncommon mental illness with an estimated prevalence of 0.03%. Its low prevalence has likely contributed to the paucity of research interest in this area, leading to substantial gaps in knowledge concerning its treatment and management. In the absence of a robust literature, most clinicians rely on their experience and guidelines for treating schizophrenia when treating patients with delusional disorder. This article reviews the available literature that is specific to the treatment of delusional disorder. In addition, it focuses on specific forensic and medicolegal aspects of managing patients with delusional disorder.

Posttraumatic stress disorder in primary care: prevalence and relationships with physical symptoms and medical utilization

OBJECTIVE

This study estimates the prevalence of posttraumatic stress disorder (PTSD) and describes the relationships among PTSD status and health indices in a civilian primary care patient sample.

METHODS

Participants (N = 232) completed a paper-and-pencil survey of life events, PTSD symptoms, physical symptoms and health functioning. Utilization was assessed from medical records.

RESULTS

Nine percent of the participants met the criteria for full PTSD (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) and another 25% were defined as partial PTSD. The full-PTSD group evidenced higher rates of medical utilization, more intense physical symptoms and poorer health functioning than the no-PTSD group. The partial-PTSD group more closely resembled the full-PTSD group.

CONCLUSIONS

This study, although limited by sample size and diagnosis by questionnaire vs. diagnostic interview, suggests research directions for enhancing our understanding of PTSD among civilian primary care patients and for developing appropriate interventions that can be conducted in the primary care setting.

Screening for mental illness in primary care clinics

OBJECTIVES

To assess the prevalence of mental disorders in inner city outpatient clinics and to improve the diagnosis of mental illness in primary care.

METHODS

The Problem Oriented Patient Report (POPR), a patient self-report checklist, was administered to 362 outpatients at two inner-city Buffalo primary care clinics. Patients' completed POPR checklists were evaluated to identify those with potential mental illness diagnoses and were available for the physicians' review during the patients' visits. After the visit, clinical charts were reviewed to determine the frequency of new mental illness diagnoses among continuing and new patients.

RESULTS

The screening checklist (POPR) revealed potential mental illnesses in 148/362 outpatients, of which 98% had not been identified by the physicians who had reviewed the patients' completed POPR forms. Only five new diagnoses of mental illnesses were independently made by clinics' physicians-all in follow-up (continuing) patients.

CONCLUSIONS

The physicians in the two clinics did not diagnose mental illnesses in their patients, even when written checklists of self-reports were available to them. Differences in staff attitudes may influence the data collection process, and patients' as well as physicians' responses. A weakness of this study is that the POPR might generate false positive results. Even if this were the case, the rate of previous diagnoses was still extremely low.

Billing for the Evaluation and Treatment of Adult Depression by the Primary Care Clinician

Depression is a common problem encountered in primary care practice. There are many barriers that the primary care clinician faces in managing patients with depression. Financial reimbursement is one infrequently addressed barrier that influences how care is provided. This article addresses the coding, documentation, and reimbursement issues that pertain to the treatment of depression in the primary care setting. Coding options are reviewed with specific documentation guidelines. Reimbursement and fee schedule issues are also addressed, including clarification of certain limitations on payment by some payers.

Anxiolytic-like actions of leaves of Casimiroa edulis (Rutaceae) in male Wistar rats

Anxiolytic-like actions of an aqueous extract of the leaves of Casimiroa edulis (Ce) La Llave ex Lex. (Rutaceae) were studied in male Wistar rats in the elevated plus-maze test, whether effect on locomotion were studied in the open-field task, and its possible antidepressant-like actions in the forced swimming task. In the elevated plus-maze test, diazepam (Dz) (1.30 mg/kg; P < 0.05) and Casimiroa edulis (25.0 mg/kg, P < 0.05; 35.0 mg/kg, P < 0.05) increased open arms exploration (i.e., anxiolytic-like action). Doses of 45.0 mg/kg (P < 0.05) and 55.0 mg/kg (P < 0.05) of Casimiroa edulis reduced locomotion in the elevated plus-maze test and in the open-field test. In the forced swimming task, desipramine (dmi) (32.0 mg/kg; P < 0.05) reduced immobility (i.e., antidepressant-like action). Conversely, as compared to control rats, neither diazepam (Dz) (1.30 mg/kg) nor Casimiroa edulis (25.0 mg/kg) modified immobility in the forced swimming task. However, diazepam (P < 0.05) or Casimiroa edulis (P < 0.05), when co-administered, canceled the antiimmobility actions of desipramine. In conclusion, the leaves of Casimiroa edulis (Rutaceae) produced anxiolytic-like actions in male Wistar rats, with several side actions, namely, reduced locomotion and neutralization of the antidepressant-like actions of desipramine.

Public health context of women's mental health research

As more attention is directed to the mental health care of women, sex and gender differences in research design and in regulatory policies have interfaced with clinical care and public policy. An emphasis on women's mental health issues in the provision of treatment and care as well as the design of large-scale screening strategies to identify and treat women with mental disorders promises to be effective public health approaches to reducing the burden of mental illness in women. The past decade has seen increased emphasis on women's mental health and sex/gender differences in the federal sector and in the research community. Federal regulations (summarized in the NIH Outreach Notebook) call for the inclusion of women and minorities in NIH-funded clinical research. The regulations also place emphasis on gender analysis of the results of clinical trials, in particular phase III trials, the findings of which are likely to influence practice. There has been substantial progress toward the goal of including women in research, but more remains to be done. A 2000 GAO report titled "Women's Health: NIH Has Increased Its Efforts to Include Women in Research" commended NIH for tracking the number of women in clinical research but the report also noted that relatively few NIH-funded studies, including major clinical trials, had reported findings by gender of study participants. This was seen as an impediment to progress in developing gender-based effective treatments. In the past decade, the women's health field has moved beyond an exclusive emphasis on women's reproductive function to one that defines health as a scientific enterprise to identify clinically important sex and gender differences in prevalence, etiology, course, and treatment of illnesses affecting men and women in the population as well as conditions specific to women. Nonetheless, for mental disorders, women's reproductive function and its impact on mental health conditions is still understudied. Based on the epidemiology of mental disorders, the course of mental disorders in women in relation to reproductive transitions remains an important issue for the mental health field because the burden of mental disorders, such as depression and anxiety, fall disproportionately on women of childbearing and childrearing age. The public health emphasis on women's mental health does not lessen the basic scientific opportunities to be had by a focus on gender and sex differences. A 2001 report of the Institute of Medicine titled "Exploring the Biological Contributions to Health: Does Sex Matter?" underscores the benefit to health care of looking for sex differences at the biological level. Basic and clinical neuroscience research is rapidly accruing a knowledge base that will provide information at the level of genes and cells of the influences of biological sex on mental health outcomes in both women and men. A focus on women's mental health and gender/sex differences research promises to yield improvement in treatments and services and thereby to improve the public health as well as to increase fundamental knowledge about the etiology and neurophysiology of mental disorders.

The pilot study of a telephone disease management program for depression

Most depressed patients are seen and treated exclusively by primary care clinicians. However, primary care patients with depression are often not adequately treated. The aims of this pilot study were to measure the impact of a telephone disease management program on patient outcome and clinician adherence to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes. Thirty-five primary care practices in the University of Pennsylvania Health System were randomized to telephone disease management (TDM) or "usual care" (UC). All patients received a baseline and a 16-week follow-up clinical evaluation performed over the telephone. Those from TDM practices also received follow-up contact at least every 3 weeks, with formal evaluations at weeks 6 and 12. These interval contacts were designed to facilitate patient and clinician adherence to a treatment algorithm based on the Agency for Health Research and Quality (AHRQ) practice guidelines. Depressive symptoms evaluated with the Community Epidemiologic Survey of Depression (CES-D) scale as well as guideline adherence were the primary outcome measures. Sixty-one patients were enrolled in this pilot project. The overall effect for CES-D scores over time was significant, (P <.001), indicating that those participating in the trial (both TDM and UC groups) showed significant improvement. The interaction between intervention condition and time was also significant (P <.05), indicating that TDM patients improved significantly more over time than did UC patients. A greater proportion of TDM patients had CES-D scores <16 by Week 16 (66.7 versus 33.3%; chi(2), P <.05). The improvement in depression outcome for the TDM group was related to its impact on improving clinician adherence to depression treatment algorithms. The TDM pilot did not show a statistically significant effect on improving patient adherence to clinician recommendations, however. This preliminary data suggests that TDM for depression improves both clinician guideline adherence and patient outcomes in the acute phase of depression. The effect on patient outcome is at least partially explained by the effect of TDM on clinician adherence to depression treatment algorithms.

Are mental health services for children distributed according to needs?

OBJECTIVES

The purpose of this study was twofold: 1) to determine whether publicly funded mental health services and resources available in 4 large regions in the province of Quebec were distributed according to the mental health needs of children aged 6 to 14 years and 2) to assess whether the variations in mental health services and resources across the 4 regions had changed over a 5-year period.

METHODS

Indicators of need according to the child's parent (presence of mental disorder, measure of adaptation, and perception of need for help) from an epidemiologic survey of 2400 noninstitutionalized children were compared with both in-school and community professional resources and with physician and hospital services in 1992-1993. Resource and service data were also collected for 1997-1998. Resource and service data came from professional colleges and government administrative databases.

RESULTS

No significant regional differences were found for need indicators, but there were large discrepancies in mental health resources and services in 1992-1993. Differences in professional resources were largest for special education teachers in the school system and for psychiatrists in the community. The regional differences in resources and services were as large in 1997-1998 as they were in 1992-1993.

CONCLUSIONS

Despite universal health care in Quebec and a government mental health policy stressing equity of access, the available mental health resources for children aged 6 to 14 years are not distributed across regions according to needs. More evidence-based planning is required, specifically using epidemiologic survey data, to match resources to needs and to monitor changes over time.

Screening for depression in medical care: pitfalls, alternatives, and revised priorities

Depression is a disorder seen commonly in general and specialty medical settings. Screening has been advocated as a means of ensuring that depressed patients are identified and receive appropriate treatment. Yet, recommendations for routine screening are frequently made without reference to empirical data demonstrating that it will have its intended effect. We examine the literature regarding screening in medical settings and suggest that screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems. We offer suggestions for how screening instruments might be used to improve the outcomes of depressed persons while minimizing negative effects on health care.

Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment

Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.