Primary care attributes and care for depression among low-income African American women

Assessing Cognitive Representations of Antidepressants: Development and Validation of the Attitudes Toward Medication–Depression Inventory

Antidepressant drugs represent the mainstay of treatment for depression; however, nonadherence is a major problem. Attitudes are predictors of long-term adherence and drive medication use. The Attitudes Toward Medication–Depression (ATM-D) Inventory was developed and tested with 131 patients in primary care settings who reported a diagnosis of depression. Content validity was assessed by experts with a 94.4% agreement on item relevancy. Exploratory factor analysis showed three factors (course of medication treatment, identity, and control) that accounted for 57% of the total variance in the final 17-item scale. The instrument demonstrated good internal consistency reliability (α = .76-.84) and test–retest reliability (α = .74-.83). Results support the construct validity and reliability of the instrument and revealed unique insights into patients’ cognitive representations of their antidepressants. This study supported that patients have cognitive representations related to depression and antidepressants that go beyond simple concerns about the effects of the medication.

A synthesis of the theory of silencing the self and the social ecological model: understanding gender, race, and depression in African American women living with HIV infection

The challenges that face African American women living with HIV are immense. African American women continue to be disproportionately infected and affected by this chronic and life-threatening infection in a complex context of individual experience, interactions with the environment, formal and informal support systems, and cultural belief systems. This article identifies the Theory of Silencing the Self (STS) and a widely known model, the Social Ecological Model (SEM), as a synthesized explanatory framework in helping nurses understand how to address research questions and clinical care that is congruent with the experience of African American women living with HIV infection. In synthesizing the components of these two frameworks, an explanation of the relationship between disempowerment and depression in this population will be uncovered as a key component to making relationships at the individual, family, and community level better. Helping African American women living with HIV infection to explore and address how choosing to be silent across their life systems will advance healthcare adherence as we currently know it to improved self-management of a chronic, gender-specific, culturally-bound experience of depression.

Financial distress and depressive symptoms among African American women: identifying financial priorities and needs and why it matters for mental health

Prior research found that financial hardship or distress is one of the most important underlying factors for depression/depressive symptoms, yet factors that contribute to financial distress remain unexplored or unaddressed. Given this, the goals of the present study were (1) to examine the relationship between perceived financial distress and depressive symptoms, and (2) to identify financial priorities and needs that may contribute to financial distress. Surveys from 111 African American women, ages 18-44, who reside in Allegheny County, PA, were used to gather demographic information and measures of depressive symptoms and financial distress/financial well-being. Correlation and regression analyses revealed that perceived financial distress was significantly associated with levels of depressive symptoms. To assess financial priorities and needs, responses to two open-ended questions were analyzed and coded for common themes: "Imagine you won a $10,000 prize in a local lottery. What would you do with this money?" and "What kinds of programs or other help would be beneficial to you during times of financial difficulties?" The highest five priorities identified by the participants were paying bills and debt, saving, purchasing a home or making home repairs, and/or helping others. The participant's perceived needs during times of financial difficulty included tangible assistance and/or financial education. The findings from this study can be used to create new and/or enhance existing programs, services, and/or interventions that focus on the identified financial priorities and needs. Collaborative efforts among professionals in different disciplines are also needed, as ways to manage and alleviate financial distress should be considered and discussed when addressing the mental health of African American women.

Characterizing depression and comorbid medical conditions in African American women in a primary care setting

BACKGROUND

African American women are more likely to seek treatment for depression in primary care settings; however, few women receive guideline-concordant depression treatment in these settings. This investigation focused on the impact of depression on overall functioning in African American women in a primary care setting.

METHODS

Data was collected from a sample of 507 African American women in the waiting room of an urban primary care setting. The majority of women were well-educated, insured, and employed. The CESD-R was used to screen for depression, and participants completed the 36-Item Short-Form Survey to determine functional status.

RESULTS

Among the participants with depression, there was greater functional impairment for role-physical (z = -0.88, 95% CI = -1.13, -0.64) when compared to individuals with diabetes and hypertension. Individuals with depression also had greater role-emotional impairment (z = -1.12, 95% CI = -1.37, -0.87) than individuals with diabetes and hypertension. African American women with comorbid hypertension and depression had greater functional impairment in role-physical when compared to African American women with hypertension and no depression (t(124) = -4.22, p < 0.01).

CONCLUSION

African American women with depression are more likely to present with greater functional impairment in role function when compared to African American women with diabetes or hypertension. Because African American women often present to primary care settings for treatment of mental illness, primary care providers need to have a clear understanding of the population, as well as the most effective and appropriate interventions.

Desired mental health resources for urban, ethnically diverse, impoverished women struggling with anxiety and depression

Depression and anxiety are mental health issues that disproportionately affect women-particularly when access to culturally sensitive care is limited. The purpose of this study was to identify mental health concerns in three urban, ethnically diverse, underserved, and impoverished neighborhoods using the ideological perspective of community-based participatory research. In the context of long-term partnerships between a department of nursing and these neighborhoods, we recruited 61 women aged 18 to 69 years and collected data via homogeneous focus groups comprised of Black, Hispanic, and White women, respectively. We conducted five of the focus groups in English and one in Spanish. The women perceived anxiety and depression as significant concerns for themselves, their families, and their communities. They used unique community resources to manage mental health issues and desired new resources, including support groups and education.

Self-report of depressive symptoms in African American and white women in primary care

OBJECTIVES

Depressive symptoms are frequently seen among female patients in primary care. The majority of screening instruments are cumbersome for a busy clinic.

METHOD

The effectiveness of a 2-item depression screening questionnaire was compared to the mental health section of the 36-Item Short Form Health Survey (SF-36). A total of 127 consecutive patients who presented for primary care service agreed to participate and completed the questionnaire.

RESULTS

Of the final sample, 65.4% were African American and 44.9% of all women reported having depressive symptoms, with no significant difference in the prevalence of reported depressive symptoms between African American and white women (chi2 = 1.97, p = .16). The women reporting depressive symptoms were more likely to be in the lower-income group (chi2 = 9.02, p = .01); however, in stratified analysis this was only significant for the African American women (chi2 = 8.69, p = .01). Analysis of variance demonstrated that the women with depressive symptoms were more likely to score low on the mental health subscales of the SF-36 when adjusted for income (F = 58.32, P < .0001). Within race groups, the mean Mental Health Index scores were higher among African American women (t = -6.45, P <.0001) and White women (t = -3.59, P = .002) who reported depressive symptoms than among those who did not report depressive symptoms. The sensitivity and specificity of the 2-item depression symptom questions compared to the overall SF-36 mental health score were 70% and 77%, respectively.

CONCLUSION

A simple 2-item questionnaire can be used to identify depressive symptoms in white and African American women in a primary care clinic.

Principles of the patient-centered medical home and preventive services delivery

PURPOSE

Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services.

METHODS

We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling.

RESULTS

Higher global PCMH scores were associated with receipt of preventive services (beta = 2.3; P <.001). Positive associations were found with principles of personal physician (beta = 3.7; P <.001), in particular, continuity with the same physician (beta = 4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (beta = 5.6; P <.001), particularly, having a well-visit within 5 years (beta = 12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (beta = 8.0; P <.001) and use of clinical decision-support tools (beta = 5.0; P = .04) were also associated with receipt of preventive services.

CONCLUSIONS

Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.

Incidence, sources, and self-management of depression in persons attending a rural health clinic in southeastern North Carolina

The purpose of this study was to determine the incidence, sources, and self-management strategies of depression in a sample of 48 persons visiting a primary care clinic in rural Southeastern North Carolina. Forty percent of the participants met the criteria of clinical depression on the Center for Epidemiological Studies Depression Scale (CES-D). Highest rates of depression found in single, African American men who were employed with adequate health insurance were attributed primarily to work related stressors in dealing with overwhelming social problems of other rural residents, as well as economic stressors. Critical incident interviews identified depression self-management strategies and sources of social support.

Depression and anxiety outcomes at a free clinic in a rural state

PURPOSE

To describe the diagnostic and treatment patterns for depression and anxiety in clients receiving care at a free clinic.

DATA SOURCES

Charts for 43 clients who received antidepressant or anxiolytic medications were randomly selected and reviewed.

CONCLUSIONS

Clients presented to the clinic symptomatic; almost two thirds had been treated elsewhere. Most clients received pharmacological treatment and referral for counseling. Forty-four percent of the clients were still being treated at their last visit, but 33% were no longer being seen, and it could not be determined if they were receiving care at another clinic.

IMPLICATIONS FOR PRACTICE

If sustained relationships with clients with depression and anxiety can be developed, appropriate care can be provided.

Overall self-rated health as an outcome indicator in primary care

RATIONALE, AIMS AND OBJECTIVES

The ultimate goal of health care systems is to improve overall health from the patient's point of view. However, overall self-rated health is not routinely monitored as a performance indicator. The purpose of this study was to investigate the feasibility of using a measure normally employed in community health surveys as a quality indicator in primary care clinics.

METHODS

In order to do so, we conducted a cross-sectional survey of community medicine patients treated in five clinics in Amarillo, Texas to test the theory that, in primary care patients, a single-item measure of self-rated health is significantly related to the usual risk factors found in community health surveys (environmental factors, demographic characteristics and health behaviours).

RESULTS

Multiple logistic regression analysis revealed that age, race, frequent mental distress, current smoking and health confidence were independently related to the odds of reporting good health.

CONCLUSION

Our results support using a single-item measure of self-rated health in primary care. Our data also suggest that encouragement of health confidence would appear to be in the best interests of patients.

Primary care quality and addiction severity: a prospective cohort study

BACKGROUND

Alcohol and drug use disorders are chronic diseases that require ongoing management of physical, psychiatric, and social consequences. While specific addiction-focused interventions in primary care are efficacious, the influence of overall primary care quality (PCQ) on addiction outcomes has not been studied. The aim of this study was to prospectively examine if higher PCQ is associated with lower addiction severity among patients with substance use disorders.

STUDY POPULATION

Subjects with alcohol, cocaine, and/or heroin use disorders who initiated primary care after being discharged from an urban residential detoxification program.

MEASUREMENTS

We used the Primary Care Assessment Survey (PCAS), a well-validated, patient-completed survey that measures defining attributes of primary care named by the Institute of Medicine. Nine summary scales cover two broad areas of PCQ: the patient-physician relationship (communication, interpersonal treatment, thoroughness of the physical exam, whole-person knowledge, preventive counseling, and trust) and structural/organizational features of care (organizational access, financial access, and visit-based continuity). Each of the three addiction outcomes (alcohol addiction severity (ASI-alc), drug addiction severity (ASI-drug), and any drug or heavy alcohol use) were derived from the Addiction Severity Index and assessed 6-18 months after PCAS administration. Separate longitudinal regression models included a single PCAS scale as the main predictor variable as well as variables known to be associated with addiction outcomes.

MAIN RESULTS

Eight of the nine PCAS scales were associated with lower alcohol addiction severity at follow-up (p<or=.05). Two measures of relationship quality (communication and whole- person knowledge of the patient) were associated with the largest decreases in ASI-alc (-0.06). More whole-person knowledge, organizational access, and visit-based continuity predicted lower drug addiction severity (ASI-drug: -0.02). Two PCAS scales (trust and whole-person knowledge of the patient) were associated with lower likelihood of subsequent substance use (adjusted odds ratio, [AOR]=0.76, 95 percent confidence interval [95% CI]=0.60, 0.96 and AOR=0.66, 95 percent CI=0.52, 0.85, respectively).

CONCLUSION

Core features of PCQ, particularly those reflecting the quality of the physician-patient relationship, were associated with positive addiction outcomes. Our findings suggest that the provision of patient-centered, comprehensive care from a primary care clinician may be an important treatment component for substance use disorders.

Overall self-rated health: a new quality indicator for primary care

RATIONALE, AIMS AND OBJECTIVES

Patient 'empowerment' gives patients choices about their own care and about the outcomes they would most prefer. Many patients can be presumed to regard overall self-rated health as an important outcome. Therefore, overall self-rated health can be considered a relevant and important outcome measure for a patient-centred medical clinic. The purpose of this study was to use this new outcome measure as a dependent variable and to test the hypothesis that patients who are confident about their ability to manage their health will have better health, in comparison to more dependent patients.

METHODS

We conducted a randomized cross-sectional postal survey of 500 veteran patients from the Panhandle of Texas and the surrounding areas; and 302 participated in the study. Multiple logistic regression analysis was used to test the hypothesis that health confidence is positively related to self-rated health, controlling for obesity, cigarette smoking and participation in recreational activities.

RESULTS

Veterans who strongly disagreed with the statement that they usually could overcome illnesses on their own were less likely to report good, very good or excellent self-rated health (adjusted odds ratio=0.25).

CONCLUSIONS

Overall self-rated health as measured by a single question proved to be significantly related to behavioural risk factors in this sample of primary care patients, attesting to its validity as an outcome indicator. Furthermore, health confidence was associated with better health. Most primary providers believe that they can, through good communication and providing self-care tools, increase healthy behaviours in their patients. If we are indeed able to increase health confidence in our patients, this study would suggest that self-rated health would improve.

Maternal depressive symptoms and infant health practices among low-income women

OBJECTIVES

To determine the relationships between maternal depressive symptoms and the use of infant health services, parenting practices, and injury-prevention measures.

METHODS

A prospective, community-based survey of women attending Philadelphia public health centers between February 2000 and November 2001 was conducted. Women were surveyed at 3 time points before and after parturition. Depressive symptoms were determined with the Center for Epidemiologic Studies Depression Scale at each time point. We studied 6 outcomes, clustered into 3 categories: 1) infant health service use (adequate well-child care and ever being hospitalized); 2) parenting practices (breastfeeding for > or =1 month and use of corporal punishment); and 3) injury-prevention measures (having a smoke alarm and using the back sleep position).

RESULTS

The sample consisted of 774 largely single (74%), uninsured (63%), African American (65%) women, with a mean age of 24 +/- 6 years and a mean annual income of 8063 dollars. Forty-eight percent of women had depressive symptoms at 1 or 2 time points (ever symptoms) and 12% had depressive symptoms at all points (persistent symptoms). Compared with women who never had depressive symptoms (without symptoms), women with persistent symptoms were nearly 3 times as likely to have their child ever hospitalized (adjusted odds ratio: 2.89; 95% confidence interval: 1.61-5.07) and twice as likely to use corporal punishment (adjusted odds ratio: 1.90; 95% confidence interval: 1.08-3.34). Mothers with persistent depressive symptoms were nearly three-quarters less likely to have smoke alarms in their homes (adjusted odds ratio: 0.28; 95% confidence interval: 0.11-0.70) and one-half as likely to use the back sleep position (adjusted odds ratio: 0.56; 95% confidence interval: 0.35-0.91), compared with women without symptoms. There was no association between maternal depressive symptoms and infant receipt of well-child care or the likelihood of breastfeeding for > or =1 month.

CONCLUSIONS

Maternal depressive symptoms persisting from the prepartum to postpartum periods were associated with increased risks of infant hospitalization and use of corporal punishment and with lower likelihood of having a smoke alarm and using the back sleep position. Additional efforts are needed to identify and evaluate mothers with depressive symptoms to improve the health and safety of young infants.