Trauma Exposure in Anxious Primary Care Patients

The present study examined rates of trauma exposure, clinical characteristics associated with trauma exposure, and the effect of trauma exposure on treatment outcome in a large sample of primary care patients without posttraumatic stress disorder (PTSD). Individuals without PTSD (N = 1263) treated as part of the CALM program (Roy-Byrne et al., 2010) were assessed for presence of trauma exposure. Those with and without trauma exposure were compared on baseline demographic and diagnostic information, symptom severity, and responder status six months after beginning treatment. Trauma-exposed individuals (N = 662, 53%) were more likely to meet diagnostic criteria for Obsessive Compulsive Disorder and had higher levels of somatic symptoms at baseline. Individuals with and without trauma exposure did not differ significantly on severity of anxiety, depression, or mental health functioning at baseline. Trauma exposure did not significantly impact treatment response. Findings suggest that adverse effects of trauma exposure in those without PTSD may include OCD and somatic anxiety symptoms. Treatment did not appear to be adversely impacted by trauma exposure. Thus, although trauma exposure is prevalent in primary care samples, results suggest that treatment of the presenting anxiety disorder is effective irrespective of trauma history.

Incremental benefits and cost of coordinated anxiety learning and management for anxiety treatment in primary care

BACKGROUND

Improving the quality of mental health care requires integrating successful research interventions into 'real-world' practice settings. Coordinated Anxiety Learning and Management (CALM) is a treatment-delivery model for anxiety disorders encountered in primary care. CALM offers cognitive behavioral therapy (CBT), medication, or both; non-expert care managers assisting primary care clinicians with adherence promotion and medication optimization; computer-assisted CBT delivery; and outcome monitoring. This study describes incremental benefits, costs and net benefits of CALM versus usual care (UC).

METHOD

The CALM randomized, controlled effectiveness trial was conducted in 17 primary care clinics in four US cities from 2006 to 2009. Of 1062 eligible patients, 1004 English- or Spanish-speaking patients aged 18-75 years with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) and/or post-traumatic stress disorder (PTSD) with or without major depression were randomized. Anxiety-free days (AFDs), quality-adjusted life years (QALYs) and expenditures for out-patient visits, emergency room (ER) visits, in-patient stays and psychiatric medications were estimated based on blinded telephone assessments at baseline, 6, 12 and 18 months.

RESULTS

Over 18 months, CALM participants, on average, experienced 57.1 more AFDs [95% confidence interval (CI) 31-83] and $245 additional medical expenses (95% CI $-733 to $1223). The mean incremental net benefit (INB) of CALM versus UC was positive when an AFD was valued ≥$4. For QALYs based on the Short-Form Health Survey-12 (SF-12) and the EuroQol EQ-5D, the mean INB was positive at ≥$5000.

CONCLUSIONS

Compared with UC, CALM provides significant benefits with modest increases in health-care expenditures.

Functioning and disability levels in primary care out-patients with one or more anxiety disorders

BACKGROUND

Anxiety disorders are the most prevalent mental health disorders and are associated with substantial disability and reduced well-being. It is unknown whether the relative impact of different anxiety disorders is due to the anxiety disorder itself or to the co-occurrence with other anxiety disorders. This study compared the functional impact of combinations of anxiety disorders in primary care out-patients.

METHOD

A total of 1004 patients with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) or post-traumatic stress disorder (PTSD) provided data on their mental and physical functioning, and disability. Multivariate regressions compared functional levels for patients with different numbers and combinations of disorders.

RESULTS

Of the patients, 42% had one anxiety disorder only, 38% two, 16% three and 3% all four. There were few relative differences in functioning among patients with only one anxiety disorder, although those with SAD were most restricted in their work, social and home activities and those with GAD were the least impaired. Functioning levels tended to deteriorate as co-morbidity increased.

CONCLUSIONS

Of the four anxiety disorders examined, GAD appears to be the least disabling, although they all have more in common than in distinction when it comes to functional impairment. A focus on unique effects of specific anxiety disorders is inadequate, as it fails to address the more pervasive impairment associated with multiple anxiety disorders, which is the modal presentation in primary care.

Development and validation of the revised Cedars-Sinai health-related quality of life for rheumatoid arthritis instrument

OBJECTIVE

To improve accuracy and content coverage of the original 33-item Cedars-Sinai Health-Related Quality of Life for Rheumatoid Arthritis Instrument (CSHQ-RA).

METHODS

A total of 312 RA patients from 55 sites were screened in a 24-week trial. Patients completed an expanded 48-item version of the CSHQ-RA, Medical Outcomes Study Short Form 36 (MOS SF-36), and Stanford Health Assessment Questionnaire (HAQ) Disability Index at 5 visits. The revised CSHQ-RA was created based on response frequencies and distributions, item-to-item correlation, factor and Rasch analysis, and input from experts. Psychometric evaluation included internal consistency, test-retest reliability, convergent and discriminant validity, and responsiveness. Minimum clinically important difference (MCID) was also measured.

RESULTS

Response rates were 93% at baseline and 71% at 12 weeks. Eighty-one percent of respondents at baseline were women, mean +/- SD age was 52 +/- 12 years, and mean +/- SD duration of RA was 10.8 +/- 10.4 years. The revised CSHQ-RA included 36 items measuring 7 domains (4 original and 3 new). All Cronbach's alpha coefficients were >0.8, indicating good internal consistency. Test-retest reliability measured intraclass correlation coefficients, which ranged from 0.86 to 0.95. All 7 domains correlated significantly with the MOS SF-36 and HAQ, indicating good convergent validity. Analysis of variance of disability group scores showed good discriminant validity (P < 0.0001). The MCIDs ranged from 6.2 for social well-being to 14.8 for pain/discomfort.

CONCLUSION

The revised CSHQ-RA was validated using a broader RA patient population. It captures 3 additional domains (social well-being, pain/discomfort, and fatigue), which allow for measuring all important aspects of health-related quality of life.

Validation of a rheumatoid arthritis health-related quality of life instrument, the CSHQ-RA

OBJECTIVE

To test the validity and reliability of a newly developed disease-specific multidimensional quality of life instrument: the Cedars-Sinai Health-Related Quality of Life Instrument (CSHQ-RA).

METHODS

A total of 350 rheumatoid arthritis (RA) patients were asked to complete the CSHQ-RA at 2 time points (4 weeks apart). Patients also completed the Medical Outcomes Study Short Form 36 (SF-36) and the Stanford Health Assessment Questionnaire (HAQ) Disability Index (DI) at the second time point. Construct validity was tested, using Pearson's correlations, by comparing subscale scores on the CSHQ-RA to those obtained from the mental component summary (MCS) and physical component summary (PCS) of the SF-36. HAQ DI scores were used to assess the discriminant validity of the CSHQ-RA. Intraclass correlation coefficients (ICCs) were used to assess test-retest reliability.

RESULTS

Response rates for the first and second survey were 83% (291) and 93% (276), respectively; 84% of respondents were women, and mean age was 57 years. Mean scores +/- SDs on instruments were: HAQ 0.73 +/- 0.69; MCS 49 +/- 12; and PCS 33 +/- 11. Pearson's correlations between the CSHQ-RA subscale scores and the SF-36 scores ranged from 0.55 to 0.76 (P < 0.001). Analysis of variance indicate that scores on the CSHQ-RA discriminated between levels of physical disability as measured by the HAQ (P < 0.001). Test-retest reliability was demonstrated in the instrument's subscale scores (ICC 0.70-0.90).

CONCLUSION

These results support the construct validity, discriminant validity, and reliability of the CSHQ-RA as a measure that captures the impact of RA on patients' health-related quality of life.

Effects of cost sharing on care seeking and health status: results from the Medical Outcomes Study

OBJECTIVES

This study sought to determine the effect of cost sharing on medical care use for acute symptoms and on health status among chronically ill adults.

METHODS

Data from the Medical Outcomes Study were used to compare (1) rates of physician care use for minor and serious symptoms and (2) 6- and 12-month follow-up physical and mental health status among individuals at different levels of cost sharing.

RESULTS

In comparison with a no-copay group, the low- and high-copay groups were less likely to have sought care for minor symptoms, but only the high-copay group had a lower rate of seeking care for serious symptoms. Follow-up physical and mental health status scores were similar among the 3 copay groups.

CONCLUSIONS

In a chronically ill population, cost sharing reduced the use of care for both minor and serious symptoms. Although no differences in self-reported health status were observed, health plans featuring cost sharing need careful monitoring for potential adverse health effects because of their propensity to reduce use of care that is considered necessary and appropriate.

The Quality Improvement for Depression collaboration: general analytic strategies for a coordinated study of quality improvement in depression care

It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States

BACKGROUND

There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders.

SUBJECTS AND METHODS

We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses.

RESULTS

Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder.

CONCLUSIONS

Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Long-term effectiveness of disseminating quality improvement for depression in primary care

BACKGROUND

This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC).

METHODS

The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years.

RESULTS

For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively).

CONCLUSIONS

While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries

OBJECTIVE

The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography.

MATERIALS AND METHODS

The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared.

RESULTS

Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800.

CONCLUSION

Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.

Psychological distress, unmet need, and barriers to mental health care for women

Using data from the Commonwealth Fund 1998 Survey of Women's Health, this article describes the characteristics of women in need of mental health services for depression or anxiety, and identifies factors related to why women do not get needed care. Depressive/anxiety symptoms are common and access to care for psychological distress remains a problem for many women, especially for minorities, those with less education, and those without a usual source of health care. Sources of unmet need include patient factors, clinician factors, and characteristics of the health system, such as costs of mental health care.

Are better ratings of the patient-provider relationship associated with higher quality care for depression?

BACKGROUND

The interpersonal patient-provider relationship (PPR) is an essential part of health care quality, particularly for patients with depression, yet little is known neither about how to measure this relationship nor about its association with quality of care.

OBJECTIVES

To evaluate properties of patient rating measures, understand the relation between 2 types of ratings, and determine the association of ratings with quality depression care.

SETTING AND PARTICIPANTS

1,104 patients with current depressive symptoms and lifetime or 12-month disorder identified through screening 27,332 consecutive primary care visitors in 6 managed care organizations participating in Partners in Care (PIC).

DESIGN

Cross-sectional analysis of 18-month data (collected in 1998) after the start of PIC depression quality improvement (QI) interventions (in which clinics were randomized to 1 of 2 QI interventions or usual care).

MEASURES

Patient ratings of the interpersonal relationship with the primary care provider and satisfaction with health care, and quality of depression care indicators.

ANALYSIS

Factor analysis and multitrait scaling to evaluate the psychometric properties of multiitem constructs and analysis of covariance to evaluate associations between patient ratings and quality.

RESULTS

Patient ratings had high internal consistency and met criteria for discriminant validity tapping unique aspects of care. Patients receiving quality care, especially for medication use, had significantly higher ratings of the interpersonal relationship (by 22% to 27% of a SD) and were more satisfied (by 26% to 34% of a SD) than patients who did not receive quality care.

CONCLUSIONS

Ratings of the interpersonal relationship and satisfaction measure distinct aspects of care and are positively associated with quality care for depression.

Utility elicitation using single-item questions compared with a computerized interview

BACKGROUND

The use of a simpler procedure for the measurement of utilities could affect primarily the variance or both the mean and the variance of measurements. In the former case, simpler methods would be useful for population studies of preferences; however, in the latter, their use for such studies might be problematic.

PURPOSE

The purpose of this study was to compare the results of utility elicitation using single-item questions to computer elicitation using the Ping-Pong search procedure.

METHODS

In a convenience sample of 149 primary care patients with symptoms of depression, the authors measured and compared standard gamble (SG) utilities elicited using a single-item "open question" to SG elicitations performed using a computerized interview procedure. Elicitations were performed 1 to 2 weeks apart to minimize memory effects.

RESULTS

More than 90% of persons with utilities of 1.0 to the single-item standard gamble had utilities of less than 1.0 on the computer SG instrument. Consistent with this finding, the mean utilities were lower in computer interviews (0.80 vs. 0.90; P < 0.0001 for differences). Within subjects, utility measures had only a fair degree of correlation (r = 0.54).

CONCLUSIONS

Use of single-item questions to elicit utilities resulted in less precise estimates of utilities that were upwardly biased relative to those elicited using a more complex search procedure.

Are barriers to mental health and substance abuse care still rising?

This study estimates unmet need and barriers to alcohol, drug, and mental health (ADM) services in 1997 to 1998 using data from a national household survey (n = 9,585). In 1997 to 1998, 10.9% of the population perceived a need for ADM services, with 15% obtaining no treatment and 11% experiencing delays or obtaining less care than needed. The rate of unmet need due to no treatment is similar to earlier studies, but the group experiencing delays/less care is almost as large. This finding emphasizes the importance of defining access to care more broadly by including timeliness and intensity of care. Economic barriers are highest for the uninsured, but also are high among the privately insured. Individuals with unmet need are significantly more likely to use complementary and alternative medicine (CAM). Those with no conventional mental health care rely on self-administered treatment, while those with delayed/insufficient conventional care use CAM providers and self-administered treatment.

The quality of care for depressive and anxiety disorders in the United States

BACKGROUND

Depressive and anxiety disorders are prevalent and cause substantial morbidity. While effective treatments exist, little is known about the quality of care for these disorders nationally. We estimated the rate of appropriate treatment among the US population with these disorders, and the effect of insurance, provider type, and individual characteristics on receipt of appropriate care.

METHODS

Data are from a cross-sectional telephone survey conducted during 1997 and 1998 with a national sample. Respondents consisted of 1636 adults with a probable 12-month depressive or anxiety disorder as determined by brief diagnostic interview. Appropriate treatment was defined as present if the respondent had used medication or counseling that was consistent with treatment guidelines.

RESULTS

During a 1-year period, 83% of adults with a probable depressive or anxiety disorder saw a health care provider (95% confidence interval [CI], 81%-85%) and 30% received some appropriate treatment (95% CI, 28%-33%). Most visited primary care providers only. Appropriate care was received by 19% in this group (95% CI, 16%-23%) and by 90% of individuals visiting mental health specialists (95% CI, 85%-94%). Appropriate treatment was less likely for men and those who were black, less educated, or younger than 30 or older than 59 years (range, 19-97 years). Insurance and income had no effect on receipt of appropriate care.

CONCLUSIONS

It is possible to evaluate mental health care quality on a national basis. Most adults with a probable depressive or anxiety disorder do not receive appropriate care for their disorder. While this holds across diverse groups, appropriate care is less common in certain demographic subgroups.

Summed-score linking using item response theory: application to depression measurement

An item response theory (IRT) approach to test linking based on summed scores is presented and demonstrated by calibrating a modified 23-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) to the standard 20-item CES-D. Data are from the Depression Patient Outcomes Research Team, II, which used a modified CES-D to measure risk for depression. Responses (N = 1,120) to items on both the original and modified versions were calibrated simultaneously using F. Samejima's (1969, 1997) graded IRT model. The 2 scales were linked on the basis of derived summed-score-to-IRT-score translation tables. The established cut score of 16 on the standard CES-D corresponded most closely to a summed score of 20 on the modified version. The IRT summed-score approach to test linking is a straightforward, valid, and practical method that can be applied in a variety of situations.

Summed-score linking using item response theory: application to depression measurement

An item response theory (IRT) approach to test linking based on summed scores is presented and demonstrated by calibrating a modified 23-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) to the standard 20-item CES-D. Data are from the Depression Patient Outcomes Research Team, II, which used a modified CES-D to measure risk for depression. Responses (N = 1,120) to items on both the original and modified versions were calibrated simultaneously using F. Samejima's (1969, 1997) graded IRT model. The 2 scales were linked on the basis of derived summed-score-to-IRT-score translation tables. The established cut score of 16 on the standard CES-D corresponded most closely to a summed score of 20 on the modified version. The IRT summed-score approach to test linking is a straightforward, valid, and practical method that can be applied in a variety of situations.

Treatment preferences among depressed primary care patients

OBJECTIVE

To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

DESIGN

Patient questionnaires and interviews.

SETTING

Forty-six primary care clinics in 7 geographic regions of the United States.

PARTICIPANTS

One thousand one hundred eighty-seven English- and Spanish-speaking primary care patients with current depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P =.001) and had greater knowledge about antidepressant medication ( OR, 2.6; 95% CI, 1.6 to 4.4; P

CONCLUSIONS

Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

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Key Words

• depression
• primary care
• patient preferences
• treatment preferences

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MESH Headings

• Adolescent
• Adult
• Depression/classification
• Depression/diagnosis
• Depression/therapy
• Female
• Humans
• Interviews as Topic
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Satisfaction
• Primary Health Care
• Socioeconomic Factors
• Surveys and Questionnaires

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Grants

• R01 HS008349 AHRQ HHS
• K12 MH00990-01-01 NIMH NIH HHS
• HS08349-02 AHRQ HHS

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Coping, conflictual social interactions, social support, and mood among HIV-infected persons. HCSUS Consortium

This study considers the interrelationships among coping, conflictual social interactions, and social support, as well as their combined associations with positive and negative mood. Research has shown that each of these variables affects adjustment to stressful circumstances. Few studies, however, examine this full set of variables simultaneously. One hundred forty HIV-infected persons completed a questionnaire containing measures of coping, social support, conflictual social interactions, and positive and negative mood. Factor analyses showed that perceived social support and conflictual social interactions formed separate factors and were not strongly related. Compared to perceived social support, social conflict was more strongly related to coping behaviors, especially to social isolation, anger, and wishful thinking. Conflictual social interactions were more strongly related to negative mood than was perceived social support. Coping by withdrawing socially was significantly related to less positive and greater negative mood. The findings point to the importance of simultaneously considering coping, supportive relationships, and conflictual relationships in studies of adjustment to chronic illness. In particular, a dynamic may occur in which conflictual social interactions and social isolation aggravate each other and result in escalating psychological distress.

Estimation of utilities for the effects of depression from the SF-12

BACKGROUND

Utilities for health conditions, including major depressive disorder, have a theoretical relationship to health-related quality of life (HRQOL). Because of the complexity of utility measurement and the existence of large numbers of completed studies with HRQOL data but not utility data, it would be desirable to be able to estimate utilities from measurements of HRQOL.

OBJECTIVE

The objective of this study was to estimate utility for remission in major depression by use of information on associated variation in Short Form 12 (SF-12) scores.

DESIGN

A mapping function for SF-12 scores (based on a 6-health-state model with patient-weighted preferences) was applied to longitudinal data from a large naturalistic study to estimate changes in utilities.

SUBJECTS

Preference ratings for states were performed in a convenience sample of depressed primary care patients (n = 140). Outcomes were evaluated in patients in the Course of Depression Study (n = 295) with a DSM III diagnosis of depression at the onset of the study.

MEASURES

From clinical interview data, differences in utilities and global physical and mental health-related quality of life at 1- and 2-year follow-up were compared for patients who did and did not experience remission as determined by the Course of Depression Interview.

RESULTS

Remission of depression resulted in health status improvement, as measured by the SF-12, equivalent to a gain of 0.11 quality-adjusted life-years over 2 years.

CONCLUSIONS

Utilities for changes in health status, associated with a clinical change in depression, can be modeled from the SF-12 scales, which results in utilities within the range of estimates described in the literature.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study

PURPOSE

To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life.

SUBJECTS AND METHODS

We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale.

RESULTS

Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health.

CONCLUSIONS

There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.

An agenda for research into uterine artery embolization: results of an expert panel conference

PURPOSE

To develop a research agenda for uterine artery embolization (UAE) for the treatment of symptomatic leiomyomata.

MATERIALS AND METHODS

An expert panel was convened to examine data and develop a consensus for UAE research. Panelists reviewed data from articles about UAE and data on hysterectomy and myomectomy, which were abstracted into evidence tables. A modified Delphi process was used to rate the importance of measuring specific outcomes and a nominal group process was used to develop ideas for study designs.

RESULTS

Panelists agreed that UAE studies would have to examine certain key measures. Outcomes identified as either "important to measure" or "essential to measure" were death, reoperation, operative injury, menorrhagia, premature menopause, recurrence of myomata, and satisfaction. The panel proposed four areas for research: randomized trial, prospective registry, disease-specific quality-of-life instrument, and cost analysis.

CONCLUSIONS

Symptomatic uterine leiomyomata are a major health concern for women. New techniques that promise to provide symptom relief deserve careful consideration. Traditionally, surgical procedures have been poorly studied until after they have been widely used. If the process described in this article can guide the acquisition of knowledge in this field, it may serve as a model for evaluating other new technologies before they become widely adopted.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection

OBJECTIVE

Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV.

METHOD

The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study.

RESULTS

HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder.

CONCLUSIONS

Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices

BACKGROUND

Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions.

METHODS

Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with self-report. Quality of life was assessed by the 12-Item Short-Form Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions.

RESULTS

Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P<.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P<.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility.

CONCLUSIONS

Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority.

Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma

PURPOSE

To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma.

MATERIALS AND METHODS

Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST).

RESULTS

A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum.

CONCLUSION

Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.

Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment

BACKGROUND

Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome.

METHOD

Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications.

RESULTS

Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p < .01), more utilization of emergency room and medical provider visits (p < .01), and more mental health visits (p < .05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy.

CONCLUSION

These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.

Relationship between age and patients' current health state preferences

This article explores age differences in preferences for current health states, which is one way to measure trade-offs between "quantity of life" and the "quality" of those health states. Data are from 17,707 adult outpatients visiting 46 primary care, managed care practices. Patient preferences (utility) for their current health were assessed by standard gamble and time trade-off methods. Although older primary care patients' utility measurements for their current health were lower than other patient groups, most of the difference in value measurements was attributable to differences in health. Health providers should take care to assess individual preferences from all patients regardless of age.

What outcomes matter to patients?

OBJECTIVE

This study estimates the relative value to patients of physical, mental, and social health when making treatment decisions. Despite recommendations to use patient preferences to guide treatment decisions, little is known about how patients value different dimensions of their health status.

DESIGN

Cross-sectional data from quasi-experimental, prospective study.

SETTING

Forty-six primary care clinics in managed care organizations in California, Texas, Minnesota, Maryland, and Colorado.

PATIENTS

Consecutive adult outpatients (n = 16,689) visiting primary care providers.

MEASUREMENTS AND MAIN RESULTS

Medical Outcomes Study 12-Item Short Form (SF-12) health-related quality of life and patient preferences for their current health status, as assessed by standard gamble and time trade-off utility methods, were measured. Only 5% of the variance in standard gamble and time trade-off was explained by the SF-12. Within the SF-12, physical health contributes substantially to patient preferences (35%-55% of the relative variance explained); however, patients also place a high value on their mental health (29%-42%) and on social health (16%-23%). The contribution of mental health to preferences is stronger in patients with chronic conditions.

CONCLUSIONS

Patient preferences, which should be driving treatment decisions, are related to mental and social health nearly as much as they are to physical health. Thus, medical practice should strive to balance concerns for all three health domains in making treatment decisions, and health care resources should target medical treatments that improve mental and social health outcomes.

Development of a brief diagnostic screen for panic disorder in primary care

OBJECTIVE

The purpose of this study was to determine the utility of a brief screening tool for panic disorder in the primary care setting.

METHODS

A total of 1476 primary care outpatients in three primary care medical clinics on the West Coast of the United States were studied. Patients completed a brief self-report measure, the five-item Autonomic Nervous System Questionnaire (ANS), while in the waiting room. The presence of DSM-IV panic disorder was subsequently determined in groups of "screen-positive" and "screen-negative" subjects using the Composite International Diagnostic Interview. A subset of patients (N = 511) also completed the 21-item Beck Anxiety Inventory. Indices of diagnostic utility were calculated using receiving operating characteristic analyses to guide the selection of optimal cutoff levels.

RESULTS

The two-question version of the ANS had excellent sensitivity (range = 0.94-1.00 across the three clinic sites) and negative predictive value (0.94-1.00) but low specificity (0.25-0.59) and positive predictive value (range 0.18-0.40). The three- and five-question versions of the ANS had only modestly improved specificity, and this was achieved at the cost of reduced sensitivity and increased respondent burden to complete the questionnaire. The 21-item Beck Anxiety Inventory had maximal clinical utility at a cutoff level of > or =20, but sensitivity was lower than desirable for a screening instrument (0.67).

CONCLUSIONS

The two-question version of the ANS shows promise as a screening instrument for panic disorder in the primary care setting.

Empirically defined health states for depression from the SF-12

OBJECTIVE

To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression.

DATA SOURCES

From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients.

METHODOLOGY

We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis.

PRINCIPAL FINDINGS

We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time.

CONCLUSIONS

Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention

OBJECTIVE

To evaluate a case management/home visitation intervention to improve access to and utilization of well-child care (WCC) visits.

STUDY DESIGN

Randomized, controlled trial with baseline and follow-up interview surveys. Mothers and infants in the intervention group were assigned to a case manager who made at least four home visits during the infant's first year of life. In addition, the case managers contacted clients by telephone and mail to see if they had kept their WCC appointments and to follow up on other issues. SAMPLE AND DATA COLLECTION: A population-based random sample of African-American mothers of newborns from South Central Los Angeles: 185 mothers in the intervention group and 180 in the control group completed both interview surveys. The principal outcome variable was number of WCC visits. Additional outcome variables included the child's type of insurance, the number of months with insurance coverage during the first year of life, age when first enrolled in Medi-Cal, age at the first WCC visit, usual source of WCC, travel time to the usual source of care, whether the child had a regular provider, and whether the child ever needed care but did not get it.

RESULTS

There was little change in the overall distribution of number of WCC visits during the first year of life. Comparisons of the cumulative numbers of visits for each possible cutoff showed that children in the intervention group were more likely than children in the control group to have at least four visits (81% vs 70%). Because this split was identified empirically rather than through an antecedent hypothesis, we conducted a Smirnov test to account for multiple comparisons. This test showed a reduced level of significance. Other outcome variables did not show significant differences for the control and intervention groups.

CONCLUSIONS

In light of the high expense of this intervention, our evaluation shows that our moderate-intensity case management and home visitation program is not an effective way to increase the number of WCC visits.

Maternal acculturation and childhood immunization levels among children in Latino families in Los Angeles

OBJECTIVES

This study examined the relationship between acculturation levels of poor Latina women in Los Angeles and their children's immunization status. Receipt of three doses of diphtheriatetanus-pertussis vaccine and two doses of oral polio vaccine by the age of 12 months was considered adequate immunization.

METHODS

Household interviews were conducted in East Los Angeles and South Central Los Angeles with mothers (n = 688) about one randomly selected child aged 12 to 36 months.

RESULTS

One fourth of the children were inadequately immunized. Less-acculturated mothers were more likely to have adequately immunized children. Inadequate prenatal care, absence of close family members, the child's birth position as other than firstborn, and more than one family relocation during the child's lifetime were associated with inadequate immunization.

CONCLUSIONS

The findings challenge the notion that children of recent immigrants bear a higher risk of underimmunization.

Treatment typically provided for comorbid anxiety disorders

OBJECTIVE

To study whether the extent and type of treatment for comorbid anxiety disorders varies for patients with depression, hypertension, diabetes, and heart disease treated by general medical clinicians.

METHODS

Data are from 2189 general medical patients with and without comorbid anxiety disorders in the Medical Outcomes Study. Treatment data were based on clinician reports of counseling provided during a visit and patient reports of recent medication use.

RESULTS

Patients with comorbid anxiety disorders were more likely to receive treatments for anxiety disorders than those without anxiety disorders. Among those with anxiety disorders, the use of psychosocial counseling and psychotropic medication was greater for patients with depression than for patients without depression who had chronic medical conditions. Minor tranquilizers were used more commonly than antidepressants, regardless of the type of comorbid condition. Among patients with anxiety disorders, those visiting medical subspecialists were more likely to use minor tranquilizers than those visiting family practitioners or internists. Patients of family physicians with chronic medical conditions (but not with depression) were less likely than similar patients of internists to use minor tranquilizers whether or not anxiety disorders were present.

CONCLUSIONS

Anxiety disorders co-occurring with another disease (medical illness or depression) increases the likelihood of counseling and the use of psychotropic medication in the general medical sector. Patients with a chronic medical illness with or without comorbid anxiety disorders visiting family physicians are less likely to use minor tranquilizers than those visiting subspecialists or internists.

Course of depression in patients with comorbid anxiety disorders

This study examined the extent to which the presence of comorbid anxiety disorder affected the course of depression. 650 depressed outpatients visiting general medical clinicians and mental health specialists were followed for 1 or 2 years. All types of anxiety increased the probability of a new depressive episode among patients with subthreshold depression. Co-occurring panic and phobia decreased the likelihood of remission. The initial number of depressive symptoms was greatest among depressed patients with comorbid anxiety and this relatively higher level persisted over two years. The findings emphasize the poor clinical prognosis associated with comorbid anxiety disorder.

Measuring health outcomes for depression

In this article, we describe the clinical and health-related quality of life outcome measures for depressed patients in the Medical Outcomes Study, a 4-year longitudinal study that started in 1986. We prioritize the measures in terms of importance, consider how they can be improved in future studies, and discuss how they should be used in more applied evaluations, such as studies by managed care companies and group practices. We emphasize the importance of identifying appropriate evaluation questions and selecting study designs and patient populations that permit meaningful answers about evaluating outcomes of care for depression. Although the outcome measures described here may be a useful starting point, they will need to be combined with carefully constructed measures of process of care as well, so that links between the two can be maximized.

Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers

BACKGROUND

The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and policy interest, in part owing to the evidence that anxiety disorders themselves are associated with morbidity. However, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples.

METHODS

A 2-year observational study of 875 adult patients with hypertension, diabetes, heart disease, and current depressive disorder or subthreshold depression receiving care from general medical providers was conducted. The unique effect of any comorbid anxiety disorder on functioning and well-being (determined with the use of the 36-Item Short-Form Health Survey [SF-36]) was estimated, as well as the differential impact at baseline, 2-year follow-up, and change over time, of any comorbid anxiety disorder for patients with chronic medical conditions or depression.

RESULTS

Patients with comorbid anxiety who received general medical care had lower levels of functioning and well-being than those without comorbid anxiety. These differences were most pronounced in mental health-related quality-of-life measures and when anxiety was comorbid with chronic medical conditions rather than with depression. Hypertensive and diabetic patients with comorbid anxiety were as debilitated as patients with depression or heart disease, and this low health-related quality of life persisted over time. Comorbid anxiety had less of an effect on patients with heart disease who already had a low health-related quality of life.

CONCLUSION

The finding of substantial differences in the quality of life between hypertensive and diabetic patients with and without comorbid anxiety disorder highlights the clinical and societal importance of identifying comorbid anxiety in these patients.

Functioning and well-being of patients with panic disorder

OBJECTIVE

The authors compared the health-related quality of life of patients with panic disorder to that of patients with other major chronic medical and psychiatric conditions.

METHOD

The physical and mental health of a group of 433 patients with current panic disorder and 9,839 outpatients with psychiatric or medical disorders were assessed with the 20- and 36-item short-form surveys of the Medical Outcomes Study. After controlling for other disease conditions, demographics, and study site, the authors used multiple regression methods to estimate health-related quality of life levels for panic disorder patients and patients with hypertension, diabetes, heart disease, arthritis, chronic lung problems, and major depression.

RESULTS

Patients with panic disorder had levels of mental health and role functioning that were substantially lower than those of patients with other major chronic medical illnesses but were higher than or comparable to those of patients with depression. However, their physical functioning levels and perceptions of current health were more like those of patients with hypertension and were similar to general population norms.

CONCLUSIONS

Panic disorder is a serious societal health problem with large consequences, and it affects primarily psychological and role domains.

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE

To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions.

DESIGN

Observational study.

SETTING

Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes.

PATIENTS

Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression.

MEASURES

Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed).

METHODS

Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers.

RESULTS

Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%).

CONCLUSION

Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.

Personal and psychosocial risk factors for physical and mental health outcomes and course of depression among depressed patients

This article focuses on personal and psychosocial factors to identify those that predict change in functioning and well-being and clinical course of depression in depressed outpatients over time. Data from 604 depressed patients in The Medical Outcomes Study showed improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles. Better clinical course of depression was associated with patients who had high levels of social support, who had more active and less avoidant coping styles, who were physically active, and who had fewer comorbid chronic conditions. Findings provide some guidance as to what can be done to improve depressed patients' levels of physical and mental health and affect the clinical course of depression.

Personal and psychosocial risk factors for physical and mental health outcomes and course of depression among depressed patients

This article focuses on personal and psychosocial factors to identify those that predict change in functioning and well-being and clinical course of depression in depressed outpatients over time. Data from 604 depressed patients in The Medical Outcomes Study showed improvements in measures of functioning and well-being associated with patients who were employed, drank less alcohol, and had active coping styles. Better clinical course of depression was associated with patients who had high levels of social support, who had more active and less avoidant coping styles, who were physically active, and who had fewer comorbid chronic conditions. Findings provide some guidance as to what can be done to improve depressed patients' levels of physical and mental health and affect the clinical course of depression.

Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses

BACKGROUND

Cross-sectional studies have found that depression is uniquely associated with limitations in well-being and functioning that were equal to or greater than those of chronic general medical conditions such as diabetes and arthritis. However, whether these relative limitations persist over time is not known.

METHODS

We conducted a 2-year observational study of 1790 adult outpatients with depression, diabetes, hypertension, recent myocardial infarction, and/or congestive heart failure. Change in functional status and well-being was compared for depressed patients vs patients with chronic general medical illnesses, controlling statistically for medical comorbidity, sociodemographics, system, and specialty of care.

RESULTS

Over 2 years of follow-up, limitations in functioning and well-being improved somewhat for depressed patients; even so, at the end of 2 years, these limitations were similar to or worse than those attributed to chronic medical illnesses. Similar patterns were observed for depressed patients in the mental health specialty sector and those in the general medical sector, but the patients in the mental health specialty sector improved more. More severely depressed patients improved more in functioning, but even initially depressed patients without depressive disorder had substantial persistent limitations.

CONCLUSION

Depressed patients have substantial and long-lasting decrements in multiple domains of functioning and well-being that equal or exceed those of patients with chronic medical illnesses.

Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients

OBJECTIVE

The authors examined the clinical significance of depressive symptoms below the threshold for depressive disorder in outpatient samples.

METHOD

The subjects were 775 adult patients with current depressive disorder, 1,420 patients with subthreshold depression, and 1,767 hypertensive patients with and without depression, all of whom were visiting the offices of mental health specialists and general medical care providers in three U.S. cities. Data on demographic characteristics, severity of depression, extent of psychiatric and medical comorbidity, family psychiatric history, and treatment history for the patients with depressive disorder and those with subthreshold depression were compared.

RESULTS

The percentage of patients with subthreshold depression who had a family history of depression (41%) was nearly as high as that of the patients with depressive disorder (59%). The two groups of patients had similar levels of medical and psychiatric comorbidity except for anxiety disorders, which were greater among the patients with depressive disorder. Among the hypertensive patients in the general medical sector, those with subthreshold depression were more similar to those with depressive disorder than to the nondepressed hypertensive patients. Treatment rates were considerably lower for patients with subthreshold depression than for patients with depressive disorder in the general medical sector, but they were similar in the mental health specialty sector.

CONCLUSIONS

In these outpatients, subthreshold depression appeared to be a variant of affective disorder and was treated as such in the mental health specialty sector but not in the general medical sector. The findings emphasize the importance of treatment outcome studies of patients with subthreshold depression.

Four-year cross-lagged associations between physical and mental health in the Medical Outcomes Study

This article provides an application of structural equation modeling to the evaluation of cross-lagged panel models. Self-reports of physical and mental health at 3 different time points spanning a 4-year interval were analyzed to illustrate the cross-lagged analysis methodology. Data were collected from a sample of 856 patients with hypertension, diabetes, heart disease, or depression (or any combination of these) participating in the Medical Outcomes Study. Cross-lagged analyses of physical and mental health constructs revealed substantial stability effects across time. A structural model with standard effects revealed positive effects of physical health on mental health but negative (suppression) effects of mental health on physical health. The effects of mental health on physical health became nonsignificant when the model was revised by adding nonstandard effects (direct effects of measured variable residuals on latent variables). Recommendations for structural equation modeling of cross-lagged panel data are provided.

The impact of patient adherence on health outcomes for patients with chronic disease in the Medical Outcomes Study

The association between adherence to medical recommendations and health outcomes (physical, role, and social functioning, energy/fatigue, pain, emotional well-being, general health perceptions, diastolic blood pressure, and glycohemoglobin) was examined in a 4-year longitudinal, observational study of 2125 adult patients with chronic medical conditions (hypertension, diabetes, recent myocardial infarction, congestive heart failure) and/or depression. Change score models were evaluated, controlling for disease and comorbidity. Patient adherence was associated minimally with improvement in health outcomes in this study. Only 11 of 132 comparisons showed statistically significant positive effects of adherence on health outcomes. We conclude that the relationship between adherence and health outcomes is much more complex than has often been assumed.

Four-year cross-lagged associations between physical and mental health in the Medical Outcomes Study

This article provides an application of structural equation modeling to the evaluation of cross-lagged panel models. Self-reports of physical and mental health at 3 different time points spanning a 4-year interval were analyzed to illustrate the cross-lagged analysis methodology. Data were collected from a sample of 856 patients with hypertension, diabetes, heart disease, or depression (or any combination of these) participating in the Medical Outcomes Study. Cross-lagged analyses of physical and mental health constructs revealed substantial stability effects across time. A structural model with standard effects revealed positive effects of physical health on mental health but negative (suppression) effects of mental health on physical health. The effects of mental health on physical health became nonsignificant when the model was revised by adding nonstandard effects (direct effects of measured variable residuals on latent variables). Recommendations for structural equation modeling of cross-lagged panel data are provided.

Do depressed patients in different treatment settings have different levels of well-being and functioning?

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in health maintenance organizations, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being "burden" but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider.

The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups

The widespread use of standardized health surveys is predicated on the largely untested assumption that scales constructed from those surveys will satisfy minimum psychometric requirements across diverse population groups. Data from the Medical Outcomes Study (MOS) were used to evaluate data completeness and quality, test scaling assumptions, and estimate internal-consistency reliability for the eight scales constructed from the MOS SF-36 Health Survey. Analyses were conducted among 3,445 patients and were replicated across 24 subgroups differing in sociodemographic characteristics, diagnosis, and disease severity. For each scale, item-completion rates were high across all groups (88% to 95%), but tended to be somewhat lower among the elderly, those with less than a high school education, and those in poverty. On average, surveys were complete enough to compute scales scores for more than 96% of the sample. Across patient groups, all scales passed tests for item-internal consistency (97% passed) and item-discriminant validity (92% passed). Reliability coefficients ranged from a low of 0.65 to a high of 0.94 across scales (median = 0.85) and varied somewhat across patient subgroups. Floor effects were negligible except for the two role disability scales. Noteworthy ceiling effects were observed for both role disability scales and the social functioning scale. These findings support the use of the SF-36 survey across the diverse populations studied and identify population groups in which use of standardized health status measures may or may not be problematic.

Prevalence of comorbid alcohol disorder and consumption in medically ill and depressed patients

OBJECTIVE

To estimate the extent to which alcohol disorder co-occurs in patients with major medical and psychiatric conditions.

DESIGN

Observational study.

SETTING

Offices of general medical providers and mental health specialists in three US cities.

PATIENTS

Adult patients (N = 2296) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current depressive disorder or subthreshold depressive symptoms.

MAIN OUTCOME MEASURES

Current and lifetime alcohol disorder, alcohol consumption, current problem drinking, perceived need for help for alcohol or other drug problems, and unmet need.

METHODS

Comparisons of the prevalence of alcohol comorbidity in medically ill nondepressed patients of general medical providers and in depressed patients of both provider types.

RESULTS

Patients with chronic medical problems or depression had similar levels of lifetime alcohol disorder (14% to 19%) and current alcohol problems (18% to 29%), but depressed patients were more likely to report needing help for problems with alcohol or drugs. Current alcohol disorder was more prevalent among depressed patients in mental health specialty practices than in general medical practices. Many patients who perceived a need for care for alcohol and other drug problems reported that this need was unmet (37% to 84%).

CONCLUSIONS

Clinicians who treat patients with major medical and psychiatric conditions need to be prepared to identify and treat comorbid alcohol disorder.

The RAND 36-Item Health Survey 1.0

Recently, Ware and Sherbourne published a new short-form health survey, the MOS 36-Item Short-Form Health Survey (SF-36), consisting of 36 items included in long-form measures developed for the Medical Outcomes Study. The SF-36 taps eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. The SF-36 items and scoring rules are distributed by MOS Trust, Inc. Strict adherence to item wording and scoring recommendations is required in order to use the SF-36 trademark. The RAND 36-Item Health Survey 1.0 (distributed by RAND) includes the same items as those in the SF-36, but the recommended scoring algorithm is somewhat different from that of the SF-36. Scoring differences are discussed here and new T-scores are presented for the 8 multi-item scales and two factor analytically-derived physical and mental health composite scores.