Minor depression in primary care.

Minor depression is defined as a mood disturbance of at least 2 weeks' duration, with between two and five symptoms of depression, including depressed mood, diminished interest, weight change, sleep disturbance, psychomotor changes, fatigue, feelings of worthlessness, poor concentration, and recurrent thoughts of death. Patients with this condition may have fewer vegetative symptoms (appetite, diurnal mood variation) and more subjective symptoms (self-blame, worry, irritability, lethargy). Minor depressive disorder is more prevalent in primary care than major depressive disorder. Failure to adequately treat this condition may have far-reaching impact on the health, functional status, quality of life, and cost of care for patients who have it. The notion that minor depression requires minor treatment is misleading. Cognitive-behavioral modes of therapy and selective serotonin reuptake inhibitor antidepressants have demonstrated efficacy for primary care patients who have minor depression.

From policy to practice: physicians' views on OBRA and mental health resources in long-term care.

OBJECTIVES: The purpose of this national survey was to seek to clarify physician beliefs about nursing home mental health needs, understand the perceived effectiveness of OBRA legislation, determine physician exposure to OBRA PASARR Level II assessments, and understand the current role of community mental health interventions in the nursing home. DESIGN: A self-administered questionnaire. SETTING: Surveyed physicians were nursing home medical directors and/or attending physicians. PARTICIPANTS: The overall response rate for the 1000 physicians surveyed nationally, was 62% (n = 620). Fifty-nine percent (n = 361) of all responders were family physicians, and 41% (n = 250) were general internists. MEASUREMENTS/RESULTS: Only 48% (n = 291) of all respondents ever saw the recommendations from their patient's OBRA PASARR Level II assessment screening. Approximately one-third of all respondents viewed each discipline's recommendations as "very" or "somewhat" helpful. Thirty-seven percent (n = 228) of respondents viewed OBRA's psychotropic guidelines as only somewhat helpful. More than two-thirds (n = 412) believed OBRA regulations had not improved access to mental health care for their nursing home patients. CONCLUSIONS: This survey demonstrated that OBRA PASARR Level II assessments are not being viewed or valued by many physicians. In nursing homes, limited access to community mental health staff and psychiatric input may leave primary care physicians treating difficult behavioral problems themselves. Collaborating on helpful mental health interventions for nursing home patients is an ongoing critical issue in long-term care.

Practice guidelines and late-life depression assessment in long-term care.

To determine how well nursing home physicians believe they can detect and treat depression, we conducted a national survey, eliciting a 63% response rate. More than 75% of respondents believed they detected and treated depression well. Excellent depression training (vs "good," "fair," "poor/none") was associated with better self-reported recognition (odds ratio [OR] 14.25; 95% confidence interval [CI] 1.81, 111.93) and treatment skills (OR 6.72; 95% CI 1. 91, 23.64). Screening tool use predicted greater self-assessed detection (OR 1.89; 95% CI 0.92, 3.87) and treatment competency (OR 2.00; 95% CI 1.14, 3.50). Practice guideline awareness was associated with greater self-reported treatment competency (OR 2.47; 95% CI 1.56, 3.91).

Late-life depression in primary care: where do we go from here?

One quarter of elderly patients in the primary care physician's office experience serious depressive symptoms. Despite efforts over the past 20 years to increase detection of late-life depression in primary care settings, patient outcomes have not improved. Undertreatment remains seriously problematic. Current efforts to improve recognition have included the development of depression practice guidelines, Depression Awareness Recognition and Treatment (D/ART) program, educational programs, and rudimentary outcomes measures. Screening tools for depression, such as the Geriatric Depression Scale, the Center for Epidemiologic Studies--Depressed, and Cornell Scale for Depression in Dementia, have also been developed to help clinicians screen for depressive symptoms in both ambulatory and inpatient settings. However, to improve clinical outcomes, increased research efforts should focus upon physicians' attitudes and practice patterns, effective treatments for minor depression, and effective ways to assess patients' perceptions of depression, as well as ways to identify age-specific barriers to treatment adherence. In addition, incorporating valid outcome measures into the primary care clinical setting will be crucial to measure the impact of our treatments.

Mental health services in managed care: quality questions remain.

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.

A survey of state financing of psychiatry residency programs.

With upcoming cuts in graduate medical education funding, it is likely that many psychiatry residencies will be searching for new sources of revenue. State funding of residency programs is one possible avenue. The authors surveyed all Accreditation Council for Graduate Medical Education-accredited psychiatry residency programs to assess the present dimensions of state funding. Some programs in both publicly funded and private settings receive large proportions of their budgets from the state. Service commitments are common. State support of psychiatry residency education is currently an important source of funding and could become even more important in the near future.

Anxiety disorders in elderly patients.

BACKGROUND: Late-life anxiety disorders, commonly seen in primary care settings, can coexist with other medical and psychiatric illnesses. A variety of effective treatment options is available for these patients. METHODS: MEDLINE was searched for articles published from 1970 to 1996 using the key words "anxiety," "elderly," "aged," "geriatric," "panic," "obsessive-compulsive," "phobia," and "generalized anxiety disorder." Studies of patients older than 65 years were reviewed. RESULTS: Generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder are the most common late-life anxiety problems seen by primary care physicians. Patients with these disorders complain of diffuse multisystem symptoms, motor restlessness, and such physiologic symptoms as tachycardia or tachypnea. Comorbid illnesses include depression, alcoholism, drug use, and multisystem disease. Behavioral strategies to address anxiety include an open discussion of the issue, an anxiety diary, psychosocial support, and cognitive-behavioral techniques. Pharmacologic strategies include carefully monitored benzodiazepine, buspirone, or antidepressant therapy. CONCLUSIONS: Clinical trials of all anxiety interventions are needed for elderly primary care patients to clarify further whether findings from mixed-age population studies are generalizable to the elderly.

Late-life depression in primary care. How well are we doing?

OBJECTIVE: To discover primary care physicians' attitudes toward their abilities to detect and treat depression in the elderly. DESIGN: A self-administered questionnaire sent to 1,000 primary care physicians in the state of Michigan. SETTING: The survey was sent to physicians who practice general internal medicine or family medicine. PARTICIPANTS: The questionnaire was sent to 500 MD and 500 DO physicians; equal representation was given to general internal medicine and family medicine. Of all 1,000 physicians, 60% (n = 604) responded, 51% (n = 309) were MD's, 48% (n = 295) were DO's, 41% (n = 245) were general internists, and 59% (n = 359) were family medicine physicians. MEASUREMENTS AND MAIN RESULTS: Despite positive attitudes about their skills for detecting and treating depression in the elderly, only one quarter of the respondents routinely used a screening tool in practice. Forty-one percent of all physicians were not aware of depression practice guidelines. Family physicians were more confident about their treatment skills than were general internists (85% vs 50%; chi 2 = 11.42, p < or = .003). Male physicians more often endorsed pharmacologic treatment, while female physicians more frequently used counseling and exercise techniques to treat depressed older patients. Half of all physicians felt knowledgeable about community resources to treat older depressed patients. CONCLUSIONS: This survey identified several perceived needs for future targeted interventions: (1) additional Agency for Health Care Policy and Research guideline exposure for all primary care physicians, (2) targeted counseling skill intervention for male physicians and medication management for female physicians, and (3) additional continuing medical education intervention for practicing general internists. Further research is needed to correlate physician attitudes with ensuing behaviors to fully appreciate the nature of late-life depression treatment within the primary care arena.

Difficult dementia: six steps to control problem behaviors.

For patients with a confirmed diagnosis of dementia, your challenge is to promote a quality life during their remaining years. This task often includes managing problem behaviors. A systematic approach starts with pinpointing the nature of the specific behavior, reviewing possible physical and emotional stressors, and checking for coexisting affective or psychotic disorders. It often helps to reduce environmental stimulation and to simplify the patient's tasks. Drug therapy with an antipsychotic or benzodiazepine is indicated if a clear-cut behavioral strategy has not proven fully effective, the behavior has been well documented, and the behavior presents a clear danger to the patient or others or prevents necessary care from occurring.

Electroconvulsive therapy: a guide for family physicians.

Electroconvulsive therapy, which works by creating a generalized seizure, is used most frequently to treat medication-resistant depression. Other indications for electroconvulsive therapy includes severe depression with suicidal ideation, acute mania and severe psychiatric illness with food and fluid refusal. Electroconvulsive therapy may be administered as an inpatient or outpatient procedure. Treatments are usually administered three times a week for six to 12 treatments. Before this therapy is used, a thorough medical and anesthetic history should be obtained, and a complete physical examination, an electrocardiogram and appropriate laboratory studies should be performed to rule out anemia, electrolyte imbalances, and cardiopulmonary and neurologic risk factors. Heart rate and rhythm, oxygenation, blood pressure and, often, the electroencephalogram are monitored continuously while the patient is anesthetized with a short-acting hypnotic agent and a muscle depolarizing agent. After electroconvulsive therapy, antidepressant or lithium therapy significantly reduces the symptom relapse rate.

Graduate medical education financing in psychiatry.

Psychiatry residency training programs are being affected by changes in graduate medical education financing. Program budgets are increasingly being constricted. Training directors will need to be better informed about how programs are financed if they are to function effectively and to advocate successfully f or training funds. The authors illustrate the present mechanisms of graduate medical education financing with examples. The possible effect of the coming reform in health care financing on psychiatry residency training is examined.