Beta-blockers and depression: the more the murkier?

OBJECTIVE: To review the literature regarding the purported association between oral ingestion of beta-blocker drugs and depressed mood. DATA SOURCE: MEDLINE was searched for published articles using the key words propranolol, atenolol, metoprolol, nadolol, timolol, beta-blocker, beta-adrenergic antagonist, or beta-adrenergic blocker in combination with the key words depression, depressive symptomatology, major depressive disorder, or depressed mood from January 1966 through December 1996. DATA SYNTHESIS: Findings regarding the association are equivocal. Plausible explanations include study design, case definition, and confounding disease states. Most of the evidence supporting an association has used case series and case reports. Findings from cross-sectional observational studies and case-control studies are equivocal. Case definition and measurement instruments may partially explain these inconsistencies. Studies using a diagnosis of depression generally do not support the relationship. Trials using depressive symptoms are about evenly split, but they have generally enrolled a small number of patients and have questionable statistical power. Studies defining antidepressant prescriptions dispensed as a marker for depression generally support the association. Evidence exists both for and against the hypothesis that lipophilic beta-blockers cause more depression than do hydrophilic beta-blockers. CONCLUSIONS: beta-Blockers may have been unjustly associated with depression and their use avoided for that reason. Future studies into the association between depression and beta-blocker use should evaluate whether the association is affected by case definition and study design characteristics, including disease, dose-response, bias, measurement error, or ability to precisely measure the length of the exposure.

Evaluation of a self-report screening instrument to predict frailty outcomes in aging populations.

The purpose of this study is to investigate the utility of a self-report screening instrument, the Health Status Form (HSF), to predict elderly members at risk of frailty in the subsequent year. The predictive ability of self-report HSF data was also compared to the predictive ability of inpatient discharges and pharmacy dispensings from administrative utilization databases. Four HSF variables best predicted elderly members at risk of frailty: (a) age, (b) indicating that health conditions interfered with daily activities, (c) needing or receiving assistance from another person for bathing, and (d) needing or receiving assistance from another person for taking medications. The predictive model yielded sensitivity 50.7%, specificity 97.8%, and correctly classified 90.9% of the population. Self-report population-based screening is a reliable method for predicting elderly members at risk of frailty in the coming year. Further studies should test a new brief instrument composed of portions of validated measures as a stand alone screener to select frail members for care management purposes.

A simple tool for designing a database: bridging the communication gaps among health care providers, researchers, and programmers.

As databases are used by a greater variety of people, highly technical methods of designing them are giving way to more human, user-centered approaches. The article describes a human approach to designing a complex, multiuse database with limited resources. The article introduces a simple data modeling tool, the entity-relationship (E-R) diagram, that crosses professional boundaries and enables providers, researchers, and programmers to communicate more easily. Constructing an E-R diagram provides a human description of the social health maintenance organization (S/HMO) multisite demonstration project. This project, now in its tenth year, provides integrated acute and community-based in-home services to allow frail elderly HMO members to stay in their homes. After briefly reviewing the three types of databases and three rules of thumb for designing a relational database, the article shows how a simple E-R diagram can clarify the management and research issues of the S/HMO health care model. The article concludes with a brief discussion of the benefits and limits of housing research-related health data in a relational database.

Medical care utilization among older HMO members with and without hypertension.

OBJECTIVES: To compare hospital utilization, health status, and sociodemographic characteristics of older persons with and without hypertension and to examine the nature of the association of hypertension with medical care utilization. DESIGN: A retrospective, nonexperimental study. SETTING: A large health maintenance organization (HMO), located in the Portland, Oregon and Vancouver, Washington areas, that provides comprehensive, prepaid benefits to its members. PARTICIPANTS: Approximately 4200 older (> or = 65 years) members enrolled in the Social HMO Demonstration Project. MEASUREMENTS: The dependent variables were (1) whether a member was hospitalized (0 = no; 1 = yes) and (2) the number of hospitalizations during the 12-month period before the return of the Health Status Form, a mail questionnaire. The predictor variables were high blood pressure and other medical conditions, health status, and sociodemographic characteristics. Patients classified as hypertensive were those who self-reported high blood pressure and who received two or more dispensings for antihypertensive medications. RESULTS: Older hypertensives were more likely than older nonhypertensives to have been hospitalized (odds ratio (OR) = 1.14 (95% CI 1.01, 1.27)), self-report their health as only good or fair (P < .001), self-report IADL functional limitations (P < .001), and to be younger than nonhypertensives (P < .001). Utilization differences were similar after controlling for patients' age and gender. Factors independently associated with an increased likelihood of hospitalization were male gender (OR = 1.14 (1.00,1.31)), age (OR = 1.35 (1.00,1.81)), poor (OR = 1.32 (1.02,1.72)) or fair (OR = 1.20 (1.01,1.44)) self-rated health status, functional limitations in activities of daily living (OR = 1.74 (1.48,2.03), and self-reported heart trouble (OR = 1.50 (1.34,1.68)), stroke (OR = 1.37 (1.15,1.64)), or cancer (OR = 2.89 (1.72,4.84)). Factors independently associated with a decreased likelihood of hospitalization were excellent self-reported health (OR = 0.65 (0.47,0.90)), no physical impairments (OR = 0.59 (0.48,0.72)), and no circulation problems (OR = 0.85 (0.74,0.98)). CONCLUSIONS: Older hypertensive patients had poorer self-reported health, more functional limitations, used more hospital services, and were not as old as nonhypertensive older patients. To the extent that general health is improved by treatment of hypertension, appropriate treatment of high blood pressure may not only improve health, it may also reduce medical care utilization. Our findings offer further support for hypertension prevention, detection, and treatment programs designed to reduce or minimize hypertension's later medical complications and to reduce future utilization.

The PREP system of nursing interventions: a pilot test with families caring for older members. Preparedness (PR), enrichment (E) and predictability (P).

The PREP system of nursing interventions, designed to increase preparedness (PR), enrichment (E), and predictability (P) in families providing care to older people, was pilot tested for acceptability and preliminary effectiveness. Eleven family units were assigned to the PREP group and 11 to a standard home health control group. The PREP group scored approximately one SD higher than the control group (p < .05) on the Care Effectiveness Scale, indicating greater preparedness, enrichment, and predictability. Further, on a rating of overall usefulness, the PREP group rated their assistance from PREP nurses (M = 9.75) as significantly higher (p < .01) than the control group rated assistance from the home health nurse or physical therapist (M = 6.57). Although not statistically significant, mean hospital costs for the PREP group ($2,775) were lower than for the control group ($6,929). Results provided support for a full intervention trial.