The 'usual care' of major depression in primary care practice.

OBJECTIVE: To determine how primary care physicians treat patients with major depression in the course of routine practice and the degree to which such practice produces outcomes anticipated with interventions recommended by the Agency for Health Care Policy and Research Depression Guideline Panel. DESIGNS: Prospective cohort study. SETTINGS: Academically affiliated ambulatory family practice centers and internal medicine clinics in urban neighborhoods of Pittsburgh, Pa. PATIENTS: Ninety-two patients who were seen in primary care practices and who met criteria for a current major depression as determined by the Diagnostic Interview Schedule and a psychiatrist's assessment. INTERVENTION: Physicians were informed of the patient's psychiatric diagnosis, and were urged to treat it in whatever manner and for whatever duration they deemed appropriate (ie, with "usual care"). MAIN OUTCOME MEASURES: The treatments that were provided, the patients' clinical course, and the relationship between the type of treatment and clinical course. RESULTS: Health center records indicated that 67 patients (73%) received a depression-specific treatment in the 8 months following study entry. A majority of the total cohort were prescribed an antidepressant drug. Of the 92 patients, 18 (20%) were asymptomatic at 8 months (Hamilton Rating Scale for Depression score, < or = 7). The treatment pattern was not clearly related to the clinical course. CONCLUSIONS: The recovery rates for the patients with major depression who were treated with usual care in routine primary care practices were lower than those anticipated from treatments consistent with the Agency for Health Care Policy and Research guidelines. Further studies of the caregiving elements that influence the effectiveness of depression-specific treatments of patients in primary care settings are needed.

Treating depressed primary care patients improves their physical, mental, and social functioning.

BACKGROUND: This study describes the functioning of primary care patients with major depressive disorder, the relationship of medical comorbidity to functional status, and the effects of depression-specific treatment on functional status after 8 months. METHODS: Patients were randomized to a protocol intervention (nortriptyline hydrochloride or interpersonal psychotherapy) or to usual care with the patient's physician in a clinical trial of primary care treatments of depression. Their functional status was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Global Assessment Scale. Medical comorbidity was assessed with the Duke Severity of Illness Checklist. The Hamilton Rating Scale for Depression and Beck Depression Inventory were used to measure depressive severity. Assessments were conducted at baseline and at 1, 2, 4, and 8 months after randomization. RESULTS: At baseline, patients reported substantial impairments in the functional domains as assessed by the SF-36 and Global Assessment Scale. Severity of general medical illness and depression were not correlated. Greater medical comorbidity was associated with diminished physical, but not psychological, functioning. Mean scores on SF-36 scales and the Global Assessment Scale improved significantly during the 8 months of follow-up. Patients assigned to protocol treatments showed greater improvement, compared with those assigned to usual care, on the SF-36 mental summary scale and most individual scales but not on the SF-36 physical summary scale. However, patients who completed protocol treatment also experienced significant improvement on the physical summary scale. Medical comorbidity was only a weak predictor of outcome. CONCLUSIONS: Primary care patients with major depressive disorder report substantial impairments in physical, psychological, and social functioning on initial assessment. Severity of baseline medical comorbidity did not correlate with severity of depression and only weakly correlated with functional status at 8 months. Functional impairments improve with time, but standardized depression-specific treatment is associated with greater improvement in more domains of functioning than is a physician's usual care.

Treating major depression in primary care practice. Eight-month clinical outcomes.

BACKGROUND: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. METHODS: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n = 91) or interpersonal psychotherapy (n = 93) provided within well-structured parameters, or a physician's usual care (n = 92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. RESULTS: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. CONCLUSIONS: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.

The study of literature in medical education.

The study of literature encourages the development of otherwise hard-to-teach clinical competencies. It provides access to the values and experiences of physicians, patients, and families; it calls for the exercise of skill in observation and interpretation, develops clinical imagination, and, especially through writing, preserves fluency in ordinary language and promotes clarity of observation, expression, and self-knowledge. Faculty in one-third of U.S. medical schools teach literature in courses that, although concentrated in the preclinical years, range from the first day of school, through residency programs. Once focused on the work of physician-authors and realist fiction about illness that encouraged moral reflection about the practice of medicine, literary study in medicine now encompasses a wide range of literature and narrative types, including the patient history and the clinical case. Literary study is intended not only to enrich students' moral education but also to increase their narrative competence, to foster a tolerance for the uncertainties of clinical practice, and to provide a grounding for empathic attention to patients. Literature may be included in medical humanities courses, and it may provide rich cases for ethics courses or introductions to the patient-physician relationship; it also may be the focus of small, elective, or selective courses, frequently on particular social issues or on the experience of illness. Reading, discussion, writing, and role-play rather than lectures are the methods employed; faculty include those with PhDs in literature and MDs who have strong interests in the contributions of literature to practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Major depression in primary care practice. Clinical characteristics and treatment implications.

Major depression is thought to be underdiagnosed and undertreated in primary medical care facilities. The authors conducted a clinical trial that included a three-phase assessment so only ambulatory medical patients judged eligible for treatment of this disorder in medical settings were recruited. In addition to administering the Center for Epidemiologic Studies-Depression scale and the Diagnostic Interview Schedule's (DIS) Depression section, the psychiatrists evaluated the DIS-positive patients. This third assessment determined that clinical characteristics of DIS-positive patients were such that 70% of the patients could be treated for major depression in a primary care setting, 13% should probably be referred to a mental health facility, and 17% were experiencing conditions other than major depression.

Using electronic mail for a small-group curriculum in ethical and social issues.

PURPOSE: To initiate an electronic mail (e-mail) program as a supplement to a medical humanities curriculum focusing on ethical and social issues. METHOD: In 1991-92 an e-mail track (called NET) was established for second-year students participating in Medicine in Contemporary Society, a four-year curriculum in medical humanities at the State University of New York at Stony Brook School of Medicine. In 1991-92 ten students volunteered to form a NET group; in 1992-93 22 students, forming two groups, were randomly selected from a volunteer pool of 76 students (from a class of 100). In both study years, the NET students analyzed and discussed electronically a series of cases posted sequentially through the academic year. Faculty tutors reviewed the students' responses, interacting with the groups and with individual students by e-mail. NET was evaluated in two ways: at the end of the course, the students completed e-mail questionnaires that included quantitative and qualitative assessments; and throughout the course, the tutors assessed the students' participation, quality of case analysis and discussion, and quality of writing. RESULTS: The students' assessments indicated that they considered NET to be more educational than the lectures, "live" group discussions, problem-based learning exercises, and formal papers in the medical humanities curriculum; that they made gains in computer literacy; and that NET enhanced their abilities to think about ethical and social issues. The tutors judged that the students had improved their written self-expression as the course progressed. CONCLUSION: NET adequately accomplished the goals set for it as an adjunct to the small-group sessions and other components of the medical humanities curriculum.

The concept of futility. Patients do not have a right to demand medically useless treatment. Counterpoint.

Traditionally, applying the principle that physicians do not provide treatments when the interventions at their disposal do not produce medical benefits has been relatively straight-forward. However, with the growing importance of patient autonomy and informed consent in treatment decisions, ethicists must now balance this principle with the principle of patient self-determination. A patient's right to choose or refuse treatment is limited by the physician's right (and duty) to practice medicine responsibly. Bizarre or destructive choices made by a patient are not sacrosanct simply because the patient made them. In some cases, physicians may choose not to act on patient decisions that appear to be unreasonably destructive. Physicians also have a right to refuse to provide futile treatments (i.e., interventions that might be physiologically effective in some sense but cannot benefit a patient). Patients themselves have a right to provide input into what would constitute a "benefit" for them, but physicians should be able to decide when a particular treatment is futile based on their knowledge of the treatment's effects and its likely impact on a patient's quality of life. Ethical rules covering futility can be developed based on socially sanctioned standards of rationality and traditional physician-based values. Clarifying the concept of futility and establishing defensible ethical policies covering futility are important steps toward eliminating unhelpful, medically inappropriate practices.

Cardiovascular disease among American Indians and Alaska Natives.

OBJECTIVE: To compare the regional differences in cardiovascular disease in AI/AN with the U.S. general population and determine the parity gap and preventable proportion of cardiovascular mortality. RESEARCH DESIGN AND METHODS: Age-adjusted cardiovascular disease mortality rates for 1981-1983 and hospital discharge rates for 1982-1984 reported by the IHS were compared with U.S. data for 1982 and 1983, respectively. RESULTS: Rates of ischemic heart disease and atherosclerosis were found to be generally low among AI/AN although those in the 25- to 44-yr age-group have higher death rates from cardiovascular disease than in the U.S. population. Although the mortality rate from cardiovascular disease in AI/AN is 19% lower than the rate for the general U.S. population, the parity gap in individual regions of the U.S. ranges from favorable to extremely unfavorable. There were also wide variations in the preventable gap theoretically possible by reduction of the three major risk factors. CONCLUSIONS: Changing nutrition and exercise patterns and the increasing prevalence of diabetes in many Indian tribes may have adverse effects in the future, possibly increasing the prevalence of heart disease. Regional differences in the prevalence of some major cardiovascular risk factors (smoking, hypertension, hypercholesterolemia, and diabetes) are the probable explanation for these differences in cardiovascular morbidity and mortality rates. Prevention and treatment of these risk factors will have the greatest impact in attempts to reduce cardiovascular disease among AI/AN. In addition, moderation in the use of alcohol, or abstinence, may prevent sudden deaths resulting from acute intoxication.

Clinical trials of primary care treatments for major depression: issues in design, recruitment and treatment.

The objective of this article is to consider whether randomized clinical trials (RCTs) are able to determine the validity of transferring treatments for major depression from the psychiatric to the primary care sector. This clinical issue is of growing concern in the United States since both governmental and professional bodies are establishing guidelines for the treatment of medical patients with the affective disorder. The article's method involves analysis of how the competing aims of rigorous scientific methodology (internal validity) and generalization of study findings (external validity) are best balanced within the RCT. Experiences in recruiting medical patients with major depression and providing pharmacologic, psychotherapeutic, and usual care interventions compatible with the sociotechnical characteristics of ambulatory medical centers are described to illustrate the complexities of investigating transferability of treatments for major depression with RCT methodology.

The inter-rater reliability and internal consistency of a clinical evaluation exercise.

OBJECTIVE: To assess the internal consistency and inter-rater reliability of a clinical evaluation exercise (CEX) format that was designed to be easily utilized, but sufficiently detailed, to achieve uniform recording of the observed examination. DESIGN: A comparison of 128 CEXs conducted for 32 internal medicine interns by full-time faculty. This paper reports alpha coefficients as measures of internal consistency and several measures of inter-rater reliability. SETTING: A university internal medicine program. Observations were conducted at the end of the internship year. PARTICIPANTS: Participants were 32 interns and observers were 12 full-time faculty in the department of medicine. The entire intern group was chosen in order to optimize the spectrum of abilities represented. Patients used for the study were recruited by the chief resident from the inpatient medical service based on their ability and willingness to participate. INTERVENTION: Each intern was observed twice and there were two examiners during each CEX. The examiners were given a standardized preparation and used a format developed over five years of previous pilot studies. MEASUREMENTS AND MAIN RESULTS: The format appeared to have excellent internal consistency; alpha coefficients ranged from 0.79 to 0.99. However, multiple methods of determining inter-rater reliability yielded similar results; intraclass correlations ranged from 0.23 to 0.50 and generalizability coefficients from a low of 0.00 for the overall rating of the CEX to a high of 0.61 for the physical examination section. Transforming scores to eliminate rater effects and dichotomizing results into pass-fail did not appear to enhance the reliability results. CONCLUSIONS: Although the CEX is a valuable didactic tool, its psychometric properties preclude reliable assessment of clinical skills as a one-time observation.

Strategies for evaluating treatments for major depression in primary care patients.

Primary care physicians are being urged to provide patients experiencing a major depression treatments validated with psychiatric patients. The propriety of transferring clinical technologies from one care-giving sector to another is questionable, however, as it has little scientific support. We suggest that clinical trials be initiated so as to expand the available knowledge base. This paper analyzes the methodologic issues involved in pursuing such experimental research and urges that it be conducted despite the possible need for initial design compromises.

The treatment act: an analysis of the clinical art in chiropractic.

This paper discusses the nature of healing as it applies to the clinical art of chiropractic. General concepts of the phenomenology of illness and healing are developed and then applied specifically toward chiropractic care. The role of metaphor in medicine and chiropractic is discussed; chiropractic may make better use of root metaphor than does the practice of medicine. Finally, the paper discusses certain implications of the clinical art of chiropractic as they relate to teaching and research within the chiropractic profession.

Medical comorbidity of major depressive disorder in a primary medical practice.

Despite much speculation about the relationship between depression and medical comorbidity in primary care settings, few investigators have examined this issue empirically. Using a two-stage screening procedure, we assessed 618 patients aged 18 to 64 years in an academic general medicine clinic. Forty-one patients (6.6%) suffered from a current episode of major depressive disorder (MDD). We compared this group with a 20% random sample of nondepressed patients. While patients with MDD were younger (mean age, 41.1 vs 47.2 years), they were assessed by the Duke University Severity of Illness Scale as having more severe medical illness. Patients with MDD were more likely to have malignant tumors and "ill-defined conditions" than nondepressed patients. The 18 patients with MDD (44%) who were correctly diagnosed by their physicians had less severe medical illness than those whose depression was clinically undetected. A logistic regression model predicting MDD group membership included female gender, younger age, higher Duke University Severity of Illness Scale score, and more frequent inactive ill-defined diagnoses. These findings are consistent with assertions: (1) patients with MDD have more physical illness than nondepressed patients and/or (2) somatic symptoms and disability caused by MDD add to the burden of physical illness.