Predicting outcomes of primary care patients with major depression: development of a depression prognosis index.

OBJECTIVE: Depression research and practice focus increasingly on diverse patient populations with varying probabilities of response to clinical care. Prognostic indices use preexisting patient characteristics to estimate the probability of subsequent negative clinical outcomes and are useful tools for improving the study and care of diverse populations. Few such measures, however, have been developed for mental health conditions. This study developed and validated a depression prognosis measure for primary care patients with major depression. METHODS: Consecutive patients in 108 primary care practices were screened for depression, and 1,471 with major depression were enrolled. A Depression Prognosis Index (DPI) predicting persistent depression six months after baseline was developed for a random one-third subsample and validated with the remaining two-thirds. Models included prior treatment, demographic characteristics, comorbidities, and other physical, psychological, and social predictors. RESULTS: Sixty-four percent to 65% of patients classified by baseline DPI score as being in the sample quartile with the worst prognosis had probable major depression six months later, compared with 14% to 15% in the best-prognosis quartile. The DPI had an R2 of .40 in the development sample and .27 in the validation sample. Important predictors included severity of depression symptoms at baseline, social support, common physical symptoms, and having completed three months of antidepressants at sample entry. CONCLUSIONS: The ability of the DPI to predict six-month outcomes compares favorably to that of prognostic indices for general medical problems. These results validate the DPI and provide conceptual guidance for further development of depression risk stratification instruments for clinical and research use.

Provider perceptions of patient psychosocial needs after orofacial injury.

PURPOSE: Vulnerable populations are at particular risk for developing psychosocial sequelae after they experience orofacial injury. To enhance understanding of awareness, perspectives, and beliefs regarding attendant psychosocial issues, surgeons who provide orofacial injury care to indigent patients were surveyed. MATERIALS AND METHODS: We surveyed 26 oral and maxillofacial surgeons and 15 otolaryngology surgeons at a large, urban, Level 1 trauma center. The survey, which measured providers' perceptions of pertinent contextual elements and patients' psychosocial needs after assaultive orofacial injury, was based on semistructured interviews with 15 oral and maxillofacial surgeons. The overall survey response rate was 85.4% (35 of 41). RESULTS: Respondents ranked interpersonal violence as the dominant cause of orofacial injury among patients. Anxiety (eg, post-traumatic stress), depression, and legal issues were the most significant psychosocial sequelae identified by respondents. Alcohol abuse, drug abuse, and homelessness were identified as the most important contributors to orofacial reinjury and patient noncompliance with postsurgical instructions. Less than half of respondents (44.7%) believed that patients' problems with depression, anxiety, or substance abuse were currently addressed in an adequate way in the hospital. The vast majority (94.7%) believed that a psychosocial aftercare program was needed, and most agreed that such a program would decrease the risk of reinjury and would promote patient compliance with aftercare instructions and return for scheduled follow-up care. Respondents identified the specialty mental health service in their hospital or a community-based setting as the preferred locations for such a program, and they indicated that lack of financial resources and trained personnel were the most significant barriers to implementation of such a program within the setting of trauma services. CONCLUSIONS: Surgeons who provide care to indigent patients with orofacial injury perceive a great need for psychosocial aftercare programs for patients, and they believe that such programs could reduce the risk of reinjury and promote patient compliance.

Psychiatric disorders among adults seeking emergency disaster assistance after a wildland-urban interface fire.

OBJECTIVE: This study estimated the prevalence of psychopathology at a three-month follow-up among persons seeking emergency relief services after a wildfire and identified a practical screener for use in these disaster assistance settings to aid early identification of persons at risk of subsequent psychopathology. METHODS: During the October 2003 California firestorm that occurred at the wildland-urban interface, 357 persons who were seeking assistance from adjacent American Red Cross and government relief centers were recruited for this study. Within days of mandatory evacuation, participants completed baseline self-administered questionnaires assessing demographic characteristics, initial subjective reactions, and degree of fire exposure. At the three-month follow-up, symptoms of posttraumatic stress disorder (PTSD) and major depression were measured via a mailed survey. RESULTS: At follow-up 33% showed evidence of probable major depression; 24% exhibited probable PTSD. On a bivariate basis, seven initial reaction and fire exposure items were significantly associated with subsequent psychopathology. Best-subsets logistic regression analyses revealed that property damage and physical injury were the best multivariate predictors of psychopathology at follow-up. No additional items provided a significant incremental improvement in prediction. CONCLUSIONS: Individuals seeking immediate emergency assistance related to the wildland-urban interface fire were at elevated risk of psychopathology in the weeks after the fire. A short, easily administered, two-item screener, composed of items assessing fire exposure severity, appears to hold promise for aiding early identification of persons at risk of postfire psychopathology. These findings may also have implications for other mass disasters.

Reactions to dating violence among Latino teenagers: an experiment utilizing the Articulated Thoughts in Simulated Situations paradigm.

Dating violence is a serious problem among adolescents and young adults. Understanding teens' reactions to dating violence offers the potential to understand the factors that lead to perpetration of violent behavior and to elucidate prevention strategies. Knowledge concerning youth attitudes about dating violence is limited, and has largely come from self-report questionnaires to date. We utilized the Articulated Thoughts in Simulated Situations (ATSS) paradigm to assessing Latino teens' reactions to dating violence. Forty-one 9th grade students were presented with four simulated dating violence scenarios, and articulated their thoughts in response to them. Teens' reactions to dating violence differed on a variety of dimensions as a function of their gender, the gender of the perpetrator, and familiarity with the perpetrator.

Perspectives on nontraditional research careers in clinical psychology.

Building on a panel presentation titled "Career opportunities for behavioral scientists: Non-academic research settings," given at the November 2004 meeting of the Association for Advancement of Behavior Therapy, this article presents the experiences of three clinical psychologists who have careers in nontraditional research settings. These authors focus on three issues: (a) What nontraditional career did they pursue and why? (b) What, if anything, in their training prepared them for that career? (c) What advice would they give to students and young professionals who are considering pursuing a similar type of nontraditional career option? An introduction and concluding remarks that highlight recent trends in the academic job market and themes across each authors' experience are provided by the chair of the panel.

The ISTSS/Rand guidelines on mental health training of primary healthcare providers for trauma-exposed populations in conflict-affected countries.

Mental health care for trauma-exposed populations in conflict-affected developing countries often is provided by primary healthcare providers (PHPs), including doctors, nurses, and lay health workers. The Task Force on International Trauma Training, through an initiative sponsored by the International Society for Traumatic Stress Studies and the RAND Corporation, has developed evidence- and consensus-based guidelines for the mental health training of PHPs in conflict-affected developing countries. This article presents the Guidelines, which provide a conceptual framework and specific principles for improving the quality of mental health training for PHPs working with trauma-exposed populations.

Trauma, depression, coping, and mental health service seeking among impoverished women.

The authors examined the relationship among trauma, coping, depression, and mental health service seeking in a probability sample of sheltered homeless and low-income housed women. Results highlight the diversity of trauma. In a longitudinal analysis, women who lived in shelters or experienced major violence had a twofold increase in their risk of depression over the 6-month follow-up. In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health service seeking among traumatized women. Modifying coping strategies may ameliorate some of the negative impact of trauma and potentially enhance mental health service use among at-risk women.

Cognitive-behavioral therapy for panic disorder: a review of treatment elements, strategies, and outcomes.

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12-15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.

Bystanders' perceptions of perpetrators and victims of hate crime: an investigation using the person perception paradigm.

This study used the person perception vignette method to examine whether people perceive hate crime victims as more culpable than non-hate crime victims. In a between-participants design, participants were randomly assigned to read a vignette depicting a nonhate crime or a comparable hate crime motivated by the perpetrator's hatred for either the victim's race, sexual orientation, or religion. Results showed that participants assigned more blame to the victim in the non-hate crime condition compared to the victims in each of the three hate crime conditions. In addition, they perceived the perpetrators as more guilty in each of the three hate crime conditions compared to the non-hate crime condition. In addition, people with prejudiced attitudes perceived both hate crime and non-hate crime victims as more culpable and both hate crime and non-hate crime perpetrators as less culpable than did unprejudiced people.

Base rates of hate crime victimization among college students.

This study uses the unmatched count technique (UCT) to estimate base rates for hate crime victimization in college students and compares the results with estimates found using conventional methods. Hate crimes, criminal acts perpetrated against individuals or members of specific stigmatized groups, intend to express condemnation, hate, disapproval, dislike, or distrust for a group. The UCT is a promising tool in the investigation of hate crime because it does not require participants to directly answer sensitive questions. This may provide more accurate responses than other methods. The UCT revealed higher estimates for a variety of serious hate crimes, including physical and sexual assault. These higher estimates provide a better feel for the level of hate crime victimization and point to the increased need for hate crime victims' assistance programs on college campuses.