Improving depression care in a psychiatry resident psychopharmacology clinic: measurement, monitoring, feedback and education.

OBJECTIVE: Better outcomes for major depressive disorder (MDD) are associated with proactive treatment, including timely follow-up, systematic assessment and treatment changes for inadequate improvement. The effectiveness of an intervention to facilitate proactive treatment for MDD in a resident psychopharmacology clinic was studied. METHODS: A quality improvement program with administrative process changes to improve flow and a 40-week pre/post study to evaluate the effect of education and feedback was conducted. A systematic assessment and reengineered scheduling system were implemented. During the first 20 weeks, baseline data were collected; during the second 20 weeks, feedback to residents and attending psychiatrists about adherence to evidence-based treatment recommendations was added. RESULTS: Reengineering our system to improve flow was successful. By linking outcomes collection to completion of billing sheets, outcomes at 90% of visits for MDD throughout the 40-week study was assessed. By centralising our scheduling system, the percentage of active-phase patients with MDD seen for follow-up within 6 weeks was improved from 19% to 59%. In response to feedback, residents did not make significant changes to their overall practice patterns. Patient outcomes did not improve as a result of feedback to residents. Residents did improve their practice patterns for a subset of patients including those without comorbid psychiatric disorders and those whose depressive episodes had lasted <1 year. CONCLUSIONS: Improving administrative processes for the treatment of patients with MDD resulted in rapid changes that were associated with improvements in the delivery of evidence-based care. Feedback to residents was more difficult and less successful.

Status of minor depression or dysthymia in primary care following a randomized controlled treatment.

This report describes the rates of recovery and remission from minor depression or dysthymia in primary care patients three months after completing a randomized controlled treatment trial. The subjects were primary care patients who received > or =4 treatment sessions with Problem-Solving Treatment, paroxetine, or placebo and who completed an independent assessment 3 months after the study (201 with minor depression, 229 with dysthymia). The 17-item Hamilton Rating Scale for Depression (HAMD), semistructured questions about postintervention depression treatments, and baseline medical comorbidity, neuroticism, and social function were the primary measures. For minor depression 76% and for dysthymia 68% of subjects who were in remission at the end of the 11-week treatment trial were recovered (HAMD < or =6) three months after the treatment trial. Of patients who were not in remission at 11 weeks, for minor depression 37% and for dysthymia 31% went on to achieve remission at 25 weeks. The majority of patients chose not to use antidepressants or psychotherapy after the trial. Patients with minor depression that had greater baseline social function and lower neuroticism scores were more likely to be recovered. For patients with minor depression, these findings suggest a need for some matching of continuation and maintenance treatment to patient characteristics rather than uniform, automatic treatment recommendations. Because of the chronic, relapsing nature of dysthymia, practical improvements in encouraging effective continuation and maintenance phases of treatment are indicated.

Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years.

OBJECTIVE: The researchers evaluated the effectiveness of paroxetine and Problem-Solving Treatment for Primary Care (PST-PC) for patients with minor depression or dysthymia. STUDY DESIGN: This was an 11-week randomized placebo-controlled trial conducted in primary care practices in 2 communities (Lebanon, NH, and Seattle, Wash). Paroxetine (n=80) or placebo (n=81) therapy was started at 10 mg per day and increased to a maximum 40 mg per day, or PST-PC was provided (n=80). There were 6 scheduled visits for all treatment conditions. POPULATION: A total of 241 primary care patients with minor depression (n=114) or dysthymia (n=127) were included. Of these, 191 patients (79.3%) completed all treatment visits. OUTCOMES: Depressive symptoms were measured using the 20-item Hopkins Depression Scale (HSCL-D-20). Remission was scored on the Hamilton Depression Rating Scale (HDRS) as less than or equal to 6 at 11 weeks. Functional status was measured with the physical health component (PHC) and mental health component (MHC) of the 36-item Medical Outcomes Study Short Form. RESULTS: All treatment conditions showed a significant decline in depressive symptoms over the 11-week period. There were no significant differences between the interventions or by diagnosis. For dysthymia the remission rate for paroxetine (80%) and PST-PC (57%) was significantly higher than for placebo (44%, P=.008). The remission rate was high for minor depression (64%) and similar for each treatment group. For the MHC there were significant outcome differences related to baseline level for paroxetine compared with placebo. For the PHC there were no significant differences between the treatment groups. CONCLUSIONS: For dysthymia, paroxetine and PST-PC improved remission compared with placebo plus nonspecific clinical management. Results varied for the other outcomes measured. For minor depression, the 3 interventions were equally effective; general clinical management (watchful waiting) is an appropriate treatment option.

Social support and treatment response in older depressed primary care patients.

A previously tested theoretical model that specifies relationships among depression, activities of daily living (ADL) impairment, and social support components was validated with 307 patients aged 60 and older from a multisite effectiveness trial of 3 treatments (antidepressant, placebo, Problem-Solving Treatment) for dysthymia or minor depression in primary care. Participants completed interviews and self-reports at baseline and at 6 and 12 weeks. The short-term, longitudinal data were analyzed with covariance structure modeling techniques. Consistent with the previous model, impairment in ADLs was associated with subsequent increases in depression, a larger emotionally close network that made frequent visits was associated with subsequent increases in perceived support, and perceived support was associated with subsequent decreases in depression. This last effect was significant only among participants randomly assigned to receive placebo with clinical management. The similar results in 2 different studies are a substantial validation of the theoretical model. The effect of perceived support primarily in the placebo group suggests that those with greater perceived social support and subsyndromal depression may be more likely to have a positive response to nonspecific clinical treatment components.

The relationship of aging and dysthymia in primary care.

The authors compared symptomatic and functional characteristics between older (age > or =60; n=91) and younger (age 18-59; n=125) primary care patients with dysthymia. Three of six significantly different depression symptoms were of moderate-to-large effect size, with the older group having a lower proportion reporting the symptom. The older group had a worse physical health function score but a better mental health function score. There appears to be a core of symptoms and functional impairment that generalizes across the age span. There are also significant age differences. Growing older appears to have an impact on the nature of what it means to have dysthymia.

Improving the precision of primary care physician self-report of antidepressant prescribing.

BACKGROUND: Methods to select physicians most likely to benefit from educational interventions to improve the outcome of depression have not been adequately developed. OBJECTIVE: The purpose of this study was to identify a combination of primary care provider (PCP) self-report questions to improve the precision of PCP estimates of actual antidepressant prescribing as a potential tool for PCP selection. METHODS: The total number of new and refill antidepressant prescriptions written by 124 PCPs and actually filled at pharmacies over a 2-year period were matched with telephone survey results of these PCPs completed before the 2-year period. Multiple regression techniques were used to identify a set of variables that improved upon PCPs' self-report of prescriptions. RESULTS: The mean for PCP-reported antidepressant prescriptions written in the last week was 7.8 (+/-11.2). The average weekly prescriptions actually filled was 6.72 (+/-5.65). Most survey variables were significantly correlated with antidepressant prescriptions. The final model included 6 variables that explained 52% of the variance in prescriptions. In addition to PCP-reported number of antidepressants prescribed, average number of primary care patients seen per week and number of patients covered by managed care were directly related to the volume of prescriptions. PCP age, percentage of patients referred immediately without treatment, and mental health services being too far away were inversely related. CONCLUSIONS: PCP self-reports on antidepressant prescribing are reasonably accurate proxies of actual prescribing. The precision of estimates of actual prescribing can be improved by considering practice structural and financial characteristics.

Referrals to psychiatrists. Assessing the communication interface between psychiatry and primary care.

The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N = 542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists' level of satisfaction was related to the quantity and quality of information provided by referring physicians.

Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature.

The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.

The treatment effectiveness project. A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients: background and research plan.

This report describes the background, rationale, and research plan for a comparative treatment trial of the effectiveness of paroxetine, problem-solving therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Patients were recruited from a variety of primary care practice settings in four separate geographic locations (Hanover, New Hampshire; Pittsburgh, Pennsylvania, San Antonio, Texas; and Seattle, Washington). Patients were randomly assigned to each of the three intervention conditions the medication/placebo conditions were double-blinded. The treatment trial was 11 weeks, with independent assessments of patient clinical status at baseline, 6 weeks, and 11 weeks. There was a follow-up at 25 weeks. Since there are relatively few placebo-controlled trials in primary care settings on patients with these disorders, the background of this project and a description of it are presented at this time, prior to the availability of outcome data, to provide methodological detail and to increase awareness in the research community of this treatment trial, with results to appear subsequently.

The need for a system in the care of depression.

BACKGROUND: Many problems have been identified in the usual care of patients with depression, including lack of identification, overreliance on medications, and inadequate treatment and follow-up. Most of these problems can be attributed to an absence of depression care systems in primary care practice. We collected information from a group of practices to assess the need for and acceptability of such systems. METHODS: We conducted 4 focus groups with primary care physicians and their staffs to identify attitudes and perceived behaviors for depression problems and to determine the participants' level of acceptance of alternative systematic approaches. We also surveyed clinicians and a sample of patients who recently visited their practices. RESULTS: Systematic screening was viewed unfavorably, and many barriers were identified with collaborative care with mental health clinicians. Participants did support involvement of other office staff and more systematic follow-up for patients with depression. The patient survey suggested that some patients with depressive symptoms were unrecognized and undertreated, but the key finding was considerable variation in care among practices. CONCLUSIONS: These findings suggest that a more systematic approach could improve the problems associated with treatment of patients with depression in primary care and would be acceptable to physicians if introduced appropriately. There are at least 2 promising approaches to introducing such changes. One involves external feedback of data about their care to the practices, followed by offering a variety of systems concepts and tools. The other involves an internal change process in which a multiclinic improvement team collects its own data and develops its own systematic solutions using rapid-cycle testing.

Prevalence of mood disorders and utility of the PRIME-MD in patients undergoing radiation therapy.

PURPOSE: To validate a short, structured interview procedure that allows practicing oncologists to quickly and reliably identify mood disorders in their patients, and to estimate the prevalence and types of mood disorders in a radiation therapy patient setting, noting relationships between mood disorders and patient characteristics. METHODS: Consecutive, eligible adult patients from the practices of two radiation oncologists were administered the Primary Care Evaluation of Mental Disorders (PRIME-MD) by the treating physician. A subset of these patients was also evaluated with the SCID, administered by trained mental health care personnel. Agreement between the two instruments was examined using the kappa statistic. Prevalence of mood disorders was determined from the PRIME-MD. The significance of relationships between patient characteristics and mood disorders was examined by chi-square and ANOVA analysis, and subsequently by multivariate logistic regression analysis. RESULTS: One hundred twenty-two patients were studied. Fifty-three of these were administered the SCID. Agreement between the two instruments was very good (kappa = 0.70). A diagnosis of a depressive or anxiety disorder by the PRIME-MD was made in 59 of the 122 patients (48%, 95% confidence interval = 39%, 58%). Multivariate analysis showed that a diagnosis of a depressive mood disorder was significantly related to pain intensity and prior history of depression. CONCLUSION: We have demonstrated the validity and feasibility of the PRIME-MD administered by oncologists in making diagnoses of mood disorders. The prevalence of mood disorders in our set of patients undergoing a course of RT was nearly 50%. Future studies should describe the natural history of these disorders, and determine optimal intervention strategies.

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness.

OBJECTIVE: Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness. METHOD: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. RESULTS: The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. CONCLUSIONS: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

Social support, depression, and activities of daily living in older heart surgery patients.

A theoretical model that specifies relationships among depression, ADL impairment, and social support components was tested using 147 patients age 55 and older undergoing open heart surgery for angina pectoris or aortic stenosis. Patients completed interviews and self-reports before surgery and one and 6 months after surgery. The longitudinal data were analyzed using covariance structure modeling techniques. Consistent with an initially theorized structural model, the number of close network members seen regularly before surgery was associated with perceived adequacy of support one month after surgery. In turn, perceived adequacy of support one month after surgery predicted less depression and less ADL impairment at 6 months. The number of close network members seen regularly was also directly associated with less ADL at one month and less depression at 6 months after surgery.

Depressive dementia: a "transitional dementia"?

This review comprises a historical, clinical, and empirical examination of the dementia spectrum of depression. The primary focus of the article is to evaluate the usual dichotomy between depressive dementia as functional-reversible and degenerative dementia as organic-irreversible. It is proposed that depression, cognitive impairment, and degenerative dementia be viewed as intersecting continua. Five prototypical groups are defined along these continua: (1) major depression without depressive dementia, (2) depressive dementia, (3) degenerative dementia without depression, (4) depression of degenerative dementia, and (5) random co-occurrence of depression and degenerative dementia. The data suggest that a subset of cases of major depression without dementia appear to evolve into depressive dementia, and in turn, depressive dementia may constitute a risk factor for degenerative dementia. Depressive dementia and degenerative dementia can sometimes represent two different points of organic deterioration and severity in a long-term, multiphasic disease course; depressive dementia sometimes appears to be a transitional stage or phase in a disease progression from depression without dementia to a degenerative dementia. The concept of "transitional dementia" is introduced in a heuristic and preliminary attempt to accommodate the nosologic entity of depressive dementia.

Geriatric psychiatry at the interface of consultation-liaison psychiatry and primary care.

OBJECTIVE: This article describes the evolution of a primary care geriatric psychiatry program which serves clinical, educational, and research functions. METHODS: Program development proceeded through stages of liaison using research, focusing on primary care attendings, and developing the common interest of geriatrics. RESULTS: Collaborative research with external funding has continued. A geriatric psychiatry primary care fellowship program was established. Clinical activity is based on consultation-liaison work in nursing homes, an outpatient dementia clinic, a general hospital medical service, and the outpatient clinic. Fellows are involved in training both psychiatry and primary care residents. CONCLUSIONS: Necessary components of a successful collaboration include: 1) primary care physicians with an interest in and aptitude for psychiatric issues; 2) delivery of service and training based on an assessment of the primary care site's needs; 3) a physical presence in the primary care site.