The effect of underlying health status on patient or surrogate preferences for end-of-life care: a pilot study.

This study explored the role of health status, as measured by the Palliative Performance Score, in shaping patient preferences for end-of-life care. Scores were correlated with 3 potential goals of care: prolonging life, maintaining function, and maximizing comfort among patients seen in palliative care consultation. Eighty-six patients expressed treatment preferences: 16 (19%) preferred prolonging life, 23 (27%) preferred maintaining function, and 47 (54%) preferred maximizing comfort (P < .0001); their average scores +/- standard deviation were, respectively, 51.9 +/- 19.4, 56.5 +/- 16.7, and 45.3 +/- 14.1 (P = .0459). There was a significant relationship between patient preferences and Palliative Performance Score, with lower scores indicating preferences for comfort and higher scores indicating a preference for maintaining function and life expectancy. Further research is needed to test the sensitivity of health status, as measured by the Palliative Performance Score, in affecting patient preferences.

Provider and patient characteristics associated with antidepressant nonadherence: the impact of provider specialty.

OBJECTIVE: Given the widespread use of anti-depressants in primary care and specialty populations, we sought to examine whether provider specialty and patient demographic and clinical characteristics were associated with nonadherence to antidepressant therapy. METHOD: We conducted an observational cohort study of 11,878 patients enrolled in Harvard Pilgrim Health Care who were newly treated with antidepressants between May 2002 and May 2004. Using generalized estimating equations, we examined predictors of 2 types of anti-depressant nonadherence: (1) immediate non-adherence: never refilling an antidepressant prescription; and (2) 6-month nonadherence: refilling an antidepressant prescription at least once, but not satisfactorily completing a 6-month treatment episode. RESULTS: Compared with patients treated by primary care physicians (PCP), being treated by a psychiatrist was associated with significantly lower odds of immediate nonadherence (PCP 18% vs. psychiatrist 13%). Being treated by another type of specialist was associated with significantly higher odds of both immediate (other specialist 23%) and 6-month nonadherence (PCP 53%, psychiatrist 49%, other specialist 62%). Treatment by multiple providers was associated with lower odds of nonadherence than being treated by only 1 provider. Younger patient age and use of pain medication were associated with greater nonadherence. CONCLUSION: Rates of both immediate and 6-month nonadherence are high, and clinicians should emphasize the importance of continuing antidepressant treatment for a sufficient duration. Patients whose depression treatment is initiated by nonpsychiatric specialists may benefit from collaborative care models. These strategies may enable providers to better manage the long-term disability associated with their patients' depression.

Depression and cost-related medication nonadherence in Medicare beneficiaries.

CONTEXT: Treatment for depression can be expensive and depression can affect the use of other medical services, yet there is little information on how depression affects the prevalence of cost-related medication nonadherence (CRN) in elderly patients and patients with disabilities. OBJECTIVE: To quantify the presence of CRN in depressed and nondepressed elderly Medicare beneficiaries and nonelderly Medicare beneficiaries with disabilities prior to the implementation of the Medicare Drug Benefit. DESIGN AND SETTING: 2004 Medicare Current Beneficiary Survey. PARTICIPANTS: Depressed and nondepressed elderly Medicare beneficiaries and beneficiaries with disabilities. MAIN OUTCOME MEASURES: Cost-related medication nonadherence included taking smaller doses or skipping doses of a prescription to make it last longer, or failing to fill a prescription because of cost, controlling for health insurance status, comorbid conditions, age, race, sex, and functional status. RESULTS: In a nationally representative sample of 13 835 noninstitutionalized elderly Medicare enrollees and Medicare enrollees with disabilities, 44% of beneficiaries with disabilities and 13% of elderly beneficiaries reported being depressed during the previous year. Among enrollees with disabilities reporting depressive symptoms, 38% experienced CRN compared with 22% of enrollees with disabilities who did not report depressive symptoms. Among elderly enrollees who reported depressive symptoms, 19% experienced CRN, compared with 12% of elderly enrollees who did not report such symptoms. In adjusted analyses, depressive symptoms remained a significant predictor of CRN in both groups (persons with disabilities: odds ratio, 1.7; 95% confidence interval, 1.3-2.3; elderly persons: odds ratio, 1.4; 95% confidence interval, 1.1-1.7). CONCLUSIONS: Depressive symptoms were associated with CRN in elderly Medicare enrollees and Medicare enrollees with disabilities. Providers should elicit information on economic barriers that might interfere with treatment of Medicare beneficiaries with depression.

Mutuality and specificity of mental disorders in advanced cancer patients and caregivers.

BACKGROUND: We sought to determine mutuality and specificity in rates of mental disorders between advanced cancer patients and their caregivers. METHOD: Data from 168 non-genetically related patient-caregiver dyads participating in the multi-site Coping with Cancer (CWC) study were included in this analysis. Multivariate logistic regression analyses were conducted to examine associations between diagnoses of a psychiatric disorder in patients with diagnoses of psychiatric disorders in caregivers, and vice versa, controlling for confounders. RESULTS: When patients met criteria for any psychiatric diagnosis, then caregivers were 7.9 times (P < 0.0001) more likely to meet criteria for any psychiatric diagnosis, and vice versa. Caregiver Panic Disorder (PD) diagnosis was associated with patient Generalized Anxiety Disorder (GAD). Patient GAD was also associated with caregiver PD. Finally, patient PD was associated with caregiver GAD and caregiver Post-Traumatic Stress Disorder (PTSD). CONCLUSIONS: To our knowledge, this is the first study that demonstrates the mutuality of psychiatric disorders in both advanced cancer patients and their informal caregivers. Specifically, the presence of anxiety disorders in one partner (either caregiver or patient) was associated with a greater likelihood of anxiety disorders in the other. Results suggest that psychiatric distress should be assessed in both patients and their caregivers, and that mental illness in one should raise concern about the possibility of a psychiatric disorder in the other. Results also suggest that targeted interventions to address shared fears and concerns of patients and caregivers might reduce anxiety in the end phases of the patient's illness.

Physician alerts to increase antidepressant adherence: fax or fiction?

BACKGROUND: Many managed care organizations use feedback based on electronically maintained claims data to alert physicians to potential treatment problems, including patient medication nonadherence. However, the efficacy of such interventions for improving adherence among patients treated for depression is unknown. METHODS: We examined an antidepressant compliance program consisting of faxed alerts to physicians beginning May 2003 using interrupted time series analysis to evaluate its impact on rates of antidepressant adherence between May 2002 and May 2004 among members of the managed care plan of Harvard Pilgrim Health Care, which is a health plan operating in 3 states in New England, with corporate headquarters in Wellesley, Mass. The program alerted prescribing physicians to patients with gaps of more than 10 days in refilling antidepressant prescriptions during the first 180 days of treatment. Our outcome measures were rates of nonadherence among patients with refill gaps of more than 10 days ("delayed refill") and proportion of days without treatment within the first 180 days of treatment. RESULTS: A total of 13 128 patients (> or = 18 years of age) who were starting treatment with antidepressants met the study criteria. Rates of nonadherence among patients with delayed refills remained constant (P = .22) over the 2-year study period, averaging 75% (95% confidence interval, 72.7%-77.3%). Rates of antidepressant nonadherence significantly increased over time (P = .04), with an average of 40% (95% confidence interval, 38.4%-41.6%) of days without dispensed antidepressants available during treatment episodes. CONCLUSIONS: Using real-time pharmacy information to alert physicians regarding patient adherence was not successful in increasing antidepressant adherence rates among members of the managed care plan. Effectiveness of electronically triggered, patient-specific, faxed feedback should be carefully evaluated before widespread implementation, because faxes are insufficient as a stand-alone policy tool.

The Stigma Receptivity Scale and its association with mental health service use among bereaved older adults.

The purpose of this article was to determine whether the Stigma Receptivity Scale (SRS) predicts use of mental health services among community-dwelling bereaved older adults. We analyzed interviews of 135 people in Connecticut to evaluate whether three subscales and 12 SRS items were associated with access to any mental health service in the past 60 days using logistic regression analysis. Two SRS items predicted recent use of mental health services among bereaved individuals with and without complicated grief: receptivity to a bereavement support group (adjusted OR = 5.14; 95% CI, 1.11, 23.85) and individuals who were not concerned about meeting criteria for a mental illness (adjusted OR = 0.07; 95% CI, 0.01, 0.58). The SRS significantly predicted recent access to mental health treatment among bereaved elderly people. This type of measure could be used to determine those most likely in need of education and support to increase their likelihood of accessing mental health services.

Characteristics of aggression in clinically referred children.

OBJECTIVE: We investigated the phenomenology of aggression in a group of psychiatrically referred children and in a comparison group of children. INTRODUCTION: Children (N=275) were evaluated at a pediatric psychopharmacology clinic in an academic medical center and compared with 100 non-referred children from the community. To assess the influence of several predictors on the child's level of clinical impairment we conducted stepwise regression analyses. RESULTS: Aggression occurred across many different psychiatric diagnoses in psychiatrically referred children. Aggression in referred children was more frequent, physical, intense, lasted for a longer duration per episode, was more resistant to intervention, and occurred at an earlier age of onset in contrast with comparison children. Controlling for psychiatric diagnosis and demographic variables, family income and number of aggressive episodes in the last 6 months were the only significant predictors of child impairment. DISCUSSION: Phenomenologically, aggression may be more maladaptive in children with a psychiatric disorder compared with non-referred youths. These phenomenological differences in characteristics of aggression support the concept of an aggressive syndrome in psychiatrically referred children. CONCLUSION: Results support the need for development of specific treatment interventions for excessive maladaptive aggression independent of psychiatric diagnosis in referred children and adolescents.

The effect of a telephone counseling intervention on self-rated health of cardiac patients.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of a telephone-based intervention on psychological distress among patients with cardiac illness. METHODS: We recruited hospitalized patients surviving an acute coronary syndrome with scores on the Hospital and Anxiety Depression Scale (HADS) indicating mild to severe depression and/or anxiety at 1 month postdischarge. Recruited patients were randomized into either an intervention or control group. Intervention patients received up to six 30-minute telephone-counseling sessions focused on identifying cardiac-related fears. Control patients received usual care. For both groups, we collected patients' responses to the HADS and to the Global Improvement (CGI-I) subscale of the Clinical Global Impressions (CGI) Scale at baseline and at 2, 3, and 6 months postbaseline using Interactive Voice Recognition (IVR) technologies. We used mixed-effects analysis to estimate patients' changes in CGI-I measures over the three time points of data collection postbaseline. RESULTS: We enrolled 100 patients, and complete CGI-I measures were collected for 79 study patients. The mean age was 60 years (standard deviation = 10), and 67% of the patients were male. A mixed-effects analysis confirmed that patients in the intervention group had significantly greater improvements in self-rated health (SRH) between baseline and month 3 than the control group (p = .01). Between month 3 and month 6, no significant differences in SRH improvements were observed between the control and intervention groups. CONCLUSIONS: Study patients reported greater SRH improvement resulting from the telephone-based intervention compared with control subjects. Future research should include additional outcome measures to determine the effect of changes in SRH on patients with comorbid physical and emotional disorders.

Using the Hospital Anxiety and Depression Scale to screen for depression in cardiac patients.

OBJECTIVE: There is an increasing interest in trying to identify patients with chronic physical illness who would benefit from interventions to decrease psychological distress. The Hospital Anxiety and Depression Scale (HADS) is one measure that can be effectively used to identify patients struggling with anxiety and/or depression in addition to comorbid medical illness such as cardiac disease. The aim of this study is to determine if the HADS correctly identified patients with depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [determined using the Primary Care Evaluation of Mental Disorders (PRIME-MD), a gold-standard diagnostic tool], as depressed and to determine which items on the HADS most strongly predicted the PRIME-MD major depression diagnosis among cardiac patients. METHOD: Patient data were obtained from a randomized controlled trial of treatment for psychological distress in patients surviving recent myocardial infarction or life-threatening ischemic heart disease. The HADS was used to evaluate depression and/or anxiety among patients hospitalized for heart disease, and the PRIME-MD was used to diagnose major depressive disorder (MDD) in these patients. We used receiver-operating characteristic (ROC) curves and logistic regression to analyze patient responses to both of these measures. RESULTS: Among the 79 study patients, the area under the ROC curve (AUC) for the HADS depression subscale was 0.81 with an S.E. of 0.05, and the AUC was 0.70 for the HADS anxiety subscale with an S.E. of 0.06. Using a cutoff of 7 on each HADS subscale to determine PRIME-MD diagnosis of MDD, the sensitivity and specificity were 81% and 54%, respectively, for the depression subscale and 81% and 40%, respectively, for the anxiety subscale. In addition, a few individual HADS items predicted PRIME-MD diagnosis of MDD, namely, concentration and positive anticipation (depression items) and relaxed and worry (anxiety items), each of which were strongly correlated with PRIME-MD diagnosis of MDD. Finally, items positive anticipation and relaxed provided reasonable approximations to the results found from the HADS depression subscale measure, which performed better than the HADS anxiety subscale in predicting PRIME-MD diagnosis of depression. CONCLUSIONS: Using the HADS to detect mental disorders in primary care populations can save valuable physician time, and perhaps ensure that patients are treated for their mental distress as well as medical disease.