Assessment and treatment of geriatric depression in primary care settings.

OBJECTIVE: To examine primary care physicians' practices relating to the diagnosis and management of geriatric depression, attitudes regarding responsibilities for and barriers to management, self-assessments of their needs in providing this care, and physician characteristics that correlate with attitudes and practices. DESIGN: Descriptive and analytic needs assessment. SETTING: A midwestern city and surrounding county and the suburb of another midwestern city. MEASUREMENTS: A self-administered survey consisting mainly of close-ended, Likert scale questions. PARTICIPANTS: One hundred forty-one family physicians and general internists (53.2%) responded. Respondents were 75.4% male and 50.8% general internists and ranged in age from 29 to 75 years (mean, 43 years; SD, 11 years). RESULTS: No standard test to screen for depression was used by 66.7% of respondents. The 2 most common laboratory studies ordered were thyroid studies (41.1%) and chemistry panels (37.6%). Selective serotonin reuptake inhibitors were most commonly prescribed for depression (53.2%). Although 98.6% of respondents agreed that treatment of depression in elderly patients was important, 29.0% reported that depressed elderly patients frustrated them, and 24.2% were too pressured for time to routinely investigate depression in the elderly. The most frequently identified needs in caring for these patients were increased time with patients (97.1%); increased reimbursement for counseling (87.8%); greater emphasis in medical training on the link between physical and mental health (85.6%); improved patient compliance with treatment (84.3%); and more training and attention to depression in residency (82.1%). In general, family physicians were more active and positive in their approach toward geriatric depression. CONCLUSIONS: Potential interventions to improve the diagnosis and management of geriatric depression include the following: use of screening instruments in a more efficient and timely manner; increased reimbursement for counseling of patients; more educational programs at the undergraduate, graduate, and continuing medical education levels; and clinical practice guidelines specific to geriatric depression.

Payment mechanism and patterns of use of medical services: the example of hypertension.

This study explores the relationship between the use of medical services by hypertensive patients and mechanisms for payment within a single primary care practice. Three payment mechanisms were explored: public assistance, a capitated health maintenance organization (HMO), and fee-for-service. Patterns were examined across reimbursement type for the following variables: age, sex, visit reason, number of visits, medications, tests ordered, referrals made, and recommendations for follow-up visits. Illness severity was controlled in two ways: (1) by the study being focused on one diagnosis--mild to moderate hypertension, and (2) by concurrent chronic illnesses being enumerated and included in the analysis. Medical visits to the physician were examined over a 2-year period for 25 to 30 patients randomly sampled from each of the three payment mechanisms. Statistically significant differences were found for patient behaviors (total number of patient visits) and physician behaviors (number of medications and recommendations for revisits). The highest visit frequency was found for those on public assistance, followed closely by those covered by an HMO, and more distantly by those choosing fee-for-service. In a climate of cost consciousness, further study is needed to explore the impact of reimbursement mechanisms on the use of health care services.

Congenital hypothyroidism.

This paper presents a case report of congenital hypothyroidism that illustrates some of the issues in screening for this disorder. Congenital hypothyroidism has several causes, the most common of which is thyroid dysgenesis. Most affected infants have no historical clues or physical findings to suggest diagnosis. Neonatal screening combining thyroxine and thyrotropin screening have resulted in increased detection, although false-negatives do occur, and the physician must carefully observe all newborns for the findings of congenital hypothyroidism. Early treatment improves the prognosis considerably. This paper reviews the pathophysiology, diagnosis, and treatment of congenital hypothyroidism.

Bloody nipple discharge.

Bloody nipple discharge is a complaint that worries both the patient and the physician. Unlike other types of nipple discharge, it signals intrinsic breast disease. A benign etiology is the rule rather than the exception, but this symptom warrants careful evaluation. If there is no palpable mass or mammographic abnormality, bloody discharge from a single duct in a nonpregnant young woman is usually due to a benign intraductal papilloma.