Reflections on DSM classification and its utility in primary care: case studies in "mental disorders".

BACKGROUND: This case series was conducted to demonstrate the limitations of the DSM system in primary care patients. METHOD: Sixty family health center patients free of mental disorders according to DSM-IV criteria completed monthly quantitative interviews, using multiple rating instruments, concerning the levels of psychiatric symptoms, presence of distress and/or a mental disorder, functional status, support, and stressors. In addition, a purposive sample of 16 subjects completed an in-depth qualitative interview concerning their situation at the time they crossed a DSM threshold. Data were collected from April 2000 to March 2001. RESULTS: Overall, there were 14 subjects with distress alone, 6 subjects with subthreshold disorders, and 3 subjects with known transient (< 2 months' duration) threshold disorders. Thus, even with the incomplete longitudinal data in this study, the clinical needs of 23 (38%) of the original 60 subjects were inadequately met by the DSM criteria. From the 10 subjects who crossed a DSM threshold and completed a qualitative interview, we selected 5 case studies with the most complete and complementary quantitative and qualitative data to illustrate several findings regarding the utility of the DSM classification in primary care. First, these cases show that psychological symptoms and DSM disorders vary considerably. Second, distress and subthreshold disorders are often seen in primary care patients. Third, the crossing of a DSM threshold corresponds to extreme levels of psychological symptoms and may therefore represent symptom severity. Fourth, psychological symptoms are often linked to physical illness. Finally, the context in which these symptoms and disorders develop often produces complex dynamic patterns. CONCLUSIONS: The current DSM system failed to adequately reflect the spectrum and context of mental illness in patients from a predominantly low-income, Hispanic primary care population.

Collaborative care needs and preferences of primary care patients with multimorbidity.

OBJECTIVE To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses. DESIGN Focus groups utilizing a series of open-ended questions elicited self-identified problems, experiences in communicating with providers, self-management needs, and preferences for monitoring and follow-up. Responses were organized and interpreted in light of the essential elements of collaborative care for chronic illness. SETTING AND PARTICIPANTS Sixty patients having two or more chronic illnesses at eight geographically dispersed primary care clinics within the Veterans Health Administration in the United States. RESULTS Identified problems included poor functioning, negative psychological reactions, negative effects on relationships and interference with work or leisure. Polypharmacy was a major concern. Problematic interactions with providers and the health care system were also mentioned, often in relation to specialty care and included incidents in which providers had ignored concerns or provided conflicting advice. Most participants, however, expressed overall satisfaction with their care and appreciation of their primary care physicians. Knowledge and skills deficits interfered with self-management. Participants were willing to use technology for monitoring or educational purposes if it did not preclude human contact, and were receptive to non-physician providers as long as they were used to augment, not eliminate, a physician's care. CONCLUSIONS Findings are consistent with the basic tenets of patient-centred, collaborative care, and suggested that health care can be organized and delivered to meet the complex needs of patients with multimorbidity.

Multiethnic perspectives on elder mistreatment.

PURPOSE: We conducted this study to understand the interpretations of elder mistreatment (EM) in multiethnic older adults. DESIGN AND METHODS: Focus group sessions were held with three ethnically homogenous groups (n = 18) and a group of elder care professionals (n = 6) eliciting responses to vignettes depicting various types of elder mistreatment. Qualitative analysis of focus group transcripts was performed to define EM occurrence, its severity, and to identify the perpetrator and victim. RESULTS: Four main categories emerged: social expectations, caregiver expectations, victim characteristics, and characteristics of the interaction. Themes included issues of gender roles, filial obligations, martial commitments, and ageism as features of the vignette discussions. Professional and lay caregiver issues were features of the caregiver expectations. Mental capacity, physical dependency, physical attributes, and complicity were the victim characteristics discussed. The characteristics of the interaction that were identified included resistance to care, retaliation, habitual occurrence, and perpetrator intent. IMPLICATIONS: Older adults identify multiple factors influencing the interpretation of elder mistreatment. These factors may determine strategies for future EM intervention.

Improving efficacy of diabetes management using treatment algorithms in a mainly Hispanic population.

OBJECTIVE: To compare clinical outcomes obtained using treatment algorithms versus standard "usual care" to treat patients with type 2 diabetes in a community setting. RESEARCH DESIGN AND METHODS: An observational group comparison was implemented in three community-based clinics in San Antonio, Texas: 1). a community clinic following treatment algorithms (CC-TA), 2). university clinic following treatment algorithms (UC-TA), and 3). a community clinic following standard "usual care" practices (CC-SC). Three hundred fifty-eight recently diagnosed type 2 diabetic patients (90% Mexican American, from low-income neighborhoods) who were consecutively identified at the three clinics were recruited. Following medical and laboratory evaluation, participants were started on treatment for hyperglycemia, hypertension, and dyslipidemia and followed for 12 months. RESULTS: Decrements in HbA(1c) at 12 months in the CC-TA and UC-TA were 3.1 and 3.3%, respectively, compared to 1.3% in the CC-SC (P < 0.0001). Corresponding decrements in fasting plasma glucose at 12 months were 94 and 99 mg/dl, respectively, versus 38 mg/dl in CC-SC (P < 0.0001). Reductions in total cholesterol, LDL cholesterol, and triglycerides at 12 months were greater in both algorithm-managed clinics compared to standard care-managed clinics (P < 0.0001). In algorithm-managed clinics, there were 30% more documented eye exams and 24% more documented foot exams than in standard care-managed patients. CONCLUSIONS: Adherence to the treatment algorithms improved metabolic outcomes in type 2 diabetic patients to a greater extent than standard care practices. These results have important clinical implications for the treatment of type 2 diabetic patients.

Interview versus self-answer methods of assessing health and emotional functioning in primary care patients.

The present study examined differences in health and emotional functioning when two different methods of gathering self-report data were used. Of 80 primary care patients who did not meet screening criteria for a psychiatric diagnosis, 44 were randomly assigned to have an interviewer read assessment items and record the participants' responses, and 36 were randomly assigned to have an interviewer read the items and have participants record their own responses directly on the test forms. There were negligible significant differences between the groups in reported symptomatology. From a practical standpoint, this suggests that the self-answer method is a more economical and efficient method of data collection since the data from more than one participant can be gathered at the same time. The findings also suggest that the measures in this study which were originally intended to be completed in a paper-and-pencil format can be used in a more traditional interviewer-administered format.

Stage of change advancement for diabetes self-management behaviors and glucose control.

PURPOSE: This study was conducted to evaluate whether patients with type 2 diabetes who participated in diabetes education advanced through stages of change for self-management behaviors and to determine if movement was related to glucose control. METHODS: A cohort of 428 patients with type 2 diabetes participated in a traditional diabetes education program in a large urban center in the Southwest. The sample was predominantly female with less than a high school education, a mean age of 52 years, and a mean duration of diabetes of 7 years. Two interviews were conducted approximately 9 months apart, at 1 to 4 weeks before the educational program and at 6 months after completing it. Blood specimens were collected at each interview to measure hemoglobin A1C (A1C) levels. RESULTS: Most of the patients advanced 1 or more stages of change for at least 1 self-management behavior. Those with diabetes for less than 2 years were significantly more likely to advance at least 1 stage of change for diet and exercise than those with diabetes for more than 2 years. Such advancement was significantly associated with a decline in A1C. CONCLUSIONS: Patients with type 2 diabetes who participated in diabetes education advanced through stages of change for self-care behaviors. The intervention was more effective for those with a shorter duration of diabetes.

Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes.

BACKGROUND: The influence of continuity of care on outcomes of care for patients with type 2 diabetes is poorly understood. OBJECTIVE: To examine the relationships between continuity, glucose control, and advancement through stages of change for self-management behaviors. DESIGN: Prospective cohort study. SETTING: Five community health centers on the Texas-Mexico border. SUBJECTS: A random sample of 256 adults, 18 years of age and older with an established diagnosis of type 2 diabetes. MEASURES: Stage of change for diet and exercise were assessed during two patient interviews, averaging 18.9 months apart. Phlebotomy was performed at each interview to measure glycosolated hemoglobin (HbA1C). Medical records were abstracted for ambulatory care utilization. A continuity score was calculated based on the number of visits and number of providers seen. RESULTS: Patients who advanced one or more stages of change for diet had higher levels of continuity. As continuity improved, the change in HbA1C was smaller. (r = -0.25; P <0.001) This relationship remained significant after controlling for number of visits, months since diagnosis, number of days in the study, duration of diabetes, and advancement in stage of change for diet. Advancement through stage of change for diet explained a significant amount of the variance in the relationship between continuity and HbA1C (t test = -11.33; P <0.01). CONCLUSIONS: Continuity of care with a primary care provider is associated with better glucose control among patients with type 2 diabetes. This relationship appears to be mediated by changes in patient behavior regarding diet.

Psychometric assessment of measures of psychological symptoms, functional status, life events, and context for low income Hispanic patients in a primary care setting.

This study assessed the psychometric properties of a set of nine commonly used lists in an English-speaking Hispanic sample taken from a primary care setting. Those were the General Health Questionnaire-12, the Anxiety, Depression, and Somatization scales from the SCL-90, the Medical Outcomes Study Short Form-36, the Holmes and Rahe Family Life Changes, abbreviated versions of the Daily Hassles and Uplifts, the Herth Hope Index, Duke Social Support and Stress scales, Alcohol Use Disorders Identification Test, and Marlowe-Crowne Brief Social Desirability Scale. 68 adult patients completed the measures via structured interview. Internal consistency was measured using Cronbach alpha and the Kuder-Richardson-20. Construct validity was assessed using Pearson correlations among sets of scores. Internal consistencies were good-to-excellent for all measures except for the Duke Social Support and Stress scales (Stress scale), and the Brief Social Desirability Scale. Construct validity was suggested for all except the Mental Health and Energy/Fatigue scales of the Short Form-36. Further study is needed to verify these results in other Hispanic populations and to address other forms of reliability and validity.