Variations in approaching the diagnosis of depression: a guided focus group study.

BACKGROUND: Primary care physicians are often held to the same standard of performance as mental health specialists, yet they face special challenges in recognizing and treating depression. The purpose of this study was to explore the range of approaches to diagnose depression. METHODS: A purposeful sample of 21 primary care physicians in three US cities participated. A semistructured series of questions and clinical cases stimulated discussions about recognizing and managing major and minor depression. The focus groups were videotaped, and data were analyzed by two independent reviewers using the classic method of content analysis. RESULTS: Primary care providers have three major ways of approaching the diagnosis of depression: a biomedical exclusionary approach, where investigation of all physical complaints occurs first; a mental health approach, where psychosocial aspects of a presentation are pursued first; and a synergistic approach, where physical and mental health complaints are addressed simultaneously. Physicians move freely across all approaches depending on patient cues. CONCLUSIONS: Physicians' approaches to depression vary depending on patient characteristics and cues. Through a better understanding of current practices, future researchers can identify the optimal clinical approaches to match the characteristics and cues of specific patients. This study informed the development of a larger objective study of primary care physician performance.

Using successful models of care to guide the teaching of psychiatry in primary care.

The focus of efforts to improve primary care physicians' recognition and treatment of psychiatric conditions has been on enhancing the content of their education, with little attention paid to the choice of models through which the content is delivered. The authors believe that existing models of primary care delivery are analogous to Strain's six basic models of teaching psychiatry to primary care physicians. Each model is especially suited to a particular segment of the primary care physician's education; for example, the consultation model has relevance for teaching about better management of identified patients and the bridge model for enhancing recognition of unrecognized disorders. All six models have a place in both education and practice.

The case for integration of social work psychosocial services into rural primary care practice.

This article argues for health and mental health collaboration between social workers and rural primary care physicians and describes a study of physicians' attitudes toward integrated services. The physicians who expressed interest in a collaborative arrangement differed in practice characteristics, attitudes toward social workers, and endorsement of social work roles. Also, interested physicians treated significantly more patients, had the lowest proportion of patients over age 65, and endorsed as useful a significantly larger number of social work activities. If social workers aspire to collaborative arrangements in rural primary care, they must provide excellent services now, continue to work toward a better understanding of their broad mental health competencies, and be willing to provide services that conform to the expectations and limitations of primary care.

Textbooks and software used to teach behavioral science and clinical psychiatry to medical students.

The authors discuss the results of a questionnaire sent to medical schools to assess textbooks and computer software used in teaching behavioral science and clinical psychiatry. Attributes concerning presentation, theoretical viewpoints, and topics covered were rated by 75 respondents. Certain texts emerged as frequently used. Although the books rated will become outdated, consumers can use the assessment attributes from the questionnaire to examine forthcoming texts. Authors considering new books or revisions may want to know why certain books are popular and to address areas identified as weak in existing textbooks. The software market needs entrees.

Choosing an antidepressant to treat depression.

Depression refers to both a symptom and a potentially life-threatening illness. Most patients with depression are seen by primary care physicians. Antidepressant medications are effective in up to 85 percent of patients with major depression. Most antidepressants tend to be equally effective. Drug selection is usually based on minimizing or taking advantage of certain side effects, including sedation and anticholinergic and cardiovascular effects. Some characteristics of patients, such as suicide potential, pregnancy, age and medical illness, also affect the choice of drug.

The relationship of alprazolam dose to steady-state plasma concentrations.

Alprazolam is a widely used antianxiety agent, yet relatively little is known about the relationship between chronic oral doses and steady-state plasma levels. This study examines the relationship over a wide range of therapeutic doses. We conducted a parallel, double-blind, placebo-controlled study in 36 patients with agoraphobia with panic attacks, or panic disorder with limited phobic avoidance based on DSM-III criteria. Patients received alprazolam (N = 25) or placebo (N = 11) beginning at 1 mg/day and increased weekly until either a maximum tolerated dose or 10 mg/day was achieved. Dosages were then gradually tapered according to a predetermined schedule. The entire study period lasted 14 weeks. Laboratory and clinical assessments were conducted weekly. Doses up to 6 mg/day were tolerated by 80% of patients on alprazolam and doses of 10 mg/day were tolerated by 40% of patients. Twenty-seven percent of the placebo patients reached 10 tablets/day. In the alprazolam group, the principal cause of intolerance was sedation. Throughout the study no significant changes in vital signs or laboratory parameters were observed. Steady state alprazolam, 4-hydroxy alprazolam, and alpha-hydroxy alprazolam plasma levels were linearly related to dose. A 1 mg dosage increment produced, on the average, a corresponding 10 ng/ml increase in steady state level of the parent drug. Significant response was observed in subjects who achieved concentrations greater than 20 ng/ml, with a maximum of 81% of the samples classified as responders within the 60 ng/ml and above group.(ABSTRACT TRUNCATED AT 250 WORDS)

Toward a resolution of contradictions. Utility of feedback from the GHQ.

Methodologic problems in prior research have contributed to contradictory findings about the effect of feedback from self-report questionnaires on the recognition of mental disorders in primary care settings. This study addresses those problems by assigning family practice resident physicians (N = 32), not their patients, to experimental and control groups, and by collecting baseline as well as postintervention data, for a total of 1040 patient encounters. The 28-item GHQ served as the screening instrument and was given to all participating patients seen by the experimental group. Following training in their interpretation, feedback of GHQ results constituted the intervention. Measures of recognition included a psychiatric diagnosis, psychologic and psychosocial chart notations, and various treatment options (e.g., therapy, consultation, referral, drugs, singly and in combination). Evidence for a diagnosis of mental disorder was limited to the Assessment portion of the SOAP note. Results indicate that GHQ feedback resulted in a significant twofold increase in the total number of psychiatric diagnoses. Recognition was heightened in all diagnostic categories, with a statistically significant increase in the number of depression diagnoses. Similarly, employment of all treatment modalities increased following feedback, although the only statistically significant increase was the prescription of antidepressant drugs. Psychologic notations increased as well, but psychosocial notations did not. Physicians who tended to recognize psychiatric morbidity at pretest benefited most from GHQ feedback. Implications for future research are discussed.

Unlearning psychiatry: a cohort effect in the training environment.

The purposes of this study were to investigate the relationship between 1) residents' psychiatric performance and their primary care training environment; 2) residents' psychiatric performance and their year of training; and 3) the utility of feedback from the General Health Questionnaire (GHQ) and the year of training. Resident physicians (N = 32) were assigned to experimental and control groups; feedback of GHQ results constituted the intervention in the experimental site. Baseline data, as well as post intervention data, were collected on a total of 1040 patient encounters. Residents' psychiatric performance was measured by notation of a mental disorder in the Assessment portion of the SOAP note. Results showed that control group residents achieved superior performance at pretest and, in spite of a two-fold increase in the number of psychiatric diagnoses following GHQ feedback, experimental site posttest diagnoses did not significantly exceed control site frequency. In addition, experimental site first-year residents outperformed second-year residents, who likewise outperformed third-year residents, in recognizing their patient's mental distress. Differences in patient morbidity, over-diagnosis by first-year residents, and failure to have acquired psychiatric skills when a first-year resident were all tested and rejected as explanations for the unexpected inverse relationship between performance and years in training. It was therefore concluded that integration of psychiatric knowledge and skills into a primary care practice may be profoundly (and negatively) influenced by factors in the residents' training environment.