Cognitive impairment in bipolar disorder in old age: literature review and findings in manic patients.

BACKGROUND: Descriptions of aged patients with bipolar (BP) disorder have commented on cognitive impairments. However, the literature regarding cognitive test performance in this population has apparently been scant. METHOD: 1. We reviewed studies reporting cognitive performance in aged BP patients. 2. We compared the performance of elderly BP manic patients and aged community comparison subjects on the Mini-Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS). RESULTS: 1. Seven published studies of cognitive measures in aged BP patients were identified. They utilized different assessment methods and addressed different illness states, but they indicate impairments in these patients. 2. In our sample, the manic patients (n=70) had lower MMSE scores and DRS scores than did the comparison subjects (n=37). In these patients, cognitive scores were not significantly associated with Mania Rating Scale scores. LIMITATIONS: The patients in our study were assessed cross-sectionally, and they were treated naturalistically. CONCLUSIONS: Manic or depressed BP elders have impaired cognitive function; in some patients these impairments may persist. Research characterizing these impairments and their clinical implications is warranted.

The effect of patient and visit characteristics on diagnosis of depression in primary care.

OBJECTIVES: The purpose of our study was to determine if factors other than the patient' clinical presentation were associated with the likelihood of depression being recognized during a physician office visit. STUDY DESIGN: We used a cross-sectional design. POPULATION: Data from the 1997 and 1998 National Ambulatory Medical Care Surveys were examined. OUTCOMES MEASURED: We assessed the association of factors such as age, sex, race, physician specialty, type of insurance, and visit duration with a recorded depression diagnosis during office visits to primary care physicians. RESULTS: After controlling for symptom presentation, primary care physicians were 56% less likely to record a diagnosis of depression during visits made by elderly patients, 37% less likely to do so during visits by African Americans, and 35% less likely to do so during visits by Medicaid patients. Visits with a depression diagnosis were, on average, 2.9 minutes longer in duration (16.4 vs 19.3) than visits without a depression diagnosis. Family practice and general practice physicians were 65% more likely to record a diagnosis of depression than internists. CONCLUSIONS: Many factors were associated with making and recording a depression diagnosis beyond the patient' reported symptoms. If rates of diagnosis are to improve, interventions that go beyond getting physicians to recognize the symptoms of depression are needed.

Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation.

Although poor psychological adjustment to organ transplantation appears to be a major contributor to reduced quality of life and increased physical morbidity, the prevalence and risk factors for psychiatric disorder have not been considered beyond the first 12-18 months after transplantation. The authors enrolled a representative sample of 191 heart transplant recipients in a prospective examination of the prevalence, clinical characteristics, and risk factors for DSM-III-R major depressive disorder (MDD), generalized anxiety disorder (GAD), associated adjustment disorders, and posttraumatic stress disorder related to transplant (PTSD-T) during the 3 years postsurgery. Survival analysis indicates that cumulative risks for disorder onset were MDD, 25.5%; adjustment disorders, 20.8% (17.7% with anxious mood); PTSD-T, 17.0%; and any assessed disorder, 38.3%. There was only one case of GAD. PTSD-T onset was limited almost exclusively to the first year posttransplant. Episodes of MDD (but not anxiety disorders) that occurred later posttransplant (8 to 36 months postsurgery) were more likely than early posttransplant episodes to be treated with psychotropic medications. For both MDD and anxiety disorders, later episodes were less likely to be precipitated by transplant-related stressors than other life stressors. Factors increasing cumulative risk for psychiatric disorder posttransplant included pretransplant psychiatric history, female gender, longer hospitalization, more impaired physical functional status, and lower social supports from caregiver and family in the perioperative period. Risk factors' effects were additive; the presence of an increasing number of risk factors bore a dose-response relationship to cumulative risk of disorder.

The benefits of a broader perspective in case-finding for disease management of depression: early lessons from the PROSPECT Study.

The PROSPECT (Prevention of Suicide in Primary Care Elderly - Collaborative Trial) Study evaluates collaborative care for the treatment of current depressive disorders in older primary care patients. Using screening data, we evaluate implications of expanding the focus to additional patients who report taking psychotropic medication or having a history of depression. Some 13.8% of the patients screened were taking a psychotropic medication and 7.3% were both taking an antidepressant and had a Center for Epidemiologic Studies - Depression Scale (CES-D) score of > 15. Patients who reported current antidepressant use and those with a history of depression also had elevated CES-D scores. Conversely, most patients having an elevated CES-D score also reported taking an antidepressant or having a history of depression. These latter criteria for potential caseness yielded a larger number of patients than those identified by the CES-D alone. More comprehensive approaches to the management of depression should attend to patients already taking psychotropic medication and symptomatic patients with a history of depression, as well as those with current syndromal depression.

Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm.

PROSPECT (Prevention of Suicide in Primary care Elderly-Collaborative Trial) is testing whether a trained clinician (the 'health specialist') can work in close collaboration with a primary care physician to implement a comprehensive depression management program and improve outcomes in older depressed patients. An algorithm guiding the selection and use of antidepressant medications has been developed to assist PROSPECT health specialists. This algorithm is presented and the rationale underlying the proposed treatment sequence is discussed. The PROSPECT algorithm builds upon existing guidelines after updating them and adapting them to the special circumstances of older primary care patients. Special attention has been paid to the tolerability and the target doses of the recommended antidepressant agents and to the duration of antidepressant trials. Patients who are unable to tolerate or do not respond to an antidepressant can be switched to another agent or be treated with interpersonal psychotherapy. Agents that produce only a partial response can be combined with other antidepressants or with interpersonal psychotherapy. Treatments for which empirical evidence exists are favored. However, treatments that are often poorly tolerated by elderly patients are given lower priority than treatments more likely to be tolerated. Similarly, trials that are simpler to implement in primary care are favored.

Managing late-life depression in primary care practice: a case study of the Health Specialist's role.

Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.

Treatment as usual (TAU) control practices in the PROSPECT Study: managing the interaction and tension between research design and ethics.

The use of treatment as usual (TAU) as a control condition may pose the considerable challenge of maintaining both scientific rigor and meeting high ethical standards in experiments on human subjects. The authors illustrate the tension and explore the relationship between research design and ethics, especially the interaction between the two, in the NIMH-funded PROSPECT study (Prevention of Suicide in Primary Care Elderly - Collaborative Trial). The goal of PROSPECT is to determine whether placement of a depression health specialist in primary care practices will have a favorable impact on rates of depression, hopelessness and suicidal ideation in elderly primary care patients with major or persistent minor depression. PROSPECT randomly assigns practices either to an intervention arm (which includes the provision of depression health specialists) or to an enhanced care arm (TAU, with the addition of screening and assessment services). TAU, enhanced by the provision of screening and assessment services, is to be used as a benchmark for measuring the effectiveness of PROSPECT's intervention. However, TAU in the epidemiological and clinical literature has also been linked to high rates of suicide in the elderly related to unrecognized and untreated or under-treated depression. The authors present their approach to managing the tension, or interaction, between the use of TAU for scientific and public health purposes and the requirement for beneficence, that is, the duty to assure the safety of human subjects in research and to do no harm. Through enhancements of TAU, by the provision of information to primary care physicians concerning the psychiatric status of their patients, the investigators attempt to meet the challenge of maintaining rigor and meeting high ethical standards.

The electronic medical record. A randomized trial of its impact on primary care physicians' initial management of major depression [corrected].

BACKGROUND: Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions. METHODS: Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months. RESULTS: Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions. CONCLUSIONS: Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.

Narrowing the gap in treatment of depression.

OBJECTIVE: Although effective treatments for depression exist, under or non-treatment of depression is common. Efforts were made in the early 1990s to improve recognition and treatment of depression, with many of those efforts targeted at groups most vulnerable to under-treatment. The purpose of this study is to assess treatment rates in 1993-1994 and 1996-1997. METHOD: Using nationally representative surveys of office-based practice covering the years 1993, 1994, 1996, and 1997, we obtained estimates of visits by adults in which depression was diagnosed and a prescription for antidepressant medication and/or psychotherapy was provided or ordered. RESULTS: The proportion of physician office visits in which a depression diagnosis was recorded did not change from 1993-1994 (3.48 percent) to 1996-1997 (3.40 percent). However, the rate of antidepressant prescription or psychotherapy rose from 74.2 percent of visits with a depression diagnosis in 1993-1994 to 82.3 percent of these visits in 1996-1997. Significantly lower rates of treatment for depression during office visits made by African American patients, elderly patients, and patients on Medicaid occurred in 1993-1994, but were not evident in 1996-1997, reflecting improved rates of depression treatment in these populations. CONCLUSIONS: Although rates of diagnosis of depression during office visits have not increased, treatment rates for depression are improving among those who are diagnosed, including groups of people who historically were less likely to be offered treatment. Additional efforts to improve recognition and diagnosis of depression in ambulatory medical practice and to improve dissemination of treatment are needed.

General medical and specialty mental health service use for major depression.

OBJECTIVE: While major depression is common, many depressed persons receive, at best, inadequate treatment. A first step in remedying inadequate detection and treatment of major depression requires understanding the pathways into treatment-from situations of no care, to disease recognition, to referral and appropriate treatment-as well as identifying factors associated with movement between these several stages. METHODS: Using the Epidemiologic Catchment Area sample, we identified factors associated with treatment in the general medical or mental health specialist section, or no treatment in a subsample of individuals with current major depression. RESULTS: Strikingly, one-fourth of the sample received no services, over half received care in the general medical sector, and only one-fifth accessed a mental health specialist. Among those receiving any health services (general or mental), men and respondents reporting suicidal symptoms were at risk of receiving no care, while perceived poor health and a cluster of core depressive symptoms were associated with increased odds of service use (general or mental). Among respondents receiving general medical services, perceived poor health, core depressive symptoms, a history of depression, and comorbid mental conditions increased the odds of treatment in the specialty mental health sector. CONCLUSIONS: The findings emphasize the need for public health initiatives to 1) improve detection and movement into treatment among those at risk of receiving no care; and 2) insure that, once within the health care system, the processes of primary care treatment and specialty referrals conform to evidence-based treatment guidelines.

Factors associated with symptomatic improvement and recovery from major depression in primary care patients.

This article describes a post-hoc analysis of clinical and psychosocial factors and beliefs about health associated with treatment outcome in a sample of depressed primary care patients (N=181) randomly assigned to a standardized treatment or physician's usual care (UC). Different factors were found to predict clinical outcomes for treatment modality [UC vs. interpersonal psychotherapy (IPT) or nortriptyline (NT)] and the type of outcome evaluated (i.e., depressive symptoms at 8 months or symptomatic and functional recovery at 8 months). Factors associated with treatment-specific outcomes are also described. Consistent with prior studies, lower depressive symptom severity at 8 months was associated with higher baseline functioning, minimal medical co-morbidity, race, and standardized pharmacologic or psychotherapeutic treatment. Additionally, an interaction between treatment modality and health locus of control indicated that individuals perceiving more self-control of their health and who received a standardized treatment experienced greater depressive symptom reduction at 8 months. Factors associated with symptomatic and functional recovery from the depressive episode were also examined. Patients who received a standardized treatment (IPT or NT) perceived greater control of their health and lacked a lifetime generalized anxiety disorder or panic disorder were more likely to recover by month 8 than those who received usual care. While clinical severity and treatment adequacy play an important role in both symptomatic improvement and full recovery from a depressive episode, other key factors such as health beliefs and non-depressive psychopathology also influence recovery.

Comorbid anxiety disorders in depressed elderly patients.

OBJECTIVE: Anxiety disorders are common in adults with depressive disorders, but several studies have suggested a relatively low prevalence of anxiety disorders in older individuals with depression. This cross-sectional study measured current and lifetime rates and associated clinical features of anxiety disorders in depressed elderly patients. METHOD: History of anxiety disorders was assessed by using a structured diagnostic instrument in 182 depressed subjects aged 60 and older seen in primary care and psychiatric settings. Associations between comorbid anxiety disorders and baseline characteristics were measured. The modified structured instrument allowed detection of symptoms that met inclusion criteria for generalized anxiety disorder in a depressive episode. RESULTS: Thirty-five percent of older subjects with depressive disorders had at least one lifetime anxiety disorder diagnosis, and 23% had a current diagnosis. The most common current comorbid anxiety disorders were panic disorder (9.3%), specific phobias (8.8%), and social phobia (6.6%). Symptoms that met inclusion criteria for generalized anxiety disorder, measured separately, were present in 27.5% of depressed subjects. Presence of a comorbid anxiety disorder was associated with poorer social function and a higher level of somatic symptoms. Symptoms of generalized anxiety disorder were associated with a higher level of suicidality. CONCLUSIONS: Contrary to previous reports, the present study found a relatively high rate of current and lifetime anxiety disorders in elderly depressed individuals. Comorbid anxiety disorders and symptoms of generalized anxiety disorder were associated with a more severe presentation of depressive illness in elderly subjects.

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.

Effectiveness of treatments for major depression in primary medical care practice: a post hoc analysis of outcomes for African American and white patients.

OBJECTIVE: To retrospectively determine whether race differentially influences treatment adherence and clinical outcomes among 68 African Americans and 92 whites treated for major depression in four urban, primary care settings. METHOD: Study participants were randomly assigned to standardized interpersonal psychotherapy or pharmacotherapy with nortriptyline, and were assessed at baseline, and successive time points up to 8 months for severity of depression, and mental and physical health-related functioning. RESULTS: Intent-to-treat analyses revealed no treatment or race-specific differences in symptomatic recovery when both groups were provided standardized psychotherapy or pharmacotherapy. However, African Americans had poorer functional outcomes than whites. CONCLUSIONS: African American and white primary medical care patients are effectively treated with standardized psychotherapy and pharmacotherapy. Future research should assess the impact of cultural context on symptom presentation, psychosocial functioning, and treatment adherence and response.

Best clinical practice: guidelines for managing major depression in primary medical care.

Practice guidelines such as those of the United States Public Health Service Agency for Health Care Policy and Research have been instrumental in addressing the significant problem of how best to manage major depression in primary medical care settings. Since this set of guidelines was published in 1993, new findings from randomized clinical trials and extensive clinical experience permit us to reevaluate trends in treatment of major depression in primary medical care. This review suggests guidelines for achieving best clinical practice given current knowledge.

Anxiety disorders among African-American and white primary medical care patients.

The prevalence of current anxiety disorders and associated clinical patterns was examined in a sample of 125 African American and 120 white primary medical care patients between ages 18 and 64. Patients who indicated they had at least one mood or anxiety symptom in response to a screening questionnaire were interviewed to determine the presence of a DSM-IV anxiety, mood, or possible alcohol abuse disorder. Demographic data and data on mental- and physical-health-related functioning and health service utilization were also collected. The authors found no racial differences in the proportions of patients who met DSM-IV criteria for the disorders, nor in their symptom patterns, level of functional disability, or rates of health and mental health service utilization.

The electronic medical record: its role in disseminating depression guidelines in primary care practice.

OBJECTIVE: Using the Agency for Health Care Policy and Research Depression Guideline Panel's recommendations as its focus, this article describes a step-by-step approach for disseminating a paper-based depression guideline to primary care physicians via a commercially available electronic medical record (EMR) system. METHOD: Description of the author's approach to disseminate an evidence-based depression treatment guideline to a group of primary care physicians using a commercially available EMR system and to evaluate the results. RESULTS: We review clinical considerations and practical barriers faced in this process with the expectation that our experiences can guide others attempting to disseminate psychiatric treatment guideline via EMR systems. CONCLUSIONS: The EMR offers critical efficiencies in disseminating state-of-the-art clinical practice guidelines and in directing the primary care physicians' use of them. Still, well-designed, randomized controlled trials are necessary to demonstrate their effectiveness at enhancing patient outcomes for major depression in primary care settings.