Assessing cow-calf welfare. Part 1: Benchmarking beef cow health and behavior, handling; and management, facilities, and producer perspectives.

Assessment programs are one way beef producers communicate information about animal welfare to retailers and the public. Programs that monitor cattle through the production cycle (e.g., the Global Animal Partnership) or at individual stages (e.g., slaughter; the North American Meat Institute) exist, but to date, there is no assessment program addressing welfare specifically in the cow-calf sector. The objectives of this study were to measure cow-calf health and handling welfare outcomes and gather management, facility, and producer perspective information to 1) describe current practices and 2) inform assessment design. A welfare assessment, designed using features of similar beef and dairy programs, was conducted on 30 California ranches that varied in size (mean 1,051 cows [SD 1,849], range 28 to 10,000 cows) and location within the state. Cattle health and behavior and stockperson handling were measured during a routine procedure (e.g., pregnancy checks) on breeding females ( = 3,065). Management and producer perspectives were evaluated through an interview, and facility features were recorded at the chute and water access points. Cattle health problems were rare and seen only on specific ranches (e.g., prevalence of lame cattle: mean 1.3% [SD 1.5], range 0 to 7.1%). Cattle behavior and stockperson handling varied between ranches (e.g., cattle balking: mean 22.0% [SD 21.9], range 1.6 to 78.3%; electric prod use: mean 23.5 [SD 21.5], range 0 to 73.0%). Although some management and facility characteristics were shared by most (e.g., all ranches castrated bull calves; 86% used alleyways with an anti-back gate), other aspects varied (e.g., weaning age: mean 8.2 mo [SD 1.4], range 6 to 11 mo; 43% used shade cover over chute). Most producers shared similar perspectives toward their herd health management plan, but their responses varied when asked to evaluate an animal's pain experience. In terms of assessment design, there were challenges with feasibility (e.g., scheduling a ranch visit on a day cattle were processed was difficult), validity (e.g., cattle may back up calmly to adjust posture or quickly in response to an aggressive handler; without this context, the welfare implications of this behavior are unclear), and comparability (e.g., an explicit animal observation period needed to be defined to make comparisons across ranches). Future assessment programs should consider these qualities when selecting measures to evaluate welfare.

Assessing cow-calf welfare. Part 2: Risk factors for beef cow health and behavior and stockperson handling.

Epidemiological studies can be used to identify risk factors for livestock welfare concerns but have not been conducted in the cow-calf sector for this purpose. The objectives of this study were to investigate the relationships of 1) herd-level management, facilities, and producer perspectives with cattle health and behavior and stockperson handling and 2) stockperson handling on cattle behavior at the individual cow level. Cow ( = 3,065) health and behavior and stockperson handling during a routine procedure (e.g., pregnancy checks) were observed on 30 California ranches. Management and producer perspectives were evaluated using an interview, and handling facility features were recorded at the chute. After predictors were screened for univariable associations, multivariable models were built for cattle health (i.e., thin body condition, lameness, abrasions, hairless patches, swelling, blind eyes, and dirtiness) and behavior (i.e., balking, vocalizing, stumbling and falling in the chute and while exiting the restraint, and running out of the restraint) and stockperson handling (i.e., electric prod use, moving aid use, tail twisting, and mis-catching cattle). When producers empathized more toward an animal's pain experience, there was a lower risk of swelling (odds ratio [OR] = 0.7) but a higher risk of lameness (OR = 1.3), which may indicate a lack of awareness of the latter. Training stockpersons using the Beef Quality Assurance program had a protective effect on cow cleanliness and mis-catching in the restraint (OR = 0.2 and OR = 0.5, respectively). Hydraulic chutes increased the risk of vocalizations (OR = 2.7), possibly because these systems can apply greater pressure to the sides of the animal than manual restraints. When a moving aid was used to move an individual cow, it increased the risk of her balking, but when hands, in particular, were used, the risk of balking decreased across the herd (OR = 34.1 and OR = 0.3, respectively). Likewise, individual cows were at a greater risk of balking, vocalizing, stumbling and falling in the chute, and stumbling and running at exit when they were touched with an electric prod (OR = 11.0, OR = 3.3, OR = 1.9, OR = 2.3, OR = 1.8, and OR = 1.7, respectively). Although the implications of using moving aids are unclear, reducing the use of electric prods could improve cattle handling. In conclusion, cattle handling was influenced by a number of facility and stockperson factors: personnel training, facility design, and electric prod use are key areas for future improvements.

Obesity and mental disorders in the general population: results from the world mental health surveys.

OBJECTIVES: (1) To investigate whether there is an association between obesity and mental disorders in the general populations of diverse countries, and (2) to establish whether demographic variables (sex, age, education) moderate any associations observed. DESIGN: Thirteen cross-sectional, general population surveys conducted as part of the World Mental Health Surveys initiative. SUBJECTS: Household residing adults, 18 years and over (n=62 277). MEASUREMENTS: DSM-IV mental disorders (anxiety disorders, depressive disorders, alcohol use disorders) were assessed with the Composite International Diagnostic Interview (CIDI 3.0), a fully structured diagnostic interview. Obesity was defined as a body mass index (BMI) of 30 kg/m(2) or greater; severe obesity as BMI 35+. Persons with BMI less than 18.5 were excluded from analysis. Height and weight were self-reported. RESULTS: Statistically significant, albeit modest associations (odds ratios generally in the range of 1.2-1.5) were observed between obesity and depressive disorders, and between obesity and anxiety disorders, in pooled data across countries. These associations were concentrated among those with severe obesity, and among females. Age and education had variable effects across depressive and anxiety disorders. CONCLUSIONS: The findings are suggestive of a modest relationship between obesity (particularly severe obesity) and emotional disorders among women in the general population. The study is limited by the self-report of BMI and cannot clarify the direction or nature of the relationship observed, but it may indicate a need for a research and clinical focus on the psychological heterogeneity of the obese population.

Longitudinal investigation of depression outcomes in primary care in six countries: the LIDO study. Functional status, health service use and treatment of people with depressive symptoms.

BACKGROUND: Screening surveys of depressive symptoms were conducted among primary care patients at six sites in different countries. The LIDO Study was designed to assess quality of life and economic correlates of depression and its treatment in culturally diverse primary health care settings. This paper describes: (1) the association between depressive symptoms and functional status, global health-related quality of life (QoL), and use of general health services across different cultural settings; and (2) among subjects with depressive symptoms, the factors associated with recent treatment for depression. METHODS: Subjects aged 18 to 75 were recruited from participating primary care facilities in Be'er Sheva (Israel), Porto Alegre (Brazil), Melbourne (Australia), Barcelona (Spain), St Petersburg (Russian Federation) and Seattle (USA). Depressive symptoms were measured using the CES-D. Also administered were the SF-12, global questions on QoL, selected demographic and social measures, and questions on recent treatment for depression, use of health care services, and lost workdays. RESULTS: A total of 18,489 patients were screened, of whom 37% overall (range 24-55%) scored > or = 16 on the CES-D and 28% (range 17-42%) scored > or = 20. Overall, 13% reported current treatment for depression (range 4 to 23%). Patients with higher depressive symptom scores had worse health, functional status, QoL, and greater use of health services across all sites. Among those with a CES-D score > or = 16, subjects reporting treatment for depression were more likely than those reporting no treatment to be dissatisfied with their health (except in St Petersburg), and to have higher depressive symptom scores. CONCLUSIONS: Higher depressive symptom scores in primary care patients were consistently associated with poorer health, functional status and QoL, and increased health care use, but not with demographic variables. The likelihood of treatment for depression was associated with perceptions of health, as well as severity of the depression.

Understanding cross-national differences in depression prevalence.

UNLABELLED: BACKGROUND. Previous epidemiological studies indicate large cross-national differences in prevalence of depression. METHODS: At 15 centres in 14 countries. 25,916 primary care patients were screened for common mental disorders. A stratified random sample of 5,447 primary care patients completed a baseline diagnostic assessment and 3,197 completed a 12-month follow-up assessment. Psychiatric symptoms and diagnoses were assessed using the Composite International Diagnostic Interview (CIDI). Interviewer-rated disability was assessed using the Social Disability Schedule (SDS). RESULTS: Prevalence of current major depression varied 15-fold across centres. When centres were divided into three groups according to prevalence rates, the symptom pattern or latent structure of depressive illness was generally similar at low-, medium-, and high-prevalence centres. Depression was universally associated with disability, but this association varied significantly (t = 3.51, P = 0.0005) across centres. At higher-prevalence centres, depression was associated with lower levels of impairment. At 1 year follow-up, higher prevalence centres had both significantly higher rates of depression onset (t = 3.11, P = 0.002) and higher rates of persistence among those depressed at baseline (t = 2 49, P = 0.013). CONCLUSIONS: Large cross-national variations in depression prevalence cannot be attributed to 'category fallacy' (cross-national differences in the nature or validity of depressive disorder). Use of identical measures and diagnostic criteria may actually identify different levels of depression severity in different countries or cultures. Cross-national differences in the onset and outcome of depression may reflect either true prevalence differences or differences in diagnostic threshold.

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.

OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Does physician education on depression management improve treatment in primary care?

OBJECTIVE: To assess the effect of physician training on management of depression. DESIGN: Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial. SETTING: One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States. PATIENTS/PARTICIPANTS: Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians. INTERVENTIONS: Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants. MEASUREMENTS AND MAIN RESULTS: Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P =.95) or new prescription of antidepressant medicines (P =.10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P =.53) as measured by 12 weeks of continuous antidepressant treatment. CONCLUSIONS: After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy.

Case report: Unusual location of Dirofilaria immitis in a 28-year-old man necessitates orchiectomy.

The fourth case of zoonotic Dirofilaria immitis infection in a California resident is reported. This case was unique in that it involved the spermatic cord, produced significant symptoms, and upon physical examination was suspected of being an incarcerated inguinal hernia. At surgery frozen sections were inconclusive regarding neoplasia and cord involvement precluded removal of the mass without orchiectomy, which was done. Histopathology revealed a well-preserved immature male D. immitis, the canine heartworm, in a branch of the spermatic artery. The morphological identification of the worm was confirmed by polymerase chain reaction (PCR) studies. This case illustrates that D. immitis infections can complicate differential diagnosis of extrapulmonary lesions and suggests that the public health significance of this vector-borne filarial worm needs to be evaluated through appropriate epidemiological studies in enzootic areas.

Course of hypochondriasis in an international primary care study.

Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.

A cross-national study of the course of persistent pain in primary care.

Data from the World Health Organization's study of psychological problems in general health care were used to examine the course of persistent pain syndromes among primary care patients. Across 15 sites in 14 countries, 3197 randomly selected primary care patients completed baseline and 12-month follow-up assessments of pain, other somatic symptoms, and anxiety and depressive disorders (the Composite International Diagnostic Interview), and an assessment of occupational role disability (the Social Disability Schedule). Of patients with a persistent pain condition at baseline, 49% had not recovered 12 months later. The probability of non-recovery varied significantly across study centers and was significantly associated with the number of pain sites at baseline. After adjustment for age, sex, and study center, baseline anxiety or depressive disorder did not predict non-recovery of persistent pain. Among those without a persistent pain disorder at baseline, the rate of onset was 8.8% with a significant variability in risk across centers. The baseline characteristics predicting the onset of persistent pain disorder were psychological disorder, poor self-rated health, and occupational role disability. A persistent pain disorder at baseline predicted the onset of a psychological disorder to the same degree that a baseline psychological disorder predicted the subsequent onset of persistent pain. Persistent pain conditions are common among primary care patients, and the probability of resolution over 12 months is approximately 50%. We found a strong and symmetrical relationship between persistent pain and psychological disorder. Impairment of daily activities appears to be a central component of that relationship.

Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians.

BACKGROUND: While many studies describe deficiencies in primary care antidepressant treatment, little research has applied similar standards to psychiatric practice. This study compares baseline characteristics, process of care, and outcomes for managed care patients who received new antidepressant prescriptions from psychiatrists and primary care physicians. METHODS: At a prepaid health plan in Washington State, patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) and primary care physicians (n = 204) completed a baseline assessment, including the Structured Clinical Interview for DSM-IV depression module, a 20-item depression assessment from the Symptom Checklist-90, and the Medical Outcomes Survey 36-Item Short-Form Health Survey functional status questionnaire. All measures were repeated after 2 and 6 months. Computerized data were used to assess antidepressant refills and follow-up visits over 6 months. RESULTS: At baseline, psychiatrists' patients reported slightly higher levels of functional impairment and greater prior use of specialty mental health care. During follow-up, psychiatrists' patients made more frequent follow-up visits, and the proportion making 3 or more visits in 90 days was 57% vs 26% for primary care physicians' patients. The proportion receiving antidepressant medication at an adequate dose for 90 days or more was similar (49% vs 48%). The 2 groups showed similar rates of improvement in all measures of symptom severity and functioning. CONCLUSIONS: In this sample, clinical differences between patients treated by psychiatrists and primary care physicians were modest. Shortcomings in depression treatment frequently noted in primary care (inadequate follow-up care and high rates of inadequate antidepressant treatment) were also common in specialty practice. Possible selection bias limits any conclusions about relative effectiveness or cost-effectiveness.

Depression and work productivity: the comparative costs of treatment versus nontreatment.

This article discusses the impact of depression on work productivity and the potential for improved work performance associated with effective treatment. We undertook a review of the literature by means of a computer search using the following key terms: cost of illness, work loss, sickness absence, productivity, performance, and disability. Published works were considered in four categories: (1) naturalistic cross-sectional studies that found greater self-reported work impairment among depressed workers; (2) naturalistic longitudinal studies that found a synchrony of change between depression and work impairment; (3) uncontrolled treatment studies that found reduced work impairment with successful treatment; and (4) controlled trials that usually, but not always, found greater reduction in work impairment among treated patients. Observational data suggest that productivity gains following effective depression treatment could far exceed direct treatment costs. Randomized effectiveness trials are needed before we can conclude definitively that depression treatment results in productivity improvements sufficient to offset direct treatment costs.

Cost-effectiveness of systematic depression treatment for high utilizers of general medical care.

BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care. METHODS: Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan-standardized claims. RESULTS: The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47). CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.

Can depression treatment in primary care reduce disability? A stepped care approach.

OBJECTIVE: To assess effects of stepped collaborative care depression intervention on disability. DESIGN: Randomized controlled trial. SETTING: Four primary care clinics of a large health maintenance organization. PATIENTS: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication. INTERVENTION: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes. MAIN OUTCOME MEASURES: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94). CONCLUSIONS: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058

Large medical databases, population-based research, and patient confidentiality.

OBJECTIVE: This article is a discussion of the use of large clinical databases in population-based research on psychiatric disorders. METHOD: The authors review uses of large clinical databases in research on the etiology, impact, and treatment of psychiatric disorders. They also describe existing privacy safeguards applicable to use of medical records data in research. RESULTS: The growth of large medical databases has prompted increasing concern about the confidentiality of patient records. Efforts to restrict access to computerized medical data, however, may preclude use of such data in important and legitimate research. Prior research using large medical databases has made important contributions across a broad range of topics, including epidemiology, genetics, treatment effectiveness, and health policy. Continued population-based research will be essential in order to preserve the accessibility and quality of treatment for people with psychiatric disorders. CONCLUSIONS: Public domain research should be distinguished from proprietary or commercial uses of health information, and existing privacy safeguards should be vigorously applied. In our efforts to protect patient privacy, however, we should take care not to endorse or reinforce prejudices against psychiatric treatment and people who suffer from psychiatric disorders. Neither should we ignore important opportunities to improve quality of care and influence public policy through population-based research.

Long-term prognosis of depression in primary care.

This article uses longitudinal data from a primary care sample to examine long-term prognosis of depression. A sample of 225 patients initiating antidepressant treatment in primary care completed assessments of clinical outcome (Hamilton Depression Rating Scale and the mood module of the Structured Clinical Interview for DSM-IIIR) 1, 3, 6, 9, 12, 18 and 24 months after initiating treatment. The proportion of patients continuing to meet criteria for major depression fell rapidly to approximately 10% and remained at approximately that level throughout follow-up. The proportion meeting criteria for remission (Hamilton Depression score of 7 or less) rose gradually to approximately 45%. Long-term prognosis (i.e. probability of remission at 6 months and beyond) was strongly related to remission status at 3 months (odds ratio 3.65; 95% confidence interval, 2.81-4.76) and only modestly related to various clinical characteristics assessed at baseline (e.g. prior history of recurrent depression, medical comorbidity, comorbid anxiety symptoms). The findings indicate that potentially modifiable risk factors influence the long-term prognosis of depression. This suggests that more systematic and effective depression treatment programmes might have an important effect on long-term course and reduce the overall burden of chronic and recurrent depression.