Erik Fernandez y Garcia

Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care

PURPOSE Depression symptoms are underreported by patients. We thus assessed individuals’ reasons for not disclosing depression to their primary care physician. METHODS We conducted a follow-up telephone survey of 1,054 adults who had participated in the California Behavioral Risk Factor Survey System. Respondents were asked about reasons for nondisclosure of depressive symptoms to their primary care physician, depression-related beliefs, and demographic characteristics. Descriptive and inferential statistical procedures were used to characterize perceived obstacles to disclosure. RESULTS Of the respondents, 43% reported 1 or more reasons for nondisclosure. The most frequent reason was the concern that the physician would recommend antidepressants (22.9%; 95% confidence interval, 18.8%–27.5%). Reported reasons for nondisclosure of depression varied based on whether the respondent had a history of depression. For example, respondents with no depression history were more likely to believe that depression falls outside the purview of primary care (P=.040) and more likely to fret about being referred to a psychiatrist (P=.036). Respondents with clinically significant depressive symptoms rated 10 of 11 barriers to disclosure as more personally applicable than did those without symptoms (all P values =.014). Number of reported disclosure barriers was predicted by demographic characteristics (being female, Hispanic, of low socioeconomic status), depression beliefs (depression is stigmatizing and should be under one’s control), symptom severity, and absence of a family history of depression. CONCLUSIONS Many adults subscribe to beliefs likely to inhibit explicit requests for help from their primary care physician during a depressive episode. Interventions should be developed to encourage patients to disclose their depression symptoms and physicians to ask about depression.

Depression treatment preferences of Hispanic individuals: Exploring the influence of ethnicity, language, and explanatory models

Purpose: There is uncertainty regarding Hispanic individuals’ depression treatment preferences, particularly regarding antidepressant medication, the most available primary care option. We assessed whether this uncertainty reflected heterogeneity among subgroups of Hispanic persons and investigated possible mechanisms. Specifically, we examined factors associated with medication preferences in non-Hispanic white and Spanish-speaking and English-speaking Hispanic persons. Methods: We analyzed data from a follow-up telephone interview of 839 non-Hispanic white and 139 Hispanic respondents originally surveyed via the 2008 California Behavioral Risk Factor Surveillance System. Measures included treatment preferences (for treatment plans including vs not including antidepressants); depression history and current symptoms; sociodemographics; and psychological measures. Results: Compared with non-Hispanic white respondents (adjusting for age, sex, history of depression diagnosis, and current depression symptoms), Spanish-speaking Hispanic (adjusted odds ratio [AOR] 0.41; 95% CI, 0.19–0.90) but not English-speaking Hispanic (AOR, 1.18; 95% CI, 0.60–2.33) respondents had a lower preference for antidepressant inclusive options. Endorsing a biomedical explanation of depression was associated with a preference for antidepressant inclusive options (AOR, 4.76; 95% CI, 3.13–7.14) for all respondents and accounted for the effect of Spanish-language interview. Accounting for other factors did not change these relationships, although older age and history of depression diagnosis remained significant predictors of antidepressant inclusive treatment preference for all respondents. Conclusions: Spanish-language interview and less belief in a biomedical explanation for depression were associated with Hispanic respondents’ lower preferences for pharmacologic treatment of depression; ethnicity was not. Understanding treatment preferences and illness beliefs could help optimize depression treatment in primary care.

Feeling labeled, judged, lectured, and rejected by family and friends over depression: cautionary results for primary care clinicians from a multi-centered, qualitative study.

BackgroundFamily and friends may help patients seek out and engage in depression care. However, patients’ social networks can also undermine depression treatment and recovery. In an effort to improve depression care in primary care settings, we sought to identify, categorize, and alert primary care clinicians to depression-related messages that patients hear from friends and family that patients perceive as unhelpful or detrimental.MethodsWe conducted 15 focus groups in 3 cities. Participants (n = 116) with a personal history or knowledge of depression responded to open-ended questions about depression, including self-perceived barriers to care-seeking. Focus group conversations were audio-recorded and analyzed using iterative qualitative analysis.ResultsFour themes emerged related to negatively-received depression messages delivered by family and friends. Specifically, participants perceived these messages as making them feel labeled, judged, lectured to, and rejected by family and friends when discussing depression. Some participants also expressed their interpretation of their families’ motivations for delivering the messages and described how hearing these messages affected depression care.ConclusionsThe richness of our results reflects the complexity of communication within depression sufferers’ social networks around this stigmatized issue. To leverage patients’ social support networks effectively in depression care, primary care clinicians should be aware of both the potentially beneficial and detrimental aspects of social support. Specifically, clinicians should consider using open-ended queries into patients’ experiences with discussing depression with family and friends as an initial step in the process. An open-ended approach may avoid future emotional trauma or stigmatization and assist patients in overcoming self-imposed barriers to depression discussion, symptom disclosure, treatment adherence and follow-up care.

Potential Antidepressant Overtreatment Associated with Office Use of Brief Depression Symptom Measures

Background: Use of brief depression symptom measures for identifying or screening cases may help to address depression undertreatment, but whether it also leads to diagnosis and treatment of patients with few or no symptoms—a group unlikely to have major depression or benefit from antidepressants—is unknown. We examined the associations of use of a brief depression symptom measure with depression diagnosis and antidepressant recommendation and prescription among patients with few or no depression symptoms. Methods: We conducted exploratory observational analyses of data from a randomized trial of depression engagement interventions conducted in primary care offices in California. Analyses focused on participants scoring <10 on a study-administered 9-item Patient Health Questionnaire (PHQ-9) (completed immediately before an office visit and not disclosed to the provider) with complete chart review data (n = 595). We reviewed visit notes for evidence of practice administration of a brief symptom measure (independent of the trial) and whether the provider (1) diagnosed depression or (2) recommended and/or prescribed an antidepressant. Results: Among the 545 patients without a practice-administered measure, 57 (10.5%) had a visit diagnosis of depression; 9 (1.6%) were recommended and another 21 (3.8%) prescribed an antidepressant. Among the 50 patients (8.4% of total sample) with a practice-administered measure, 10 (20%) had a visit diagnosis of depression; 6 (12%) were recommended and another 6 (12%) prescribed an antidepressant. Adjusting for nesting within providers, trial intervention, stratification variables, and sample weighting, use of a brief symptom measure was associated with depression diagnosis (adjusted odds ratio, 3.2; 95% confidence interval, 1.1–9.2) and antidepressant recommendation and/or prescription (adjusted odds ratio, 3.80; 95% confidence interval, 1.0–13.9). Analyses using progressively lower PHQ-9 thresholds (<9 to <5) and examining antidepressant prescription alone yielded consistent findings. Analyses by practice-administered measure (PHQ-9 vs PHQ-2) indicated the study findings were largely associated with PHQ-9 use. Conclusions: These exploratory findings suggest administration of brief depression symptom measures, particularly the PHQ-9, may be associated with depression diagnosis and antidepressant recommendation and prescription among patients unlikely to have major depression. If these findings are confirmed, researchers should investigate the balance of benefits and risks (eg, overdiagnosis of depression and overtreatment with antidepressants) associated with use of a brief symptom measure.

Pediatric-Based Intervention to Motivate Mothers to Seek Follow-up for Depression Screens: The Motivating Our Mothers (MOM) Trial

OBJECTIVE To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens. METHODS In this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention (ClinicalTrials.gov NCT01453790). RESULTS Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference -0.1 to 38.5, P = .052). CONCLUSIONS Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen-positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.

Bilateral renal venous thrombosis and adrenal hemorrhage: sequential prenatal US with postnatal recovery

A neonate presented with bilateral renal venous thrombosis (RVT) and adrenal hemorrhage. Serial fetal ultrasonography showed progressive development of severe atrophy of one kidney and mild atrophy of the other. At sequential postnatal imaging, both kidneys showed progressive growth. Bilateral fetal RVT is quite uncommon, and postnatal recovery of a kidney severely affected by RVT is very rare.

Continuous quality improvement for postpartum depression screening and referral

It is critical for pediatricians to identify mothers with postpartum depression because it is common, causes significant maternal disability, and has negative effects on child behavior and health outcomes that improve with mothers’ treatment. Furthermore, for many mothers, accompanying their infants to pediatric visits presents an important opportunity for depression identification and connection to care. Given that informal assessment may lead to many missed cases, Chaudron et al. studied the feasibility of identifying postpartum depression through universal screening in mothers accompanying their children for well-child visits in the first year of life. While finding that universal screening was feasible, positive screens were referred to on-site social workers. Without on-site resources, general pediatricians rely on unpredictable access to community mental health services. This unpredictability can inhibit the uptake of screening by mothers and pediatricians and can result in the quandary of identifying depressed mothers without adequate support for follow-up care. While there is no standard way of implementing clinic interventions, the Continuous Quality Improvement (CQI) technique of iterative Plan, Do, Study, and Act (PDSA) cycles offers pediatricians a way to modify postpartum depression screening and referral processes in response to changing implementation barriers. This report focuses on describing how we used the PDSA method in a pilot project implementing universal postpartum depression screening and referral for English-speaking mothers accompanying their children to well-child visits at our resident general pediatric clinic in the children’s first 6 months of life. A group of seven pediatric residents concurrently involved in a residency-required CQI didactic curriculum and their two supervising pediatricians assigned to the same continuity clinic day each week, undertook the project. Reporting the results of this project was exempt from review by the Institutional Review Board of the University of California Davis. The article format parallels the PDSA structure and cycle evaluation points are summarized in Table 1.

A Lack of Living Donor Renal Transplantation for Asian Children Represents an Opportunity to Improve Pediatric Healthcare

INTRODUCTION The relationship between pediatric primary care practitioners and families provides an early opportunity to address ethnic/racial pediatric subspecialty health care disparities. Living donor pediatric renal transplantation is safe and more effective than deceased donor renal transplantation. The purpose of this study is to identify groups of children who may be less likely to receive living donor renal transplantation, as the first step in assisting pediatric clinicians to increase living donor renal transplantation. METHOD We employed a retrospective cohort design. We analyzed data from the medical records of 80 children receiving renal transplantation over 20 years in a large pediatric medical center. RESULTS The proportions of children receiving a living donor renal allograft differed by ethnicity/race (P = .04). Specifically, children of Asian ethnicity/ race were significantly less likely than children of White ethnicity/race to receive a living donor renal allograft (P = .01). There were no significant differences in age at transplantation or wait time for deceased donor transplantation. DISCUSSION We discuss the possible reasons for the discrepancy and potential directions for family-centered pediatric practice, policy, and research to address this potential pediatric healthcare disparity.

Exploring the Role of Faith-Based Organizations in Addressing Adolescent Relationship Abuse:

Adolescent relationship abuse (ARA) is prevalent with significant health and social consequences. Faith-based organizations could play an important role in ARA prevention and intervention. Studies on the role of faith-based organizations in interpersonal violence have focused on adult survivor perspectives rather than adolescents. Focus groups and interviews were conducted with faith-based organization leaders, parents, and youth. Findings highlight that church leaders, parents, and youth all expect that faith-based organizations can play a role in educating teens about healthy relationships. Divergent perspectives about how faith-based organizations should address adolescent sexuality and privacy need to be addressed.

The Theory of Planned Behavior as it predicts potential intention to seek mental health services for depression among college students

ABSTRACT Background: Between 9.5% and 31.3% of college students suffer from depression (American college health association national college health assessment II: reference group executive summary spring 2013. Amer. Coll. Health Assoc. 2013; Eagan K, Stolzenberg EB, Ramirez JJ, Aragon, MC, Suchard, RS, Hurtado S. The American freshman: national norms fall 2014. Higher Educ. Res. Inst.; 2015). Universities need to understand the factors that relate to care-seeking behavior. Objective: Across 3 studies, to relate attitudes, social norms, and perceived behavioral control to intention to seek mental health services, and to investigate barriers to care-seeking. Participants: University college students (N = 845, 64% female, 26% male, and 10% unspecified). Methods: New measures were created in Studies 1 and 2, and were examined using structural equation modeling in Study 3. Results: Partially consistent with the Theory of Planned Behavior (Ajzen, I, Fishbein, M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980), a model with an excellent fit revealed that more positive attitudes about care and higher perceived behavioral control directly predicted higher intention to seek mental health services. Conclusions: Educating college students about mental health disorders and treatments, enhancing knowledge about available services, and addressing limited access to long-term care might improve treatment rates for students suffering from depression.