Gene A. Kallenberg

Mental health treatment preferences of older and younger primary care patients

Objective: To compare mental health treatment history and preferences in older and younger primary care patients. Method: We surveyed 77 older (60+) and 312 younger adult primary care patients from four outpatient medical clinics about their mental health treatment history and preferences. Results: Older adults were less likely than younger adults to report a history of mental health treatment (29% vs. 51%) or to be currently receiving treatment (11% vs. 23%). They were also less likely to indicate that they currently desire help with emotional problems (25% vs. 50%). Older adults were more likely to hold a belief in self-reliance that could limit their willingness to accept treatment for mental health problems, although they were less likely than younger adults to identify other barriers to treatment. Older adults reported that they were less likely to attend programs in primary care targeting mental health issues (counseling, stress management) than younger adults, although they were as willing as younger adults to attend programs targeting physical health issues (healthy living class, fitness program). Age remained a significant predictor of mental health treatment history and preferences even after controlling for other demographic variables. Conclusion: These results suggest that older adults in the primary care setting may be less willing to accept mental health services than younger adults. Results further suggest that perceived barriers may differ for older and younger patients, which may indicate the need for age-specific educational messages and services targeted to older adults in primary care.

Effect of Antidepressant Medication Treatment on Suicidal Ideation and Behavior in a Randomized Trial: An Exploratory Report From the Combining Medications to Enhance Depression Outcomes Study

OBJECTIVE To explore relationships between baseline sociodemographic and clinical features and baseline suicidal ideation, and treatment effects on suicidal ideation and behavior, in depressed outpatients. METHOD From March 2008 to September 2009, the Combining Medications to Enhance Depression Outcomes study, a single-blind, 7-month randomized trial, enrolled outpatients with nonpsychotic chronic and/or recurrent major depressive disorder (DSM-IV-TR criteria) in primary and psychiatric care (N = 665). Participants received escitalopram plus placebo, bupropion sustained release (SR) plus escitalopram, or venlafaxine extended release (XR) plus mirtazapine. The primary outcome measure for this report is presence of suicidal ideation assessed by the Concise Health Risk Tracking Self-Report, which measures suicidal ideation and behaviors over the last 24 hours. Sociodemographic and clinical features were compared in those with versus without baseline ideation. At 4, 12, and 28 weeks, treatment effects on suicidality were assessed, and unadjusted and adjusted outcomes were compared among those with and without baseline ideation using linear, logistic, ordinal logistic, and negative binomial regression models. RESULTS Baseline suicidal ideation was associated with greater depressive severity, childhood neglect, childhood abuse, early major depressive disorder onset, greater psychiatric comorbidity, and worse functioning and quality of life. After adjustment for treatment, gender, age at first depressive episode, obsessive-compulsive symptoms, and depressive severity, depressive symptom outcomes did not differ between ideation groups at 12 or 28 weeks or between treatments. Overall, 79% of participants with baseline suicidal ideation had none at week 4, 83% had none at week 12, and 86% had none at week 28. All treatments reduced ideation, with bupropion-SR plus escitalopram the most effective at week 12 (P < .01). In participants without baseline ideation, emergent ideation did not differ between treatments: 2.5% had ideation at 4 weeks, 1.3% had ideation at 12 weeks, and only 1.7% had ideation at 28 weeks. Four patients (all receiving venlafaxine-XR plus mirtazapine) attempted suicide (P = .0162). CONCLUSION Baseline ideation did not affect depressive symptom outcome. Bupropion-SR plus escitalopram most effectively reduced ideation. Ideation emergence was uncommon. Venlafaxine-XR plus mirtazapine may pose a higher risk of suicide attempts. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00590863.

Verbal interaction analysis: viewing feedback through a different lens.

Background: Verbal interaction analysis, though seldom applied to the feedback-giving process, can be used to assess feedback dimensions not easily assessed by other means. Description: The purpose of this study was to explore verbal interaction analysis as a method to assess feedback interactions between senior medical students trained as teachers and their sophomore learners. We randomly selected 14 videotaped encounters of senior teachers giving feedback to sophomore learners and classified 417 utterances to address (a) verbal dominance, (b) feedback balance, and (c) cognitive level. Evaluation: Teachers did most of the talking (65.2%). Although some feedback was corrective (20.6%), teacher utterances were mostly positive (33.5%) or neutral (45.9%). Cognitively, the teacher utterances occurred largely at the factual (lowest) level (74.3%). Conclusions: Interaction analysis enabled us to describe 3 dimensions of teacher–learner feedback not easily assessed by other means: verbal dominance, positive-corrective balance, and cognitive level. Assessing these dimensions provides information about two theoretically important indices of feedback-giving effectiveness: learner involvement and feedback balance. Future study of verbal interaction analysis in this and other populations is warranted to further evaluate its usefulness.

Effects of Medical Comorbidity on Anxiety Treatment Outcomes in Primary Care

Objective To evaluate the effects of medical comorbidity on anxiety treatment outcomes. Methods Data were analyzed from 1004 primary care patients enrolled in a trial of a collaborative care intervention for anxiety. Linear-mixed models accounting for baseline characteristics were used to evaluate the effects of overall medical comorbidity (two or more chronic medical conditions [CMCs] versus fewer than two CMCs) and specific CMCs (migraine, asthma, and gastrointestinal disease) on anxiety treatment outcomes at 6, 12, and 18 months. Results At baseline, patients with two or more CMCs (n = 582; 58.0%) reported more severe anxiety symptoms (10.5 [95% confidence interval {CI} = 10.1–10.9] versus 9.5 [95% CI = 9.0–10.0], p = .003) and anxiety-related disability (17.6 [95% CI = 17.0–18.2] versus 16.0 [95% CI = 15.3–16.7], p = .001). However, their clinical improvement was comparable to that of patients with one or zero CMCs (predicted change in anxiety symptoms = −3.9 versus −4.1 at 6 months, −4.6 versus −4.4 at 12 months, −4.9 versus −5.0 at 18 months; predicted change in anxiety-related disability = −6.4 versus −6.9 at 6 months, −6.9 versus −7.3 at 12 months, −7.3 versus −7.5 at 18 months). The only specific CMC with a detrimental effect was migraine, which was associated with less improvement in anxiety symptoms at 18 months (predicted change = −4.1 versus −5.3). Conclusions Effectiveness of the anxiety intervention was not significantly affected by the presence of multiple CMCs; however, patients with migraine displayed less improvement at long-term follow-up. Trial Registration: ClinicalTrials.com Identifier: NCT00347269

Found in Translation: Exporting Patient-Centered Communication and Small Group Teaching Skills to China

Abstract The Chinese Medical Doctor’s Association asked us to develop a train-the-trainers program in doctor-patient communication and in teaching skills for a select group of Chinese health care professionals, who would then serve as trainers for practicing physicians throughout China. The request came in the context of increasing doctor-patient friction related, in part, to the dissolution of the socialist health care safety net in China. In this article we recount the implementation of our 5-day training program in Beijing. We explore cross-cultural issues that arose in presenting the program’s two principal training domains: small group teaching and patient-centered doctor-patient communication. We also explore the linguistic challenges we encountered as non-Chinese speaking teachers. Finally, we reflect on the lessons learned from this project that may be of value to others called upon to export Western doctor-patient communications training to other cultures. In this age of increasing globalization, cross-cultural sharing of medical education represents a growing trend.

Advising Oliver Mann--a case-based, small-group orientation to medical school.

In 1998, the authors implemented a new academic orientation built around a problem-based clinical exercise for entering medical students, to prepare them for a curriculum emphasizing active learning in small groups. The exercise enables students to begin their professional studies with a “hands on” understanding of two major emphases of the curriculum: (1) the process of small-group learning that will guide their medical education and (2) the principles of patient care that will guide their future practice of medicine. Called “Advising Oliver Mann,” this orientation presents students with a clinical problem that they must work in small groups to solve. By collaborating in teams of ten, they become acquainted with the small-group learning methods at the heart of the schools curriculum. Through solving a clinical problem, they discover vital principles of patient care, such as the need in clinical decision making to integrate the scientific perspective with the perspective of patient and family. In developing “Oliver Mann,” the authors came to realize that orientations can be much more than introductions. They can be reflective moments in a busy curriculum, a time for students and faculty to step back and take stock of important issues in education and doctoring. The authors are currently experimenting with exercises linking their freshman orientation with orientations in the second and third years so participants can reflect on the challenges of each new year and carry forward the small-group methods and practice of medicine themes of the new curriculum.

Looking back and looking forward.

As the authors tenure as President of the Board of Collaborative Family Healthcare Association (CFHA) comes to a close its time for some reflection on CFHAs past year and where the field of integrated behavioral health care is going. In summary, CFHA is growing, maturing and broadening its partners and its reach. CFHAs accomplishments are increasing, but there is an abundance of work still to do.

Integrated behavioral health: The train has left the station. Where to next?

Its time for the final push to make integrated behavioral health (IBH) the way primary care (and indeed all medical care) is practiced in the United States. Too many of our patients are still suffering from the fragmentation in our health system. Team-based care that includes integrated behavioral health care has the best chance of achieving the Triple Aims of a transformed and efficient health care delivery system that delivers better care, better health, and lower cost for all Americans. (PsycINFO Database Record