George Rust

Prevalence, Treatment, and Control of Depressive Symptoms in the United States: Results from the National Health and Nutrition Examination Survey (NHANES), 2005–2008

Background:Depression remains a major public health problem that is most often evaluated and treated in primary care settings. The objective of this study was to examine the prevalence, treatment, and control of depressive symptoms in a national data sample using a common primary care screening tool for depression. Methods:We analyzed a sample of adults (n = 4836) from 2005 to 2008 National Health and Nutrition Examination Survey data. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9) to determine the overall prevalence, rates of treatment, and antidepressant control of mild, moderate, moderately severe, and severe depressive symptoms. Results:Of the sample, 20.1% reported significant depressive symptoms (PHQ-9) score, ≥5), the majority of whom had mild depressive symptoms (PHQ-9) score, 5–9). Even among individuals with severe depressive symptoms, a large percentage (36.9%) received no treatment from a mental health professional or with antidepressant medication. Of those taking antidepressants, 26.4% reported mild depressive symptoms and 18.8% had moderate, moderately severe, or severe depressive symptoms. Conclusions:Despite greater awareness and treatment of depression in primary care settings, the prevalence of depressive symptoms remains high, treatment levels remain low, and control of depressive symptoms are suboptimal. Primary care providers need to continue to focus their efforts on diagnosing and effectively treating this important disease.

E-mail in patient-provider communication: a systematic review.

OBJECTIVE To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care. METHODS A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008. RESULTS A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed. CONCLUSION The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool. PRACTICE IMPLICATIONS It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Cardiovascular risk factors among Asian Americans: results from a National Health Survey.

PURPOSE We assessed the prevalence of major cardiovascular disease (CVD) risk factors among Chinese, Asian Indian, Filipino, and other Asian populations compared to non-Hispanic Whites in the United States. METHODS We analyzed aggregated data from the National Health Interview Survey (NHIS) from 2003 to 2005. Bivariate analyses were used to determine differences in the prevalence of CVD risk factors among Asian subgroups and white adults. Logistic regression analyses were also conducted to compare each Asian subgroup with white adults after taking sociodemographic variables into account. RESULTS The unadjusted prevalence of physical inactivity was highest among Asian Indians and other Asians. After we controlled for covariates, Asian Indians still had higher odds of physical inactivity than Whites (odds ratio [OR]=1.50, 95% confidence interval [CI]=1.22-1.84). All Asian ethnic groups were significantly less likely than Whites to report smoking, obesity, and binge drinking. Compared with Whites, Filipinos were more likely to have hypertension (OR=1.18, 95% CI=1.02-1.44) and Asian Indians were more likely to have diabetes (OR=2.27, 95% CI=1.63-3.20). CONCLUSION Although Asian race was generally associated with lower risk for CVD, certain risk factors were particularly high among some Asian subgroups. Future interventions should specify the needs of specific subgroups and design culturally specific programs to reduce health risk behaviors in each Asian subpopulation.

Health Status of Migrant Farmworkers: A Literature Review and Commentary.

I made a computerized search of MEDLINE files from 1966 through October 1989 followed by a review of this literature. Four hundred eighty-five articles were scanned; 152 were found specifically related to migrant families, while another 51 articles addressed the health of agricultural workers or farmers in general. Solid data exist on dental health, nutrition and, to a lesser extent, childhood health. Data also were prominent in several disease categories including certain infectious diseases, pesticide exposures, occupational dermatoses, and lead levels in children. Estimates of the size of the migrant and seasonal farmworker population vary widely. Basic health status indicators such as age-related death rates are unknown. Prevalence rates of the most common cause of death in the United States have yet to be studied. More research is needed into the health problems and health status of migrant and seasonal farmworker families.

Black–White Mortality From HIV in the United States Before and After Introduction of Highly Active Antiretroviral Therapy in 1996

OBJECTIVES We sought to describe Black-White differences in HIV disease mortality before and after the introduction of highly active antiretroviral treatment (HAART). METHODS Black-White mortality from HIV is described for the nation as a whole. We performed regression analyses to predict county-level mortality for Black men aged 25-84 years and the corresponding Black:White male mortality ratios (disparities) in 140 counties with reliable Black mortality for 1999-2002. RESULTS National Black-White disparities widened significantly after the introduction of HAART, especially among women and the elderly. In county regression analyses, contextual socioeconomic status (SES) was not a significant predictor of Black:White mortality rate ratio after we controlled for percentage of the population who were Black and percentage of the population who were Hispanic, and neither contextual SES nor race/ethnicity were significant predictors after we controlled for pre-HAART mortality. Contextual SES, race, and pre-HAART mortality were all significant and independent predictors of mortality among Black men. CONCLUSIONS Although nearly all segments of the Black population experienced widened post-HAART disparities, disparities were not inevitable and tended to reflect pre-HAART levels. Public health policymakers should consider the hypothesis of unequal diffusion of the HAART innovation, with place effects rendering some communities more vulnerable than others to this potential problem.

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

CONTEXT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. METHODS We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). CONCLUSIONS The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Disparities in Antidepressant Treatment in Medicaid Elderly Diagnosed with Depression

Objectives: To determine whether there were racial or ethnic disparities in the use of antidepressants in low‐income elderly patients insured by Medicaid.

Trends in mental health and substance abuse services at the nation's community health centers: 1998-2003

OBJECTIVE We examined trends in delivery of mental health and substance abuse services at the nations community health centers. METHODS Analyses used data from the Health Resources and Services Administration (HRSA), Bureau of Primary Cares (BPHC) 1998 and 2003 Uniform Data System, merged with county-level data. RESULTS Between 1998 and 2003, the number of patients diagnosed with a mental health/substance abuse disorder in community health centers increased from 210,000 to 800,000. There was an increase in the number of patients per specialty mental health/substance abuse treatment provider and a decline in the mean number of patient visits, from 7.3 visits per patient to 3.5 by 2003. Although most community health centers had some on-site mental health/substance abuse services, centers without on-site services were more likely to be located in counties with fewer mental health/substance abuse clinicians, psychiatric emergency rooms, and inpatient hospitals. CONCLUSIONS Community health centers are playing an increasingly central role in providing mental health/substance abuse treatment services in the United States. It is critical both to ensure that these centers have adequate resources for providing mental health/substance abuse care and that they develop effective linkages with mental health/substance abuse clinicians in the communities they serve.

Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-State Analysis

Background:Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees. Methods:For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures. Results:A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82–0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29–1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations. Conclusions:Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options

Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders. Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders. Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.