Janet H. Senf

Sertraline to treat hot flashes : a randomized controlled, double-blind, crossover trial in a general population

Objective: To evaluate the effectiveness of a selective serotonin reuptake inhibitor (SSRI) (sertraline) in decreasing hot flashes in a general population of women. Design: A double-blind, placebo-controlled, crossover trial was conducted in a southwestern urban setting. A total of 102 women aged 40 to 65 who were experiencing hot flashes and not taking any hormone therapy were recruited. After 1 week of baseline hot flash data collection, study participants were randomized to receive placebo or active drug (sertraline 50 mg) for 4 weeks. This intervention was followed by a 1-week washout and cross over to the opposite treatment for 4 weeks. The number and severity of hot flashes were measured. Results: One hundred two women were enrolled in the study. Five dropped out before providing baseline data. Of the 97 remaining, 52 were randomized to active drug first and 45 to placebo first. Ten dropped out of the study before completing all 10 weeks, leaving 46 in the active drug-first arm and 41 in the placebo-first arm. At baseline, the mean number of hot flashes reported was 45.6 per week (SD = 29.6), ranging from 2 to 148. During the sertraline phase of the study, women experienced five fewer hot flashes per week than they did on the placebo (P = 0.002). The severity of hot flashes was not significantly different; however, the hot flash score (number × average severity) was significantly improved during the sertraline phase. Conclusion: Sertraline reduced the number of hot flashes and improved the hot flash score relative to placebo and may be an acceptable alternative treatment for women experiencing hot flashes.

Literacy Education as Treatment for Depression in Patients with Limited Literacy and Depression: A Randomized Controlled Trial

AbstractBACKGROUND: Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame. OBJECTIVE: To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone. DESIGN: Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment. PARTICIPANTS: Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM). MEASUREMENTS: Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups. RESULTS: The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group. CONCLUSIONS: There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.

Patient satisfaction survey instrument for use in health maintenance organizations

The objective of this research was to devise a survey instrument specifically applicable to prepaid health care plans that could accurately predict whether patients would disenroll from their current plan because of dissatisfaction when given the opportunity to do so. A “prequestionnaire” was sent to all employees at a southwestern university whose employee benefit package included the option of selecting one of several health maintenance organizations (HMOs) as a source of health care. The prequestionnaire included 90 variables reported in the literature as related to patient satisfaction. The prequestionnaire was mailed two months before “open enrollment,” the time at which subjects would have the opportunity, if desired, to change HMOs. After open enrollment, a “postquestionnaire” was sent to the same subjects, asking whether or not they did change plans during open enrollment. There were 2,365 respondents enrolled in HMOs who formed the study population. Of these, 189 (8.0%) changed HMOs during open enrollment. Discriminant function analysis was used to identify prequestionnaire variables which were predictive that subjects had changed plans; 10 variables were identified. They were combined into a survey instrument, which can be scored to predict an individual subjects probability of changing plans.

Young adults, alcohol and condom use: what is the connection?

PURPOSE Concern about HIV in adolescents and young adults has led a number of investigators to examine the link between drinking and risky behavior, including failure to use condoms. Most of the studies that conclude that this link exists have used global measures of both variables and have not investigated drinking and use of condoms on the same occasion. If drinking leads to low condom use, both behaviors must occur together and the failure to find that they do weakens the hypothesis that they are causally related. METHODS Data from three separate studies on different adolescent and young adult populations are reported. In each study the relationship between drinking behavior and condom use at last intercourse was examined. RESULTS Drinking was not related to lower condom use in any of the populations studied. CONCLUSIONS This negative result implies that the dis-inhibiting effect of alcohol is not a major factor in the failure of young adults to use condoms.

Does literacy education improve symptoms of depression and self-efficacy in individuals with low literacy and depressive symptoms? A preliminary investigation.

Background and Objectives: Individuals with low literacy and symptoms of depression have greater improvement of depression symptoms when their treatment includes education to enhance literacy skills. The reason why literacy enhancement helps depression symptoms is unknown, but we hypothesize that it might be due to improved self-efficacy. We studied whether providing literacy education to individuals with both depression symptoms and limited literacy might improve their self-efficacy. Methods: We studied 39 individuals enrolled in an adult literacy program and who, on further testing with the Patient Health Questionnaire (PHQ-9) had symptoms of depression. While they participated in the literacy program, we monitored their self-efficacy using the General Self Efficacy (GSE) scale, and also monitored the severity of depression symptoms with the PHQ-9. Changes in GSE and PHQ-9 scores from baseline were assessed with the Wilcoxon Signed Ranks Test. Results: Thirty-one (79.5%) subjects participated for 1 year. There was a significant increase in their self-efficacy (P = .019) and a significant decrease in depression symptoms (P < .002). Conclusion: The results of this preliminary study suggest that among persons with low literacy and symptoms of depression, depression symptoms lessen as self-efficacy scores improve during participation in adult basic literacy education.

Intervention in Overweight Children Improves Body Mass Index (BMI) and Physical Activity

Background: Childhood obesity is a growing epidemic in family medicine with few clinical treatment options. We implemented and evaluated a group office-visit intervention by family physicians for overweight children and their parents, emphasizing nutrition and physical activity within a resiliency psychosocial model. Methods: The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months in the study. Participants included 35 children who met eligibility criteria of being in third through fifth grades and having a body mass index (BMI) above the 85th percentile. The 3-month, 12-session intervention, “Choices,” included topics on nutrition, physical activity, and resiliency. The sessions were developed for delivery by a family physician and a nutritionist who received training in positive psychology and resilience skills. Main outcome measures were BMI z scores for age and sex and z scores for weight by age and sex, as well as qualitative interviews to understand individual and family processes. Results: The intervention resulted in a significant effect on one primary outcome, BMI z score (−0.138 per 9 months [P = .017]) and a trend toward significance on the weight for age z score (−0.87 per 9 months [P = .09]). The net shift of activity from the low metabolic equivalents (METs) to the high METs had an intervention effect of 2.84 METs (P = .037). Families reported lasting changes in behaviors and attitudes. Discussion: The innovative approach used in this study demonstrated modest efficacy in reducing BMI z score, changing physical activity levels, and possibly shifting family dynamics.

Food Cravings, Ethnicity and Other Factors Related to Eating Out

Objective: Our objective was to study factors related to eating patterns, specifically whether certain food cravings were associated with frequency of meals eaten away from home. Methods: Data were collected from 277 patients from a family medicine residency office in Arizona. The survey questionnaire included information about the respondents’ demographics, socioeconomic status, food cravings, as well as, number of meals eaten away from home. The food craving inventory included foods in four categories identified by factor analysis: fast foods, carbohydrates, sweets and snacks. Data on food cravings were factor analyzed and scale scores were derived. Results: Being a Hispanic adult, working outside the home, and cravings for individual food items were related to eating more meals away from home. If the mother was working outside the home, the youngest child ate an average of two additional meals away from home each week. In general respondent’s cravings for some specific food items were also related to higher numbers of meals their child ate away from home. Cravings for both fast food and snacks were positively correlated with adult eating out. None of the respondents’ scale scores were related to child’s eating away from home. Adults with Arizona Health Care Cost Containment System insurance (AHCCCS—a form of Medicaid) and older adults were less likely to eat away from home compared to patients with other types of insurance. Conclusions: Socioeconomic status, ethnicity, and food cravings are related to adult and child patterns of eating meals away from home.

The variable response of women with menopausal hot flashes when treated with sertraline

Objective:To evaluate the variable response of women when treated with a selective serotonin reuptake inhibitor (sertraline) to decrease hot flashes. Design:A double-blind, placebo-controlled, crossover trial was conducted in 102 women aged 40 to 65 years who were experiencing hot flashes and not taking any hormone therapy. The original purpose of the study was to evaluate the effectiveness of sertraline for the treatment of hot flashes. After 1 week of baseline hot flash data collection, study participants were randomized to receive placebo or active drug (sertraline 50 mg) for 4 weeks. This intervention was followed by a 1-week washout and crossover to the opposite treatment for 4 weeks. The number and severity of hot flashes were measured. Results:One hundred two women were enrolled in the study, and 87 completed the study. The average response was a statistically significant but clinically modest reduction in hot flash frequency and hot flash index (frequency × severity). These data on the average response have been previously published. Although the average response was modest, some women responded vigorously, others modestly, and some women actually worsened. This is a post hoc analysis of those data. Percentage of change was divided into three categories of clinical response: women with a clinically significant reduction (≥30%, n = 27), women with a nonsignificant reduction (<30% to none, n = 28), and women with an increase (1%-100%, n = 32). A vigorous response to sertraline for the treatment of hot flashes was related to activity level, education, and menopausal status. Conclusions:Women have markedly variable responses when treated with antidepressants for their hot flashes. We have begun to describe the characteristics of those most likely to respond to treatment with a selective serotonin reuptake inhibitor.

Characteristics of medical schools related to the choice of family medicine as a specialty.

Abstract Previous research has identified five characteristics of medical schools that are related to the choice of family medicine as a specialty: (1) the amount of time devoted to required training in family medicine, (2) the timing of the required family medicine training, (3) the type of ownership of the school (public or private), (4) the geographic location of the school, and (5) the administrative structure of family medicine within the school. These five characteristics of U.S. medical schools during the mid‐1980s, together with the school tuition levels, were examined with both univariate and multivariate analysis to observe their relationships to the percentage of U.S. medical graduates entering family medicine between July 1986 and December 1987. With univariate analysis, each characteristic was significantly related to the percentage of graduates entering family medicine. Using multivariate analysis, only the number of weeks required and the type of ownership of the school were significantly related to the percentage of graduates entering family medicine, with the higher percentages related to greater numbers of required weeks of family medicine training and to public ownership of the school. Acad. Med. 64(1989):610–615.

Outcomes of combined internal medicine-pediatrics residency programs: a review of the literature.

Purpose To evaluate the outcomes of combined internal medicine and pediatrics (IMP) residency programs using the published literature. Method A literature search was conducted using Medline. Published articles were categorized as research or non-research (commentary, program requirements, program descriptions). Research articles were summarized and the results grouped under ten outcome variables. Results Of the 32 articles located, 18 were research articles, of which only four had been published since 1993. All the research conducted was cross-sectional and most involved surveys of program directors (seven studies) or graduates (four studies). At the time the studies were conducted, 20-33% of IMP residents did not complete their combined training; attrition rates have not been documented recently. Approximately 80% of IMP graduates achieved certification in both specialties, one third subspecialized to some degree, and 80% provided care to both adults and children. One fourth of the graduates felt that more training was needed in ambulatory settings and less was needed in intensive care. Very few studies of the outcomes of IMP physicians were found. Conclusion The outcomes of IMP residency programs are important for health workforce policy, and this study documents a need for more extensive research on the outcomes of training programs for primary care physicians.