Jeanne Miranda

Case-Finding Instruments for Depression: Two Questions Are as Good as Many

ObjectiveTo determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.DesignThe test characteristics of a two-question case-fidning instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.SettingUrgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.ParticipantsFive hundred thirty-six consecutive adult patients without mania or schizophrenia.Measurements and main resultsMeasurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Beck Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90–99%) and a specificity of 57% (95% CI 53–62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.ConclusionsThe two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.

Disparities in Care for Depression Among Primary Care Patients

AbstractCONTEXT: Ethnic minorities traditionally receive less care for depression than do white populations; we examine ethnic minority care for depression in a large cross-national primary care sample. DESIGN: This is a cross-sectional study of identification and treatment of depression among diverse primary care patients, using self-report of symptoms and care. SUBJECTS: One thousand four hundred and ninety-eight depressed primary care patients participating in four large studies of quality improvement for depression care are examined at baseline. RESULTS: Primary care providers recommend depression treatments for Latino and African-American patients as frequently as they do for white patients. However, Latino and African-American patients are less likely to take antidepressant medications (adjusted odds ratio [OR], 0.30; 95% confidence interval [CI], 0.21 to 0.42 and adjusted OR, 0.56; 95% CI, 0.36 to 0.87, respectively) and Latinos are less likely to obtain specialty mental health care (adjusted OR, 0.50; 95% CI, 0.36 to 0.75). CONCLUSIONS: Primary care providers are now able to recognize depression and recommend treatment for Latino and African-American patients, with this care recommended at equal rates to that of white patients. However, Latino and African-American patients remain less likely to obtain appropriate care, such as antidepressant medications or specialty care. New approaches to improving access to appropriate care for Latino and African-American primary care patients are needed.

Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities? Results of a Randomized, Controlled Trial

OBJECTIVE Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities. STUDY SETTING The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. STUDY DEIGN: Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians). DATA EXTRACTION METHODS Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups. PRINCIPAL FINDINGS At baseline, all ethnic groups Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients. CONCLUSIONS Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.

Five-Year Impact of Quality Improvement for Depression Results of a Group-Level Randomized Controlled Trial

BACKGROUND Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN A group-level randomized controlled trial. SETTING Forty-six primary care practices in 6 managed care organizations. PATIENTS Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.

Trauma exposure, mental health functioning, and program needs of women in jail

A convenience sample of 100 female jail inmates was interviewed by two female clinical psychologists using measures of trauma exposure, psychopathology, sexual risk behavior, parenting skills, and perceived needs for service. Participants had high rates of lifetime trauma exposure (98%), current mental disorders (36%), and drug/alcohol problems (74%).More than half of the women showed deficits in parenting skills. Participants described their primary problems as being in the areas of substance abuse and family issues, and they endorsed a variety of potential services they would like to be able to access. Unless trauma and victimization experiences, mental health needs, and functional difficulties are taken into account in program development, incarcerated women are unlikely to benefit optimally from in-house and postrelease programs.

Prevention of depression with primary care patients: A randomized controlled trial

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasbile, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.

Endorsement of dysfunctional beliefs depends on current mood state.

In two studies we tested the hypothesis that endorsement of dysfunctional beliefs depends on current mood state for persons who are vulnerable to depression. The first study showed that reports of dysfunctional beliefs vary with spontaneous diurnal mood fluctuations in 47 depressed psychiatric patients. The effect of mood state was highly significant (p less than .01); dysfunctional thinking increased when mood was worst and decreased when mood was best. The second study conceptually replicated this finding in a population of asymptomatic subjects. As predicted, reports of dysfunctional beliefs varied as a function of mood state in 14 persons who had experienced a depressive episode but not in 27 who had never been depressed. These findings support the cognitive theory of depression, which proposes that dysfunctional beliefs are vulnerability factors for depression but also that reporting of dysfunctional beliefs depends on current mood state.

New Evidence Regarding Racial And Ethnic Disparities In Mental Health: Policy Implications

Minorities have, in general, equal or better mental health than white Americans, yet they suffer from disparities in mental health care. This paper reviews the evidence for mental health and mental health care disparities, comparing them to patterns in health. Strategies for addressing disparities in health care, such as improving access to and quality of care, should also work to eliminate mental health care disparities. In addition, a diverse mental health workforce, as well as provider and patient education, are important to eliminating mental health care disparities.

Cognitive theories of vulnerability to depression: Reconciling negative evidence

Cognitive theories of depression propose that stable beliefs predispose vulnerable individuals to depression. Empirical evidence appears to contradict the stability hypothesis; the cognitions described by the theories appear to covary with depressive symptoms. As a result of these findings, many investigators have concluded that the etiological portions of the cognitive theories are incorrect. We propose an alternative account of the empirical evidence that is consistent with the theories. We propose that the beliefs that are vulnerability factors for depression are stable, but they are accessible only during negative mood states; we call this the mood-state hypothesis. This article describes the mood-state hypothesis, reviews evidence supporting it, and outlines its implications for the cognitive theories of depression. We also describe implications of the mood-state hypothesis for other theories of depression, including biological theories, for studies of psychotherapy process, for studies of other psychopathologies, for epidemiological studies of depression, for the prevention and treatment of depression, and for theories of cognition.

Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005.

Context:Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. Objective:To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. Design and Setting:Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995–2005 (n = 96,075). Participants:Visits to office-based primary care physicians and psychiatrists in the United States. Main Outcome Measures:Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. Results:In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. Conclusions:Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.