Jeffrey M. Lyness

Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review.

Purpose To evaluate published evidence that the Accreditation Council for Graduate Medical Educations six general competencies can each be measured in a valid and reliable way. Method In March 2008, the authors conducted searches of Medline and ERIC using combinations of search terms “ACGME,” “Accreditation Council for Graduate Medical Education,” “core competencies,” “general competencies,” and the specific competencies “systems-based practice” (SBP) and “practice based learning and improvement (PBLI).” Included were all publications presenting new qualitative or quantitative data about specific assessment modalities related to the general competencies since 1999; opinion pieces, review articles, and reports of consensus conferences were excluded. The search yielded 127 articles, of which 56 met inclusion criteria. Articles were subdivided into four categories: (1) quantitative/psychometric evaluations, (2) preliminary studies, (3) studies of SBP and PBLI, and (4) surveys. Results Quantitative/psychometric studies of evaluation tools failed to develop measures reflecting the six competencies in a reliable or valid way. Few preliminary studies led to published quantitative data regarding reliability or validity. Only two published surveys met quality criteria. Studies of SBP and PBLI generally operationalized these competencies as properties of systems, not of individual trainees. Conclusions The peer-reviewed literature provides no evidence that current measurement tools can assess the competencies independently of one another. Because further efforts are unlikely to be successful, the authors recommend using the competencies to guide and coordinate specific evaluation efforts, rather than attempting to develop instruments to measure the competencies directly.

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability.

OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions.

Completed suicide among older patients in primary care practices: a controlled study.

OBJECTIVE: To determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not.

Insomnia as a Risk Factor for Onset of Depression in the Elderly

There are at least 9 studies that provide evidence that insomnia is a significant risk factor for recurrent and new onset major depressive disorder (MDD), two of which suggest that this association also exists specifically for the elderly. In this study, archival data from a community sample of healthy elderly participants were used to assess the extent to which insomnia predicts future illness in this age cohort. Out of the 147 participants with no prior history of mental illness, 66 participants were classified as having no insomnia, 47 had indeterminate insomnia, and 34 had persistent insomnia. Twelve participants developed MDD during the 1-year follow-up period. Two had no insomnia, 4 had indeterminate insomnia, and 6 had persistent insomnia. Persistent insomnia with onset of depression occurred only in female participants and was significantly associated with middle insomnia. These data suggest that elderly participants with persistent insomnia are at greater risk for the development of new onset depression.

Outcomes of Minor and Subsyndromal Depression among Elderly Patients in Primary Care Settings

Context The spectrum of depressive illness includes milder forms, about which we know relatively little. Content Older patients selected from 10 primary care practices for depressive symptoms had major depression, minor or subsyndromal depression, or were not depressed. After 1 year, depression symptom severity was closely associated with the initial depression diagnosis. Patients with minor or subsyndromal depression had a much higher incidence of major depression than nondepressed patients, but most were no longer depressed or still had minor or subsyndromal depression. Cautions Approximately 29% of patients withdrew before the end of the study. Implications Minor or subsyndromal depression causes substantial morbidity and is a risk factor for major depression. The Editors Depressive conditions in later life are a major public health problem because they are common and associated with considerable morbidity (1-10). However, most elderly persons who have clinically significant depressive symptoms do not meet diagnostic criteria for major depression or dysthymic disorder (4, 7, 11). Terms such as minor, subsyndromal, or subthreshold depression have been used to describe such sub-major depressive conditions. In younger adults, minor and subsyndromal depression are associated with greater cumulative functional disability than major depression (12); they probably exist along a dimensional spectrum of symptomatic severity (11, 13, 14), sometimes (but not always) representing a prodromal or residual phase of a major mood disorder. In older persons, minor and subsyndromal depression are seen in various settings more commonly than major depression (1, 4, 11, 15-17) and are associated with similar functional morbidity. Most elderly persons with depressive symptoms never see mental health specialists but do see their primary care physicians (18). Because there is limited evidence to support specific treatments for minor and subsyndromal depression (19, 20), it is important for primary care physicians to initiate treatment primarily for patients at highest risk for poor outcomes. However, there are few published longitudinal data from primary care settings to guide identification of such patients. Previous observational studies did not include patients with minor or subsyndromal depression (21, 22) or distinguish them from those with major depression (23, 24). One previous study (25) found that patients with minor depression had outcomes that were poorer than those of persons who were not depressed. Outcomes were not universally poor, however, and were better than those of patients with major depression. The researchers noted that these findings required replication in a larger and more diverse sample. Furthermore, little is known about predictors of geriatric depression outcomes in patients in primary care settings. Studies that reported a predictive role for medical illness burden (26) rarely focused on primary care, and many used self-reports of medical illness that were subject to confounding by depression (27). Small-vessel brain disease may contribute to the pathogenesis of some forms of depression seen later in life (28-31); cerebrovascular risk factors are associated with depression outcomes in other settings (32-35), but their role remains unclear in primary care (35, 36). Psychosocial factors, such as functional disability, social support, and stressful life events, contribute to depression in younger adults and to more severe depression in senior citizens, but their role in elderly patients in primary care settings is generally unknown (2, 37). We hypothesized that 1) patients with minor or subsyndromal depression have an intermediate outcome in severity and diagnosis of depression, medical burden, and functional status compared with patients who have major depression and those who are not depressed and 2) initial overall medical burden, particularly cerebrovascular risk factors, are independently associated with outcomes of depression in elderly patients. We tested these 2 hypotheses in a large, multisite sample of elderly primary care patients who were followed for 1 year. We also explored functional status, social support, and stressful life events as outcome predictors. Methods Patient Sample and Randomization Protocol The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) was a randomized trial of a collaborative care intervention for geriatric depression (38) in patients of primary care practices in greater New York City, and Philadelphia and Pittsburgh, Pennsylvania. Within matched pairs, practices were randomly assigned to an intervention group or a usual care (control) group. This study used only data from patients in 10 usual care practices; these sites comprised 2 academic practices and 8 community-based practices, 1 of which served primarily African-American patients. All patients received usual care from their primary care physicians; the physicians were initially educated about published treatment guidelines (39) and, for ethical reasons, were notified when a patient met research criteria for a depression diagnosis (40). The institutional review board of each of the 3 participating universities approved the research protocol and its formal written consent procedures. Recruitment Procedures As described elsewhere (38), the patients who participated in PROSPECT were recruited to generate a demographically representative sample. Depressive conditions were oversampled to increase the power to examine depression outcomes without precluding the ability to examine specific predictors because the relationships between variables over time were not affected by the enriched sample. Protocol eligibility requirements included age of 60 years or older, ability to give informed consent in English, and a score of 18 or higher on the Mini-Mental State Examination (41). We oversampled for depressive symptoms by using the Center for Epidemiologic Studies Depression Scale (42); all patients with scores of greater than 20 (43) and a random sample of 5% of patients with scores of 20 or less were approached for study participation. In addition, patients with scores of 20 or less who were not included in the latter random sample were recruited if they responded positively to supplemental questions about previous depressive episodes or treatment. Research personnel at the practice interviewed consenting patients in person. Patients received telephone assessments at 4 and 8 months and an in-person interview 1 year after the baseline evaluation. Of the 622 usual care patients completing intake measures, 441 (70.9%) completed 1-year follow-up visits. The withdrawal rate probably reflected the lack of direct benefits offered to patients in this observational study. The group of patients who completed 1-year evaluations contained fewer cigarette smokers at baseline than the group that did not complete follow-up (13.3% vs. 19.7%; chi-square = 3.9; P= 0.047); other demographic and baseline clinical characteristics of the groups were not significantly different. Study Measures All study measures were obtained from patient interviews that were conducted by trained research associates; study psychiatrists reviewed patient responses. We measured the primary outcome of depressive symptom severity by using the 24-item examiner-rated Hamilton Rating Scale for Depression (Ham-D) (44). We used the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual for Mental Disorders, fourth edition) (SCID) to make depression diagnoses (45, 46). The intraclass correlation coefficient of research associates across the 3 study sites was 0.97 for the Ham-D and 0.92 for the SCID, and reliability was monitored throughout the study to prevent drift. Patients were classified into 1 of 3 diagnostic groups: major depression (n= 122), minor or subsyndromal depression (n= 205), or nondepressed (n= 114). Patients were assigned to the major depression group if they met SCID criteria for current major depression. To receive a diagnosis of minor or subsyndromal depression, a patient needed to have at least 2 SCID-defined depressive symptoms, of which 1 symptom had to be depressed mood or anhedonia. The symptoms had to be present at threshold (that is, meeting DSM-IV criteria for severity and 2-week duration) or subthreshold (that is, present but not meeting the threshold criterion) levels. The nondepressed category comprised all other patients. The minor or subsyndromal depression group included patients who 1) met DSM-IV criteria for dysthymic disorder; 2) did not meet the criteria for dysthymic disorder or minor depression (nonDSM-IV subsyndromal depression); and 3) had minor depression as defined by PROSPECT criteria. Modified from the DSM-IV appendix criteria, the PROSPECT criteria require 4 threshold depressive symptoms, a Ham-D score of 10 or higher, and a symptom duration of 4 weeks or more. Secondary analyses compared outcomes between the patients with PROSPECT-defined minor depression and those with nonDSM-IV subsyndromal depression; separate analysis of the patients with dysthymic disorder was precluded by the subgroups small size. We rated the cumulative severity of specified cerebrovascular risk factors (presence of antihypertensive therapy, cardiovascular disease, diabetes mellitus, cigarette smoking, atrial fibrillation, and left ventricular hypertrophy) by the weighted sum of points that were obtained from the American Heart Associations chart for predicting stroke risk, which is derived from the Framingham Heart Study (47). According to this measure, womens scores for antihypertensive therapy are based on a patients systolic blood pressure (range, 0 to 6); because blood pressure measurements were not available, we assigned a score of 3 if the patient used antihypertensive therapy and a score of 0 if they did not. The Charlson Comorbidity Index was used as a validated measure of overall medical

Provisional diagnostic criteria for depression in Parkinson's disease: Report of an NINDS/NIMH Work Group

Mood disorders are the most common psychiatric problem associated with Parkinsons disease (PD), and have a negative impact on disability and quality of life. Accurate diagnosis of depressive disturbances in PD is critical and will facilitate the testing and use of new interventions; however, there are no clear diagnostic criteria for depressive disorders in PD. In their current form, strict Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are difficult to use in PD and require attribution of specific symptoms to PD itself or the depressive syndrome. Additionally, DSM criteria for major depression and dysthymia exclude perhaps half of PD patients with comorbid clinically significant depression. This review summarizes an NIH‐sponsored workshop and describes recommended changes to DSM diagnostic criteria for depression for use in PD. Participants also recommended: (1) an inclusive approach to symptom assessment to enhance reliability of ratings in PD and avoid the need to attribute symptoms to a particular cause; (2) the inclusion of subsyndromal depression in clinical research studies of depression of PD; (3) the specification of timing of assessments for PD patients with motor fluctuations; and (4) the use of informants for cognitively impaired patients. The proposed diagnostic criteria are provisional and intended to be defined further and validated but provide a common starting point for clinical research in PD‐associated depression.

Psychiatric Disorders in Older Primary Care Patients

AbstractOBJECTIVE: Most older people with psychiatric disorders are never treated by mental health specialists, although they visit their primary care physicians regularly. There are no published studies describing the broad array of psychiatric disorders in such patients using validated diagnostic instruments. We therefore characterized Axis I psychiatric diagnoses among older patients seen in primary care. DESIGN: Survey of psychopathology using standardized diagnostic methods. SETTING: The private practices of three board-certified general internists, and a free-standing family medicine clinic. PARTICIPANTS: All patients aged 60 years or older who gave informed consent were eligible. MEASUREMENTS AND MAIN RESULTS: For the 224 subjects completing the study, psychiatric diagnoses were based on the Structured Clinical Interview for DSM-III-R. Point prevalence estimates used weighted averages based on the stratified sampling method. For the combined sites, 31.7% of the patients had at least one active psychiatric diagnosis. Prevalent current disorders included major depression (6.5%), minor depression (5.2%), dementia (5.0%), alcohol abuse or dependence (2.3%), and psychotic disorders (2.0%). Dysthymic disorder and primary anxiety and somatoform disorders were less common and frequently comorbid with major depression. CONCLUSIONS: Mental disorders, particularly depression, are common among older persons seen in these primary care settings. Clinicians should be particularly vigilant about depression when evaluating older patients with anxiety or putative somatoform symptoms, given the relatively low prevalences of primary anxiety and somatoform disorders.

A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease

Objective: To evaluate the efficacy and safety of a selective serotonin reuptake inhibitor (SSRI) and a serotonin and norepinephrine reuptake inhibitor (SNRI) in the treatment of depression in Parkinson disease (PD). Methods: A total of 115 subjects with PD were enrolled at 20 sites. Subjects were randomized to receive an SSRI (paroxetine; n = 42), an SNRI (venlafaxine extended release [XR]; n = 34), or placebo (n = 39). Subjects met DSM-IV criteria for a depressive disorder, or operationally defined subsyndromal depression, and scored >12 on the first 17 items of the Hamilton Rating Scale for Depression (HAM-D). Subjects were followed for 12 weeks (6-week dosage adjustment, 6-week maintenance). Maximum daily dosages were 40 mg for paroxetine and 225 mg for venlafaxine XR. The primary outcome measure was change in the HAM-D score from baseline to week 12. Results: Treatment effects (relative to placebo), expressed as mean 12-week reductions in HAM-D score, were 6.2 points (97.5% confidence interval [CI] 2.2 to 10.3, p = 0.0007) in the paroxetine group and 4.2 points (97.5% CI 0.1 to 8.4, p = 0.02) in the venlafaxine XR group. No treatment effects were seen on motor function. Conclusions: Both paroxetine and venlafaxine XR significantly improved depression in subjects with PD. Both medications were generally safe and well tolerated and did not worsen motor function. Classification of Evidence: This study provides Class I evidence that paroxetine and venlafaxine XR are effective in treating depression in patients with PD.

Depression and medical illness in late life: Report of a symposium.

Clinically significant depression in older people is an important public health problem. Medical illness is the most consistently identified factor associated with the presence of late‐life depression and is the most powerful predictor of poor depressive outcome. Closer examination of these associations holds promise for revealing insights into depressive pathogenesis at biological, psychological, and social levels of organization.

Social Support, Depression, and Functional Disability in Older Adult Primary-Care Patients

OBJECTIVE The authors asked whether social support and depression are independently associated with functional disability and examined the potential role of social support as a moderator in the depression-functional disability association. METHODS Subjects were 305 patients age 60 years and over. Predictor variables were social support, depressive symptoms, and depression diagnosis. Dependent variables were the Instrumental Activities of Daily Living Scale, the Physical Self-Maintenance Scale, and the Physical Functioning subscale of the Medical Outcomes Study 36-Item Short-Form Health Survey. Authors used multiple-regression analyses. RESULTS Depressive symptoms and all dimensions of social support were independently associated with functional disability: the specifics of these relationships varied among types of social support and functional disability. Depression diagnosis was not independently associated with any functional disability measure. Social support (more instrumental help, more perceived satisfaction) moderated some depression diagnosis-functional disability associations, and one depressive symptom-functional disability association. CONCLUSIONS The study hypotheses were partially confirmed. Different dimensions of social support have important and varied roles in the depression-functional disability dynamic. Future research is needed to further specify the complex relationships among depression, social support, and functional disability.