Juned Siddique

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.

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.

Association of Workload of On-Call Medical Interns With On-Call Sleep Duration, Shift Duration, and Participation in Educational Activities

CONTEXT Further restrictions in resident duty hours are being considered, and it is important to understand the association between workload, sleep loss, shift duration, and the educational time of on-call medical interns. OBJECTIVE To assess whether increased on-call intern workload, as measured by the number of new admissions on-call and the number of previously admitted patients remaining on the service, was associated with reductions in on-call sleep, increased total shift duration, and lower likelihood of participation in educational activities. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of medical interns at a single US academic medical center from July 1, 2003, through June 24, 2005. Of the 81 interns, 56 participated (69%), for a total of 165 general medicine inpatient months resulting in 1100 call nights. MAIN OUTCOME MEASURES On-call sleep duration, estimated by wrist watch actigraphy; total shift duration, measured from paging logs; and participation in educational activities (didactic lectures or bedside teaching), measured by experience sampling method via a personal digital assistant. RESULTS Mean (SD) sleep duration on-call was 2.8 (1.5) hours and mean (SD) shift duration was 29.9 (1.7) hours. Interns reported spending 11% of their time in educational activities. Early in the academic year (July to October), each new on-call admission was associated with less sleep (-10.5 minutes [95% confidence interval {CI}, -16.8 to -4.2 minutes]; P < .001) and a longer shift duration (13.2 minutes [95% CI, 3.2-23.3 minutes]; P = .01). A higher number of previously admitted patients remaining on the service was associated with a lower odds of participation in educational activities (odds ratio, 0.82 [95% CI, 0.70-0.96]; P = .01]. Call nights during the week and early in the academic year were associated with the most sleep loss and longest shift durations. CONCLUSION In this study population, increased on-call workload was associated with more sleep loss, longer shift duration, and a lower likelihood of participation in educational activities.

Interest in behavioral and psychological treatments delivered face-to-face, by telephone, and by internet.

Little is known about the acceptability of internet and telephone treatments, or what factors might influence patient interest in receiving treatments via these media. This study examined the level of interest in face-to-face, telephone, and internet treatment and factors that might influence that interest. Six hundred fifty-eight primary care patients were surveyed. Among patients interested in some form of behavioral treatment, 91.9% were interested or would consider face-to-face care compared to 62.4% for telephone and 48.0% for internet care. Symptom severity was unrelated to interest in treatment delivery medium. Interest in specific treatment targeting mental health, lifestyle, or pain was more strongly predictive of interest in face-to-face treatment than telephone or internet treatments. Only interest in lifestyle intervention was predictive of interest in internet-delivered treatment. Time constraints as a barrier were more predictive of interest in telephone and internet treatments compared to face-to-face. These findings provide some support for the notion that telephone and internet treatments may overcome barriers. People who seek help with lifestyle change may be more open to internet-delivered treatments, while interest in internet intervention does not appear to be associated with the desire for help in mental health, pain, or tobacco use.

One-Year Outcomes of a Randomized Clinical Trial Treating Depression in Low-Income Minority Women

This study examines 1-year depressive symptom and functional outcomes of 267 predominantly lowincome, young minority women randomly assigned to antidepressant medication, group or individual cognitive- behavioral therapy (CBT), or community referral. Seventy-six percent assigned to medications received 9 or more weeks of guideline-concordant doses of medications; 36% assigned to psychotherapy received 6 or more CBT sessions. Intent-to-treat, repeated measures analyses revealed that medication (p=.001) and CBT (p=.02) were superior to community referral in lowering depressive symptoms across 1-year follow-up. At Month 12, 50.9% assigned to antidepressants, 56.9% assigned to CBT, and 37.1% assigned to community referral were no longer clinically depressed. These findings suggest that both antidepressant medications and CBT result in clinically significant decreases in depression for low-income minority women.

Depression prevalence in disadvantaged young black women: African and Caribbean immigrants compared to US-born African Americans

Research with Mexican Americans suggests that immigrants have lower rates of mental disorders than U. S.-born Mexican Americans. We examine the prevalence of depression, somatization, alcohol use and drug use among black American women, comparing rates of disorders among U. S.-born, Caribbean-born, and African-born subsamples. Women in Women, Infants and Children (WIC) programs, county-run Title X family planning clinics, and low-income pediatric clinics were interviewed using the PRIME-MD. In total, 9,151 black women were interviewed; 7,965 were born in the U. S., 913 were born in Africa, and 273 were born in the Caribbean. Controlling for other predictors, U.S.-born black women had odds of probable depression that were 2.94 times greater than the African-born women (p<0.0001, 95% CI: 2.07, 4.18) and 2.49 times greater than Caribbean-born women (p<0.0016, 95% CI: 1.41, 4.39). Likelihood of somatization did not differ among women who were U. S. born, African born, or Caribbean born. Rates of alcohol and drug problems were exceedingly low among all three groups, with less than 1% of the women reporting either alcohol or drug problems. These results mirror similar findings for Mexican immigrant as compared with American-born Mexican Americans. The findings suggest that living in the U. S. might increase depression among poor black women receiving services in county entitlement clinics. Further research with ethnically validated instruments is needed to identify protective and risk factors associated with depression in immigrant and U. S.-born poor black women.

Improving chronic illness care: A longitudinal cohort analysis of large physician organizations

Background:An increasing number of people suffer from chronic illness. Processes exist to provide better chronic illness care and yet for the most part, they are not used. Objective:To examine the change in use of commonly recommended chronic illness care management processes (CMPs) in large medical groups between 2000 and 2006 and the factors associated with the change. Design and Measures:Cohort analysis of data from a national telephone survey in year 2000 and again in 2006. Participants provided information on their organizations’ ownership, size, use of defined chronic illness CMPs, financial incentives, quality improvement involvement, profitability, and use of electronic medical records. Setting:Medical groups and independent practice associations of 20 physicians or more (N = 369) that treat patients with asthma, congestive heart failure, depression, and diabetes, and that responded to the survey in 2000 and 2006. Results:Use of CMP increased from 6.25 to 7.67 (of a total of 17; P ≤ 0.001), that is, by 23%, between 2000 and 2006. Increases were greatest for those practices receiving financial rewards for quality; those participating in quality improvement activities; and those practices that were profitable. Most of the increase was in use of registries and in patient self-management support services. Conclusions:There is significant opportunity for improving chronic illness care even in larger physician organizations. Public policies that promote financial rewards for improving quality and that encourage quality improvement initiatives are likely to be associated with improved chronic illness care.

Improving Chronic Illness Care: Findings From a National Study of Care Management Processes in Large Physician Practices

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations—medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

Changes in Pediatric Renal Transplantation After Implementation of the Revised Deceased Donor Kidney Allocation Policy

In October 2005, the United Network for Organ Sharing (UNOS) implemented a revised allocation policy requiring that renal allografts from young deceased donors (DDs) (<35 years old) be offered preferentially to pediatric patients (<18 years old). In this study, we compare the pre‐ and postpolicy quarterly pediatric transplant statistics from 2000 to 2008. The mean number of pediatric renal transplants with young DDs increased after policy implementation from 62.8 to 133 per quarter (p < 0.001), reflecting a change in the proportion of all transplants from young DDs during the study period from 0.33 to 0.63 (p < 0.001). The mean number of pediatric renal transplants from old DDs (≥35 years old) decreased from 22.4 to 2.6 per quarter (p < 0.001). The proportion of all pediatric renal transplants from living donors decreased from 0.55 to 0.35 (p < 0.001). The proportion from young DDs with five or six mismatched human leukocyte antigen (HLA) loci increased from 0.16 to 0.36 (p < 0.001) while those with 0 to 4 HLA mismatches increased from 0.18 to 0.27 (p < 0.001). Revision of UNOS policy has increased the number of pediatric renal transplants with allografts from young DDs, while increasing HLA‐mismatched allografts and decreasing the number from living donors.

Missing Data in Longitudinal Trials - Part B, Analytic Issues

Longitudinal designs in psychiatric research have many benefits, including the ability to measure the course of a disease over time. However, measuring participants repeatedly over time also leads to repeated opportunities for missing data, either through failure to answer certain items, missed assessments, or permanent withdrawal from the study. To avoid bias and loss of information, one should take missing values into account in the analysis. Several popular ways that are now being used to handle missing data, such as the last observation carried forward (LOCF), often lead to incorrect analyses. We discuss a number of these popular but unprincipled methods and describe modern approaches to classifying and analyzing data with missing values. We illustrate these approaches using data from the WECare study, a longitudinal randomized treatment study of low income women with depression.