Junius J. Gonzales

The acceptability of treatment for depression among African-American, hispanic, and white primary care patients

Background. Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. Methods. A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. Results. African Americans (adjusted OR, 0.30; 95% CI 0.19–0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26–0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35–1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08–9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. Conclusions. African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients’ cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Patterns of rural mental health care: An exploratory study

In rural areas, it is important to clarify our understanding of how primary care and specialty mental health professionals organize care for those with mental disorders, and the role that linkages between specialty mental health and primary health care providers can play in the effectiveness of such care. Although these are issues that must be generally addressed, in rural areas fewer institutional and individual providers per capita accentuate problems of health care organization and delivery. This paper reports findings from an exploratory study of service use in two primary care sites in a rural, group-model HMO (Site A enrollment = 2,625; Site B = 6,019). We found that patients in the primary care site who had weaker mental health consultative linkages, higher rurality, and less availability of mental health specialty care used more mental health services by primary care providers (RR = 5.19 (3.78,6.61)), received more ambulatory care from joint mental health/ primary care providers (RR = 1.68 (1.02,2.78)), and had more mental health hospital utilization (adjusted OR = 1.84 (0.54,6.23)). These findings point to the need for further study of primary care providers and their linkage relationships in rural areas, in this large and currently often underserved population.

Do family physicians and internists differ in knowledge, attitudes, and self-reported approaches for depression?

Objectives: The purpose of this investigation was to assess the relationship of primary care specialty training with self-assessed skill, knowledge, attitudes, and behavior toward depression recognition and management. Method: A baseline self-report questionnaire was administered to 184 internists and 138 family physicians participating in a multisite depression intervention study. Results: There were no marked differences in knowledge of internists and family physicians regarding depression, in attitudes about the effectiveness of specific therapies, or in barriers to providing optimum treatment for depression. However, compared to internists, family physicians rated themselves as more skilled in the management of depression. When considering management of patients with moderate to severe depression, family physicians were more likely to report that they prescribed a selective serotonin-reuptake inhibitor (relative odds (RO) = 3.51, 95 percent Confidence interval (CI) [2.19, 5.60] and to personally counsel patients (RO = 1.97, 95 percent CI [1.16, 3.38]) more than half the patients, but were less likely to refer to a specialist in mental health (RO = 0.52, 95 percent CI [0.33, 0.82]) than were internists. Additional potentially influential characteristics did not wholly account for the reported differences in practice according to specialty. Physicians of both specialties expressed considerable uncertainty in their knowledge of psychotherapy and in their evaluation of the effectiveness of other strategies for the prevention of recurrence of depression. Conclusion: Strategies to improve mental health care should account for the orientation of primary care physicians to mental health issues.

Reinvention of Depression Instruments by Primary Care Clinicians

PURPOSE Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use. METHODS Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators’ field notes on office practice environments complemented individual interviews. RESULTS The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients’ acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician’s time, the lack of objective evidence of depression, and the clinician’s familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions. CONCLUSIONS Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making—primarily to suggest, tell, or convince patients to accept the diagnosis of depression.

Modifying ICD-9-CM Coding of Secondary Diagnoses to Improve Risk-Adjustment of Inpatient Mortality Rates

Objective . To assess the effect on risk-adjustment of inpatient mortality rates of progressively enhancing administrative claims data with clinical data that are increasingly expensive to obtain. Data Sources . Claims and abstracted clinical data on patients hospitalized for 5 medical conditions and 3 surgical procedures at 188 Pennsylvania hospitals from July 2000 through June 2003. Methods . Risk-adjustment models for inpatient mortality were derived using claims data with secondary diagnoses limited to conditions unlikely to be hospital-acquired complications. Models were enhanced with one or more of 1) secondary diagnoses inferred from clinical data to have been present-on-admission (POA), 2) secondary diagnoses not coded on claims but documented in medical records as POA, 3) numerical laboratory results from the first hospital day, and 4) all available clinical data from the first hospital day. Alternative models were compared using c-statistics, the magnitude of errors in prediction for individual cases, and the percentage of hospitals with aggregate errors in prediction exceeding specified thresholds. Results . More complete coding of a few under-reported secondary diagnoses and adding numerical laboratory results to claims data substantially improved predictions of inpatient mortality. Little improvement resulted from increasing the maximum number of available secondary diagnoses or adding additional clinical data. Conclusions . Increasing the completeness and consistency of reporting a few secondary diagnosis codes for findings POA and merging claims data with numerical laboratory values improved risk adjustment of inpatient mortality rates. Expensive abstraction of additional clinical information from medical records resulted in little further improvement.

Treatment patterns and outcomes of depressed medically ill and non-medically ill patients in community psychiatric practice.

The prevalence of depression among the medically ill, the recognition of depression in general medical practice, and the association between depression and medical illness have all been a focus for research in recent years. Less is known about the process and outcomes of depression care in the medically ill compared with the non-medically ill, but some studies suggest that those with concomitant physical illness have poorer outcomes. In a study of community psychiatric practice, a sample of 53 patients with no medical comorbidity (NMI) was compared with 50 patients, categorized by higher (HMI) or lower (LMI) levels of physical comorbidity, approximately 5 months after beginning treatment for a current episode of major depression. No differences were found in treatments received or in mental health outcomes between the three groups. The HMI group showed greater impairment in social and occupational functioning at baseline and significantly greater improvement in these variables at follow-up. Since medical comorbidity does not appear to adversely affect treatment decisions or outcomes in community psychiatric practice, depressed, physically ill patients should be encouraged to seek treatment, regardless of their medical condition or level of disability.

Cost-effective enhancement of claims data to improve comparisons of patient safety

Tools that support screening for medical errors can help to identify potential patient safety events for further investigation and can provide benchmarks against which providers, localities, and states can compare themselves. The Agency for Healthcare Research and Quality Patient Safety Indicators, which are based solely on hospital administrative or claims data, represent one such tool. Without sufficient clinical detail, measures based on claims data may not accurately reflect hospital quality of care. To construct risk-adjustment models, we used hospital discharge data from July 2000 to June 2003 from 188 Pennsylvania hospitals supplied by the Pennsylvania Health Care Cost Containment Council. We augmented the hospital claims data with clinical data (also supplied by the Pennsylvania Health Care Cost Containment Council) abstracted from medical records using MediQuals proprietary Atlas™ (MediQual, Westborough, MA, a subsidiary of CardinalHealth) clinical information system. Clinical data elements included such items as patient history, laboratory results, vital signs, and other clinical findings. Our cost-effectiveness analyses strongly support the value of enhancing administrative claims data with a present-on-admission code and adding a limited set of numerical laboratory values. Reasonable additional benefit may be gained by adding vital signs to this data set, but the trade-off between effectiveness and cost is not as clear. Also, more accurate International Classification of Diseases, Ninth Revision, Clinical Modification coding of specific secondary diagnoses that are currently undercoded could improve the validity of risk-adjustment equations without the added cost of abstracting clinical findings from medical records. There seems to be little justification for secondary abstraction of medical records to obtain data for risk-adjusting the Agency for Healthcare Research and Quality Patient Safety Indicators.

Teaching psychiatric residents to teach.

Teaching other residents and medical students is one of the primary activities of psychiatric residents, yet most receive minimal or no formal training or supervision on how to teach. This report describes a Teaching Day Workshop, designed and implemented by residents at the Massachusetts General Hospital with the support of their faculty and an educational consultant, as one model to introduce the concepts and techniques of teaching to psychiatric residents. The participating residents were unanimous in their positive appraisal of the workshop, and they recommended that additional seminars on teaching be integrated into the residency’s core curriculum. Ways that the Teaching Day Workshop can be adapted for use by other residency training programs are discussed. The authors believe that teaching residents to be better teachers can have an impact on recruitment of medical students into psychiatry and psychiatric residents into careers in academic psychiatry.

CONSULTATION-LIAISON PSYCHIATRY IN THE MANAGED CARE ARENA

This article describes the history and current state of consultation-liaison psychiatry and managed care, the impact of managed care on consultation-liaison psychiatry, including service delivery and ethical issues, and recommendations for survival. The implications of managed health care delivery system reorganization for consultation-liaison psychiatry are important and offer challenges as well as opportunities for the field.

Research Development Mechanisms

Studies designed to reduce the burden of affective disorders should apply and develop theories and methods from diverse social sciences that could strengthen current interventions. A series of papers from diverse fields, such as quality engineering, behavioral economics, etc. might be a needed first step. Methodological research on design strategies such as group-level randomized trials, or instrumental variables analyses are needed. Finaly, qualitative studies to understand diverse stakeholder views are also needed. To pursue these areas, interdisciplinary training programs are needed to develop skilled researchers to study communities and community- based delivery settings. New research infrastructures are needed to support community and research collaborations, as well as supporting development of new technologies to enable diffusion of care.