Kenneth B. Wells

Development of a brief screening instrument for detecting depressive disorders.

A very short (8-item), self-report measure was developed to screen for depressive disorders (major depression and dysthymia). The screener departs from traditional depressive symptom scales in that 1) individual items are differentially weighted and 2) two of the eight items concern diagnostically relevant durations of depressed mood. Analyses of data from a general population and from primary care and mental health patients showed that the screener had high sensitivity and good positive predictive value for detecting depressive disorder, especially for recent disorders and those that met full DSM-III criteria. The high predictive utility of the screener, in combination with its brevity, suggests that it may be a useful tool for screening for depression in health care settings.

Treatment Preferences Among Depressed Primary Care Patients

AbstractOBJECTIVE: To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients. DESIGN: Patient questionnaires and interviews. SETTING: Forty-six primary care clinics in 7 geographic regions of the United States. PARTICIPANTS: One thousand one hundred eighty-seven English-and Spanish-speaking primary care patients with current depressive symptoms. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P=.001) and had greater knowledge about antidepressant medication (OR, 2.6; 95% CI, 1.6 to 4.4; P≤.001) than those who did not want treatment. A majority (67%, n=660) of those preferring treatment preferred counseling, with African Americans (OR, 2.2; 95% CI, 1.0 to 4.8, P=.04 compared to whites) and those with greater knowledge about counseling (OR, 2.1; 95% CI, 1.6 to 2.7, P≤.001) more likely to choose counseling. Three hundred twelve (47%) of the 660 desiring counseling preferred group over individual counseling. Depression severity was only a predictor of preference among those already in treatment. CONCLUSIONS: Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

Who Is at Risk of Nondetection of Mental Health Problems in Primary Care

AbstractOBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians. DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study. PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians. MEASUREMENTS AND MAIN RESULTS: We counted “detection” of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection. CONCLUSIONS: Patients’ race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.

Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study

This study was carried out to determine whether levels of physical activity of patients with various chronic diseases are associated with subsequent functioning and well-being. It was an observational 2-year longitudinal design. The setting was offices of medical and mental health practices within health maintenance organizations, large multispecialty groups, and solo practices or small single-specialty group practices in three U.S. cities. Included in the study were 1758 adult patients with one or more of the following: diabetes, hypertension, congestive heart failure, recent myocardial infarction, depressive symptoms, or current depressive disorder. Outcome measures included physical, role, and functioning; energy/fatigue; pain intensity; sleep problems; depressed affect, anxiety, positive affect, and overall psychological distress/well-being; health distress; and current health perceptions. Cross-sectional (base-line), 2-year endpoint, and change score relationships were evaluated between baseline levels of physical activity and each outcome, controlling for chronic conditions, comorbidity, smoking, alcohol use, overweight, self-reported adherence, and other patient and study characteristics. Higher baseline levels of exercise were uniquely associated with better functioning and well-being at baseline and 2 years later for some measures. The magnitude of the differences varied by disease group, but tended to be between 0.17 and 0.39 of the baseline SD. Greater levels of exercise are associated with feeling and functioning better for patients with chronic conditions over a 2-year period, suggesting that this is a fruitful area for further study using controlled interventions.

Barriers to mental health treatment: results from the National Comorbidity Survey Replication.

BACKGROUND The aim was to examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the US general population. METHOD Respondents in the National Comorbidity Survey Replication with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders were asked about perceived need for treatment, structural barriers and attitudinal/evaluative barriers to initiation and continuation of treatment. RESULTS Low perceived need was reported by 44.8% of respondents with a disorder who did not seek treatment. Desire to handle the problem on ones own was the most common reason among respondents with perceived need both for not seeking treatment (72.6%) and for dropping out of treatment (42.2%). Attitudinal/evaluative factors were much more important than structural barriers both to initiating (97.4% v. 22.2%) and to continuing (81.9% v. 31.8%) of treatment. Reasons for not seeking treatment varied with illness severity. Low perceived need was a more common reason for not seeking treatment among individuals with mild (57.0%) than moderate (39.3%) or severe (25.9%) disorders, whereas structural and attitudinal/evaluative barriers were more common among respondents with more severe conditions. CONCLUSIONS Low perceived need and attitudinal/evaluative barriers are the major barriers to treatment seeking and staying in treatment among individuals with common mental disorders. Efforts to increase treatment seeking and reduce treatment drop-out need to take these barriers into consideration as well as to recognize that barriers differ as a function of sociodemographic and clinical characteristics.

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.

Agreement between face-to-face and telephone-administered versions of the depression section of the NIMH diagnostic interview schedule

To increase the feasibility of identifying persons with depressive disorders in a large-scale health policy study, we tested the concordance between face-to-face and telephone-administered versions of the depression section of the NIMH Diagnostic Interview Schedule (DIS). This section was administered over the telephone to 230 English-speaking participants of the Los Angeles site of the NIMH Epidemiologic Catchment Area Program (ECA) after their completion of a face-to-face interview (Wave II) with the full DIS. Time lag between interviews was 3 months, on the average. Persons with depressive symptoms were oversampled. Using the face-to-face version as the criterion measure, the sensitivity, specificity, and positive predictive value of the telephone version for identifying the presence or absence of any lifetime unipolar depressive disorder were 71, 89, and 63 percent, respectively; the kappa statistic was 0.57, and agreement was unbiased. The comparable figures for concordance between two face-to-face interviews administered one year apart to the same subjects were 54, 89, and 60 percent and 0.45 (kappa), respectively. Thus, disagreement was due primarily to test-retest unreliability of the DIS rather than the method of administration.

Somatization in the community: relationship to disability and use of services.

We tested the hypotheses that an abridged somatization construct that we had developed would be associated with use of health services, preferential use of medical over mental health services, and an index of disability. These hypotheses were tested using structured interview data from 3,132 randomly selected community respondents. We found that: respondents meeting criteria for somatization reported a heavier use of health services than non-somatizers; of those respondents meeting criteria for a psychiatric diagnosis, somatizers preferentially used medical over mental health services whereas non-somatizers reported the opposite trend; and somatizers were more likely than non-somatizers to report recent sick leave or restricted activity.

Interventions in Organizational and Community Context: A Framework for Building Evidence on Dissemination and Implementation in Health Services Research

The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: (1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; (2) distinguishing among key components of the diffusion process—including contextual factors, adoption, implementation, and sustainment of interventions—showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; (3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and (4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.

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.