M. Audrey Burnam

Evaluating quality-of-life and health status instruments: development of scientific review criteria

The Medical Outcomes Trust is a depository and distributor of high-quality, standardized, health outcomes measurement instruments to national and international health communities. Every instrument in the Trust library is reviewed by the Scientific Advisory Committee against a rigorous set of eight attributes. These attributes consist of the following: (1) conceptual and measurement model; (2) reliability; (3) validity; (4) responsiveness; (5) interpretability; (6) respondent and administrative burden; (7) alternative forms; and (8) cultural and language adaptations. In addition to a full description of each attribute, we discuss uses of these criteria beyond evaluation of existing instruments and lessons learned in the first few rounds of instrument review against these criteria.

Substance use and mental health correlates of nonadherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection

PURPOSE Mental health and substance use problems are common among patients infected with human immunodeficiency virus (HIV) and may impede adherence to antiretroviral regimens. This study investigated associations of antiretroviral medication nonadherence with specific types of psychiatric disorders and drug use, and varying levels of alcohol use. METHODS Data were drawn from a survey of a national probability sample of 2267 (representing 181,557) adults enrolled in the HIV Cost and Services Utilization Study. This study focused on 1910 patients who reported their antiretroviral medication adherence during the past week. RESULTS Patients with depression (odds ratio [OR] = 1.7; 95% confidence interval [CI]: 1.3 to 2.3), generalized anxiety disorder (OR = 2.4; 95% CI: 1.2 to 5.0), or panic disorder (OR = 2.0; 95% CI: 1.4 to 3.0) were more likely to be nonadherent than those without a psychiatric disorder. Nonadherence was also associated with use of cocaine (OR = 2.2; 95% CI: 1.2 to 3.8), marijuana (OR = 1.7; 95% CI: 1.2 to 2.3), amphetamines (OR = 2.3; 95% CI: 1.2 to 4.2), or sedatives (OR = 1.6; 95% CI: 1.0 to 2.4) in the previous month. Compared with patients who did not drink, those who were moderate (OR = 1.6; 95% CI: 1.3 to 2.0), heavy (OR = 1.7; 95% CI: 1.3 to 2.3), or frequent heavy (OR = 2.7; 95% CI: 1.7 to 4.5) drinkers were more likely to be nonadherent. These associations could not be explained by demographic, clinical, and treatment factors. CONCLUSION These findings suggest the need for screening and treatment for mental health and substance use problems among HIV-positive patients to improve adherence to antiretroviral medications.

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.

Underdiagnosis of Depression in HIV: Who Are We Missing?

AbstractOBJECTIVE: To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV. DESIGN: Cross-sectional survey. PATIENTS/PARTICIPANTS: National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data. MEASUREMENTS AND MAIN RESULTS: We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1,140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P<.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P<.01) and those with ≥3 outpatient visits (P<.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers. CONCLUSIONS: Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.

Measurement of Acculturation in a Community Population of Mexican Americans

A 26-item acculturation measure was administered to a probability sample of 1245 adult Mexican Americans residing in Los Angeles. This measure demonstrated high internal reliability for the total sample and for specific sex, educational, and language groups. Construct validity was supported by showing acculturation scores predicted length of exposure to U.S. culture. Data suggested that, among first generation Mexican Americans, those who were younger and male acculturated more rapidly than those who were older and female. This sex difference, but not the age difference, could be explained by educational and employment experiences. Among later generation Mexican Americans, those who were younger again had higher acculturation levels, possibly due to age differences in education and employment, or to historical factors differentially effecting age cohorts.

Social support sources following sexual assault

Considerable research suggests that social support plays a crucial role in coping with stressful life events. The present study used data from 3,132 randomly selected survey respondents to investigate the use and helpfulness of seven potential social support sources in coping with a particular life crisis: sexual assault. About two-thirds of the 447 sexually assaulted respondents had told someone about the assault. Over half had talked to a friend or relative (59.3%). Fewer respondents consulted police (10.5%), mental health professionals (16.1%), physicians (9.3%), clergy (3.9%), rape crisis centers (1.9%), and legal professionals (1.6%). Assault by a stranger, physical threat, fighting against the assailant, a high degree of sexual contact, and emotional distress concerning the assault were associated with talking about the assault, especially with police and physicians. Most of those who told someone found at least one person helpful (73.8%). Rape crisis centers (94.2%) and legal professionals (82.7%) were most frequently described as helpful, followed by mental health professionals (70.1%), friends and relatives (66.6%), clergy (63.1%), physicians (55.6%), and police (38.2%). Results are compared to previous findings, and implications for research and intervention are discussed.

Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions

The authors estimated the sex- and age-adjusted prevalence of affective, substance use, and anxiety disorders in persons in a general population sample who identified themselves as having arthritis, diabetes, heart disease, high blood pressure, chronic lung disease, or no chronic medical conditions. Persons who reported ever having arthritis, heart disease, chronic lung disease, or high blood pressure had a significantly increased adjusted prevalence of each of the three groups of lifetime psychiatric disorders, relative to a no-chronic conditions comparison group (each p less than 0.05). Persons who ever had diabetes had an increased adjusted prevalence of lifetime affective and anxiety but not substance use disorder. Persons with current (i.e., active) arthritis, heart disease, or high blood pressure had a significantly increased adjusted prevalence of recent (6-month) anxiety disorder, whereas those with current chronic lung disease had an increased adjusted prevalence of recent affective and substance use but not anxiety disorder.

Methodology for Obtaining a Representative Sample of Homeless Persons The Los Angeles Skid Row Study

Recent efforts on the part of survey researchers to understand the characteristics and needs of homeless individuals have been hampered by factors which make it extra ordinarily difficult to draw representative samples of this population. To date, only one study (Rossi et al., 1987) has drawn a probability sample of homeless persons that includes unsheltered individuals. Because the design of the Rossi study can only accommodate a short interview and is best carried out in one night, additional designs that allow more lengthy interview protocols and data collection periods are needed. An effort to draw a probability sample of homeless adults in the inner-city area of Los Angeles resulted in a sampling design that meets these criteria. This article describes this design in detail.

Utilization of Mental Health and Substance Abuse Services Among Homeless Adults in Los Angeles

OBJECTIVES Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

Sexual assault history and use of health and mental health services

A history of sexual assault may be associated with increased current use of mental health and medical services because of the psychologically and physically disruptive consequences of assault. To test this hypothesis, we estimated rates of mental health and medical services use among 2560 randomly selected community residents, 343 of whom had been sexually assaulted. Sexual assault was associated with seeking both forms of care. Controls for demographic variables, psychiatric diagnosis, health status, and insurance suggested that assault increases use indirectly, through poor mental and physical health. Uninsured, assaulted respondents were especially likely to consult medical providers. Respondents assaulted during childhood were particularly likely to seek mental health care. Assault was more common among mental health service users than nonusers, and among women using medical services compared to female nonpatients. The high prevalence of assault among service users underscores the need for providers to recognize and treat sexual assault-related problems.