Marian R. Block

The efficiency of depression questionnaires for case finding in primary medical care.

ConclusionThere is a need for case-finding procedures that can efficiently identify depressed persons seeking care in primary medical settings. Several brief, self-administered questionnaires are available for this purpose, but published studies assessing their predictive powers are surprisingly sparse and varied in the quality of relevant information. Different practice settings, cut-off points, and criterion measures limit the generalizability of previous reports. Nevertheless, case finding with a brief questionnaire is an attractive strategy that should be further investigated in specified patient groups, given the need to improve the primary care physician’s diagnosis and treatment of depression.

Clinical trials of primary care treatments for major depression: issues in design, recruitment and treatment

The objective of this article is to consider whether randomized clinical trials (RCTs) are able to determine the validity of transferring treatments for major depression from the psychiatric to the primary care sector. This clinical issue is of growing concern in the United States since both governmental and professional bodies are establishing guidelines for the treatment of medical patients with the affective disorder. The articles method involves analysis of how the competing aims of rigorous scientific methodology (internal validity) and generalization of study findings (external validity) are best balanced within the RCT. Experiences in recruiting medical patients with major depression and providing pharmacologic, psychotherapeutic, and usual care interventions compatible with the sociotechnical characteristics of ambulatory medical centers are described to illustrate the complexities of investigating transferability of treatments for major depression with RCT methodology.

Psychiatric Decision Making in Family Practice Future Research Directions

Psychiatric illnesses in family practice are significantly underdiagnosed because of factors associated with both the physician and patient. Clinicians too often fail to utilize a biopsychosocial approach in the assessment process, tending to assess symptoms as organic regardless of their etiology. Patients similarly tend to emphasize the physical nature of their complaints when presenting in medical settings. Efforts have been made to improve the physicians diagnostic accuracy through the use of screening scores. The results, however, are inconclusive. It remains unclear whether the physician disregards this information or considers it irrelevant. We suggest that future research investigate not only the accuracy of the clinicians diagnostic formulation but also the processes whereby the family practitioner elicits, analyzes, and synthesizes or discards cues pertinent to mental illness. By combining statistical analyses with the analytic techniques developed in studies of medical decision making and general problem solving, detailed leads should emerge for the design of improved didactic and experiential training programs.

Depressive Symptomatology and Medical Co-Morbidity in a Primary Care Clinic

Most primary care patients exhibiting significant depressive symptomatology fail to meet DSM-III criteria for a major depressive disorder (MDD). Yet, such patients have substantial morbidity and dysfunction attributable to their affective syndrome. Since surprisingly little is known about this groups clinical characteristics, we studied 618 general medicine patients aged eighteen to sixty-four years. In this population, fifty-seven (9.2%) scored quite high when screened on the Center for Epidemiological Studies Depression Scale (≥ 27) while not meeting MDD criteria on the Diagnostic Interview Schedule. Membership in the “depression symptoms only” (DSO) group was predicted by a logistic regression model including female gender, more severe medical illness, higher likelihood of operative procedures, and less frequent cardiovascular diagnoses. Our findings suggest that the DSO state is associated with substantial “medical” morbidity. Prospective studies of subclinical depression in the primary care setting are urged to clarify etiologic and treatment concerns.

Symptom Patterns of Depression in Ambulatory Medical and Psychiatric Patients

The failure of primary care physicians to recognize depressive disorders in medical patients has been attributed to the differing clinical syndromes presented by these persons in comparison with psychiatric patients. Earlier British studies have found inter sector difference in the prevalence and severity of somatic, affective, and cognitive symptoms. Our investigation with American patients did not replicate these findings. The need for further research along these lines is discussed, as are the implications for assessing depression in generalist and specialist practices.

Strategies for evaluating treatments for major depression in primary care patients

Primary care physicians are being urged to provide patients experiencing a major depression treatments validated with psychiatric patients. The propriety of transferring clinical technologies from one care-giving sector to another is questionable, however, as it has little scientific support. We suggest that clinical trials be initiated so as to expand the available knowledge base. This paper analyzes the methodologic issues involved in pursuing such experimental research and urges that it be conducted despite the possible need for initial design compromises.

Treating depression in primary care practice: An application of decision analysis

Decision analysis approaches complex treatment issues by considering alternative strategies in an explicit and logical manner, and examining their outcomes in the face of varied assumptions. Significant data gaps impede full application of this framework to the treatment of depressed primary care patients. Nevertheless, decision analysis already can be useful in emphasizing needed clinical information in treating these patients and highlighting future directions for research.

Diagnosing Depression Among New Patients In Ambulatory Training Settings

A research-validated instrument, based upon the Diagnostic and Statistical Manual of Mental Disorders-III, is used as a “gold standard” to compare physician assessments of depression. Twenty-seven of 294 patients (9.2 percent) presenting to three primary care clinics for the first time met clinical criteria for a depressive disorder. Although the 27 depressed patients differed from the nondepressed patients on sociodemographic characteristics, prior service utilization patterns, and clinical variables, only 7 of the 27 were diagnosed as depressed by their primary care physicians. Factors associated with accurate assessment include comment in the patient’s chart of a prior psychiatric history. Many depressed patients reporting high levels of dysphoria on a screening instrument had no mood symptoms recorded on their charts.