Mark J. Yaffe

Physician characteristics and the recognition of depression and anxiety in primary care.

We examined physician characteristics associated with the recognition of depression and anxiety in primary care. Fifty-five physicians treating a total of 600 patients completed measures of psychosocial orientation, psychological mindedness, self-rating of sensitivity to hidden emotions, and a video test of sensitivity to nonverbal communication. Patients were classified as cases of psychiatric distress based on the CES-D scale and the Diagnostic Interview Schedule. Physician recognition was determined by notation of any psychosocial diagnosis in the medical charts over the ensuing 12 months. Of 192 patients scoring 16 or above on the CES-D, 44% (83) were recognized as psychiatrically distressed. Three findings were central to this study: 1) Physicians who are more sensitive to nonverbal expressions of emotion made more psychiatric or psychosocial assessment of their patients and appeared to be over-inclusive in their judgments of psychosocial problems; 2) Physicians who tended to blame depressed patients for causing, exaggerating, or prolonging their depression made fewer psychosocial assessments and were less accurate in detecting psychiatric distress; 3) False positive labeling of patients who had no evidence of psychiatric distress was rare. Surprisingly, more severe medical illness increased the likelihood of labeling and accurate recognition. Physician factors that increased recognition may indicate a greater willingness to formulate a psychiatric diagnosis and an ability notice nonverbal signs of distress.

Development and Validation of a Tool to Improve Physician Identification of Elder Abuse: The Elder Abuse Suspicion Index (EASI)©

ABSTRACT This study aimed to develop and validate a brief tool for physician use to improve suspicion about the presence or absence of elder abuse. A literature review on elder abuse, obstacles to its identification, limitations of detection tools, and characteristics of screeners employed by physicians were used to generate elder abuse detection questions for critique by 31 doctors, nurses, and social workers in focus groups. Six resulting questions became the Elder Abuse Suspicion Index (EASI) administered by 104 family doctors to 953 cognitively intact seniors in ambulatory-care settings. Findings were compared to a recognized, detailed elder abuse Social Work Evaluation (SWE) later administered to participants by social workers blinded to the results of the EASI. The EASI had an estimated sensitivity and specificity of 0.47 and 0.75, usually took less than 2 minutes to ask, and 97.2% of doctors felt it would have some or big practice impact. This research is a first phase in the development and validation of a user-friendly tool that might sensitize physicians to elder abuse and promote referrals of possible victims for in-depth assessment by specialized professionals.

Use of Complementary and Alternative Medicine by Cancer Patients at a Montreal Hospital

Objectives: To assess feasibility of methods for a future study of complementary and alternative medicine (CAM) use by cancer patients treated in conventional health care settings. Methods: Patients aged 18 years and older, fluent in English or French, and diagnosed with cancer from St. Mary’s Hospital Center, Montreal, Canada participated. Feasibility was measured by the rates of participation and CAM use in the past 1 and 12 months. Following the survey, one patient focus group was held to better understand cancer patient perspectives on discussions of CAM that occur or not with their family physicians. Results: Of 103 patients approached, 100 (97.1%; 77% female, 87% white) participated. Overall, 86% and 91% of respondents used at least one CAM in the past 1 and 12 months, respectively. More patients with breast compared with colorectal and other cancers (90.2%, 86.2%, and 80%, respectively) used CAM in the previous year. In the past 1 and 12 months, natural health products were used by 70% and 80% of respondents, respectively; mind–body therapies by 61% and 64%, respectively, and CAM practitioners by 11% and 29%, respectively. More than 98% of patients used CAM to improve quality of life and 68% disclosed CAM use to their physicians. Four of 5 focus group participants used CAM. Patient–physician CAM discussions varied from receiving a CAM referral to complete dismissal of the topic. Conclusion: Recruitment methods were well accepted but a sampling strategy stratified by sex and ethnicity will ensure sufficient representation by males and non-whites. Whereas disclosure of natural health products use is occurring, informative CAM discussion is not.

Seniors' Self-Administration of the Elder Abuse Suspicion Index (EASI): A Feasibility Study

This study explored the feasibility of seniors aged 65 and over with MMSE ≥24 completing the EASI-sa, a self-administrable version of the Elder Abuse Suspicion Index (EASI). A convenience sample of 210 was stratified by age, sex, and language (English and French). All completed the EASI-sa within an estimated 5 minutes, 82.9% within 2 minutes. Completion time decreased with higher education, but was not affected by age, sex, language, or measured physical or mental health. No questions went unanswered; no words were poorly understood or discomforting. The EASI-sa completion was associated with a significantly increased understanding about elder abuse (p < 0.0001).

An integrated curriculum for teaching preparatory clinical skills at a traditional medical school

In 1991, the Liaison Committee on Medical Education stated that medical schools must be responsible for designing and managing a coherent and coordinated curriculum. With respect to preparatory clinical skills, there have been no reports in the literature of an integrated and longitudinal approach to curriculum design or a description of a medical school with the administrative and educational structure to implement one. This article describes such an effort at McGill Universitys Faculty of Medicine. aVarious advantageous features are described: (a) a subcurriculum committee and an administrative structure to oversee the project, (b) early introduction to patients, (c) a comprehensive small‐group program, (d) the use of “near‐peer”; teachers, and (e) a process of faculty development. The longitudinal integration of these features is particularly noteworthy because the overall curriculum at McGill has been based largely on the traditional Flexnerian model of medical education consisting of approximately 2...

Developing an Evaluation Framework for Consumer-Centred Collaborative Care of Depression Using Input from Stakeholders

Objective: To develop a framework for research and evaluation of collaborative mental health care for depression, which includes attributes or domains of care that are important to consumers. Methods: A literature review on collaborative mental health care for depression was completed and used to guide discussion at an interactive workshop with pan-Canadian participants comprising people treated for depression with collaborative mental health care, as well as their family members; primary care and mental health practitioners; decision makers; and researchers. Thematic analysis of qualitative data from the workshop identified key attributes of collaborative care that are important to consumers and family members, as well as factors that may contribute to improved consumer experiences. Results: The workshop identified an overarching theme of partnership between consumers and practitioners involved in collaborative care. Eight attributes of collaborative care were considered to be essential or very important to consumers and family members: respectfulness; involvement of consumers in treatment decisions; accessibility; provision of information; coordination; whole-person care; responsiveness to changing needs; and comprehensiveness. Three inter-related groups of factors may affect the consumer experience of collaborative care, namely, organizational aspects of care; consumer characteristics and personal resources; and community resources. Conclusion: A preliminary evaluation framework was developed and is presented here to guide further evaluation and research on consumer-centred collaborative mental health care for depression.

Development and validation of subscales to assess perceived support for self-management of mood or emotional problems: Results from a randomized trial

OBJECTIVES To validate 2 new patient-reported measures of self-management support from health professionals for mood and emotional problems. METHODS The sample comprised primary care patients with chronic physical conditions and co-morbid depressive symptoms enrolled in a randomized trial of telephone coaching of a depression self-care intervention (n=120). At 6-month follow-up, patients completed 2 subscales with respect to support for self-management of their chronic physical condition(s): 1) Self-Management Information (SMInfo-Phys); and 2) Care Plan (CP-Phys) and equivalent subscales adapted to assess self-management support for mood and emotional problems: SMInfo-Mood and CP-Mood. Subscale scoring was assessed with Item Response Theory (IRT) analysis. Convergent validity of the mood subscales was assessed. The sensitivity of the mood and physical condition subscales to mental health interventions was assessed with generalized estimating equations (GEE). RESULTS The mood subscales were associated with relevant measures of perceived unmet mental health needs. Both SMInfo-Mood and CP-Mood were sensitive to the coaching intervention; CP-Mood was also sensitive to receipt of depression treatment outside the trial. CONCLUSION This study provides preliminary evidence for the validity of the 2 new subscales. PRACTICE IMPLICATIONS The subscales may be used to assess perceived health professional support for self-management of mood and emotional problems.

Supported depression self-care may prevent major depression in community-dwelling older adults with chronic physical conditions and co-morbid depressive symptoms.

Self-care programs for depression use educational and cognitive-behavioral techniques (e.g. written information, audiotapes, videotapes, computerized, or group courses) to assist patients in the management of depressive symptoms (Morgan and Jorm, 2008 ). In the UK, these interventions are recommended as step 1 in a stepped care program for treating depression in primary care (National Institute for Health and Clinical Excellence, 2007 ). One meta-analysis suggests that supported self-care (self-care with coaching) is more effective than unsupported self-care (Gellatly et al. , 2007 ).

What Affects Family Physicians’ Participation in Research: Outcomes from a Depression Self-Care Study

Background: To describe factors associated with family physicians (FPs) recruitment and participation in a mental health research project. Methods: 400 FPs were randomly approached for a feasibility study of telephone-supported self-care for depression in adults with chronic physical diseases. FP participation included (1) completing questionnaires at study enrolment and termination to identify personal characteristics, attitudes to patient self-care, and aspects of study implementation; and (2) encouraging patient self-completion of screening forms on depression and comorbid chronic disease in order to assess study eligibility. Outcome measures were the number of FPs who adhered to these tasks, as well as the number of eligible patients recruited from each practice. Chi square and Fisher’s Exact Tests permitted comparison of binary or categorical values, while the Kruskal-Wallis non-parametric test was used for continuous scales. Results: Of the 400 FPs randomly selected, 29.8% (119/400) were not reachable by telephone; 42.8% (171/400) were assessed as not meeting eligibility criteria; and 59 (53.6%) of the remaining 110 met eligibility criteria, consented, and participated. Predominant reasons for participation were past experience with research projects, interest in the specific topic of mental health care, enthusiasm about self-care, and sense of collegiality. 86.4% (51/59) completed the study entry questionnaire, and 62.7% (37/59) the end of study questionnaire. 66.1% (39/59) submitted at least one positive screening form (range 1-43), with such participation occurring more often amongst FPs in solo practice or with previous research experience. Conclusion: Recruiting FPs to participate in mental health research and adhere to protocols is challenging and time intensive. To optimize such involvement researchers may need to employ creative strategies unique to study sites, idiosyncrasies of the doctors, and the nature of the topic undergoing study.

Detection of elder abuse: Exploring the potential use of the Elder Abuse Suspicion Index© by law enforcement in the field

ABSTRACT There are no known instruments to aid law enforcement officers in the assessment of elder abuse (EA), despite officers’ contact with older adults. This study aimed to identify: 1) officers’ perceptions and knowledge of EA, 2) barriers in detecting EA in the field, 3) characteristics officers value in a detection tool, and to explore 4) the potential for officers to use the Elder Abuse Suspicion Index (EASI)©. Data was collected from 69 Connecticut officers who confirmed that barriers to effectively detecting EA included a lack of EA detection instruments, as well as a lack of training on warning signs and risk factors. Officers indicated that the important elements of a desirable tool for helping to detect EA included ease of use, clear instructions, and information on follow-up resources. Approximately 80% of respondents could see themselves using the EASI© in the field, and a modified version has been developed for this purpose.