Mohsen Bazargan

Depression symptomatology and diagnosis: discordance between patients and physicians in primary care settings

BackgroundTo examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and then to examine how the presence of these symptoms affects depression diagnosis in primary care settings.MethodsInterviewer administered surveys and medical record reviews. A total of 304 participants were recruited from 2321 participants screened for depression at two large urban primary care community settings.ResultsOf the 2321 participants screened for depression 304 were positive for depression and of these 75.3% (n = 229) were significantly depressed (PHQ-9 score ≥ 10). Of these, 31.0% were diagnosed by a physician with a depressive disorder. A total of 57.6% (n = 175) of study participants had both significant depression symptoms and functional impairment. Of these 37.7% were diagnosed by physicians as depressed. Cohens Kappa analysis, used to determine the agreement between depression symptoms elicited using the PHQ-9 and physician documentation of these symptoms showed only slight agreement (0.001–0.101) for all depression symptoms using standard agreement rating scales. Further analysis showed that only suicidal ideation and hypersomnia or insomnia were associated with an increased likelihood of physician depression diagnosis (OR 5.41 P sig < .01 and (OR 2.02 P sig < .05 respectively). Other depression symptoms and chronic medical conditions had no affect on physician depression diagnosis.ConclusionTwo-thirds of individuals with depression are undiagnosed in primary care settings. While functional impairment increases the rate of physician diagnosis of depression, the agreement between a structured assessment and physician elicited and or documented symptoms during a clinical encounter is very low. Suicidality, hypersomnia and insomnia are associated with an increase in the rate of depression diagnosis even when physician and self report of the symptom differ. Interventions that emphasize the use of routine structured screening of primary care patients might also improve the rate of diagnosis of depression in these settings. Further studies are needed to explore depression symptom assessment during physician patient encounter in primary care settings.

The Impact of Literacy Enhancement on Asthma-Related Outcomes among Underserved Children

STATEMENT OF PROBLEM Despite the availability of improved healthcare access, self-management programs, disease management protocols, and advances in pharmacologic and immunotherapy therapy, the prevalence of asthma in the urban inner city remains one of the major health disparities in the United States. Additionally, sustainability of effective intervention programs after the funding has ended remains a significant issue for asthma programs. OBJECTIVE This study examines the effectiveness of a longitudinal intervention program that was designed with the assumption that improved literacy plays a role in improving asthma-related health outcomes among high-risk children with the most severe forms of asthma. METHODS A longitudinal intervention over 6 months prospectively addressed the literacy and asthma self-management skills of 110 minority children in South Los Angeles utilizing weekly Saturday-school format. RESULTS The results demonstrated that there was a statistically significant decrease in both hospitalization and emergency department (ED) visits during the intervention. In addition, all the children showed significant improvement in their reading level and self-efficacy. Multivariate logistic analysis demonstrated that enhanced self-efficacy was directly related to decreased hospitalizations and ED visits. CONCLUSION This intervention demonstrated that literacy enhancement is an important factor in improving self-efficacy and impacting asthma-related outcomes. Improved literacy is a sustainable factor that will not only improve asthma outcomes but will enhance the potential for educational success.

Self-Reported Sleep Disturbance among African-American Elderly: The Effects of Depression, Health Status, Exercise, and Social Support:

The prevalence and correlates of self-reported difficulties in initiating and maintaining sleep were investigated for a sample of 998 Black elderly. In terms of prevalence, only 68.3 percent of this sample had no trouble falling asleep. Over 14.5 percent of men and 23.6 percent of women participants in this study reported sleep latencies exceeding thirty minutes. Almost 13 percent reported getting less than four hours of sleep at night. Moreover, 14.5 percent of participants wake up at least three times during a typical nights sleep other than to use the bathroom and 45.3 percent said when they wake up during the night, they remain awake at least thirty minutes before falling back to sleep. Compared to men, women reported longer sleep latency, waking up more frequently at night, and were more likely to visit a health practitioner for sleeping problems. Multivariate analysis indicates that self-reported sleep problems were significantly greater among Black elderly who were women, with a higher level of depression/anxiety, those with a higher number of chronic illnesses, those who did not exercise, and those who reported lower levels of emotional social support.

Muslim Breast Cancer Survivor Spirituality: Coping Strategy or Health Seeking Behavior Hindrance?

We explored the role of religiosity and spirituality on (i) feelings and attitudes about breast cancer, (ii) strategies for coping with breast cancer, and (iii) health care seeking behaviors among breast cancer survivors in Iran. We conducted in-depth semistructured interviews with 39 breast cancer survivors. We found that spirituality is the primary source of psychological support among participants. Almost all participants attributed their cancer to the will of God. Despite this, they actively have been engaged with their medical treatment. This is in surprising contrast to Western cultures in which a belief in an external health locus of control diminishes participation in cancer screening, detection, and treatment. These findings can help researchers to provide a framework for the development of appropriate and effective culturally sensitive health interventions.

Perceived discrimination and depression among low-income Latina male-to-female transgender women

BackgroundThis study examines exposure to perceived discrimination and its association with depression among low-income, Latina male-to-female transgender women as well as evaluates the impact of sexual partner violence and mistreatment on depression.MethodsA total of 220 Latina male-to-female transgender women who resided in Los Angeles, California, were recruited through community based organizations and referrals. Participants completed individual interviews using a structured questionnaire. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Perceived discrimination was assessed using a fifteen-item measure that was designed to assess the experiences of maltreatment of transgender individuals. Multinomial logistic regression was used to examine the association between perceived discrimination and depression after controlling for the presence of other variables.ResultsOf the sample, 35% reported significant depressive symptoms (PHQ-9 ≥ 15). Additionally, one-third of the participants indicated that in the two weeks prior to the interviews they had thought either of hurting themselves or that they would be better off dead. The extent of perceived discrimination in this population was extensive. Many of the participants experienced discrimination on a daily basis (14%) or at least once or twice a week (25%) as demonstrated by a positive response to at least 7 of 15 items in the measure of perceived discrimination. Almost six out of ten participants admitted that they had been victims of sexual partner violence. Those who reported more frequent discrimination were more likely to be identified with severe depression. There was also a notable association between self-reported history of sexual partner violence and depression severity.ConclusionsA significant association between depression severity and perceived discrimination was identified. How exposure to discrimination leads to increased risk of mental health problems needs additional investigation. Models investigating the association between perceived discrimination and depression among transgender women should include sexual partner violence as a potential confounding variable.

Access to Vision Care in an Urban Low-Income Multiethnic Population

Objective: This study applied a well-known, recently revised theoretical model of healthcare access and utilization, the Behavioral Model for Vulnerable Populations, to examine the relationship between access to care and utilization of eye care services among a mutiethnic, predominately minority sample of residents from low-income public housing. Design: Population-based, cross-sectional survey of community sample. Setting: Urban Public Housing Communities in Los Angeles County, California. Participants: A geographically defined stratified random sample of 152 residents (86% Latino or African American) 40 years of age and older from three urban public housing communities. Results: Only 62% of our sample of persons 40 years and older had received an eye examination within the past 2 years. Sixty-one percent of participants reported having vision care coverage. Yet, one out of four respondents claimed that no health care provider had ever told them that they needed an eye-examination. Applying multiple logistic regression and controlling for a number of predisposing, enabling, and need-for-care characteristics, the variables 1) receiving advice from health care providers for eye examination (OR = 3.9, p < 0.01), 2) possessing coverage for eye-care (OR = 3.2, p < 0.01), and 3) having regular and continuity of medical care (OR = 2.4, p < 0.01) remained significant predictors of eye-examination within the past 2 years. Conclusion: This study documents significantly diminished utilization of eye care services relative to recommended guidelines for a low-income, predominately minority sample of residents from public housing communities. We documented no association between presence of diabetes or hypertension and recency of eye examination. Affordability, continuity, and regular sources of care, as well as receiving physician advice, remain the core factors significantly associated with receiving vision care. These results underscore the need for continued efforts to ensure that the medically underserved minority have access to vision care services. These findings also point toward the urgent need for educational and motivational interventions that encourage health care providers serving underserved communities to promote eye examination, particularly among diabetic patients, hypertensive patients, and other individuals at risk for eye-related disease and complications.

Preventive, Lifestyle, and Personal Health Behaviors among Physicians.

ObjectiveThis study examines personal health behaviors and wellness, health-related lifestyles, and prevention screening practices among licensed physicians.MethodsAn anonymous questionnaire was mailed to a random sample of 1,875 physicians practicing in California. Data from 763 returned questionnaires (41%) were analyzed.ResultsOur data show that 7% of this sample were clinically depressed, 13% reported using sedatives or tranquilizers, over 53% reported severe to moderate stress, and only 38% described their level of daily stress as slight. About 4% self-reported recent marijuana use. More than 6% screened positive for alcohol abuse and 5% for gambling problems. Thirty-five percent of participants reported “no” or “occasional” exercise. About 27% self-reported “never” or “occasionally” eating breakfast. In addition, 34% reported 6 or fewer hours of sleep daily, while 21% self-reported working more than 60 hours per week. Physicians’ excessive number of work hours (more than 65 hours per week) was associated with lack of exercise, not eating breakfast, and sleeping fewer than 6 hours per night. California physicians report breast, cervical, colorectal, and prostate cancer screening behaviors that exceeded population estimates in California and Healthy People 2010 national goals.ConclusionAdditional interventions designed to improve physicians’ lifestyles and personal health behaviors should be encouraged. A focus on creating healthy lifestyles will benefit physicians as much as the general population.

Demographic and clinical characteristics of patients with diabetes presenting to an urban public hospital ophthalmology clinic

OBJECTIVE This study aims to describe the clinical and sociodemographic characteristics of patients with diabetes who are newly presenting to an inner city public hospital eye clinic. This study also aims to determine the prevalence and severity of ocular morbidity in this population at time presentation and to assess the adequacy of the ophthalmic surveillance to which this population was exposed before presentation. DESIGN A clinic-based, cross-sectional study. PARTICIPANTS A total of 118 consecutive patients with diabetes participated. METHOD During a 2-month interval, all patients with diabetes newly presenting to the Los Angeles County King-Drew Medical Center eye clinic were recruited who were at risk for diabetic eye complications according to American Diabetes Association criteria. Each patient underwent a standardized interviewer-administered questionnaire and a comprehensive ophthalmic examination. RESULTS Of the 118 patients, 65 (55%) were Hispanic and 51 (43%) were African American. Forty-six percent had a grade school education or less, 91% were unemployed, and 64% had no health insurance. Type two diabetes was predominant (91%), including 24 (22%) of new onset. Thirty-six patients with diabetes (31%) reported duration of diabetes greater than 10 years at time of presentation. At time of presentation, 62% had clinically apparent ophthalmic disease, whereas 40% had advanced ocular disease, including 6.8% of the sample that were legally blind. Sixty-nine patients (58.5%) reported never having had a dilated fundus examination, whereas 31 (63%) of the 49 patients reporting a previous dilated examination were last examined more than 2 years before presentation. Timing of ophthalmic examination was classified as appropriate for 38 patients (32%), marginal for 20 patients (17%), and inappropriate for 60 patients (51%). CONCLUSION In the setting of an inner city county hospital eye clinic, where the patient population is predominately minority and of low socioeconomic status, ophthalmic surveillance of high-risk patients with diabetes is inadequate and advanced disease often is present at initial presentation. Strategies must be developed to increase the routine use of eye services within this population.

The Effects of Health, Environmental, and Socio-Psychological Variables on Fear of Crime and Its Consequences among Urban Black Elderly Individuals.

Despite extensive research on fear of crime among elder members of the population, little attention has been paid to the fear of crime among Black urban elderly individuals. Using a sample of 372 low income urban Black persons aged sixty-two and over the causes and consequences of such fear were investigated. Fear of crime reduces subjective well-being of these older adults and limits their mobility. Age, gender, education, marital status, loneliness, self-reported health status, previous victimization experience, media exposure, trust of neighbors, length of residence, and type of housing were tested to identify significant predictors of fear of crime. Some of these variables had a diverse impact on fear of crime at home versus outside of the home. For example, while gender was the strongest predictor of fear of crime outside the home, it was not significantly associated with fear inside the home. Surprisingly, self-reported health status was not related to fear of crime among this sample of urban Black elderly individuals.

Heat Shock Protein and Gliadin Peptide Promote Development of Peptidase Antibodies in Children with Autism and Patients with Autoimmune Disease

ABSTRACT Searching for a mechanism underlying autoimmunity in autism, we postulated that gliadin peptides, heat shock protein 60 (HSP-60), and streptokinase (SK) bind to different peptidases resulting in autoantibody production against these components. We assessed this hypothesis in patients with autism and in those with mixed connective tissue diseases. Associated with antigliadin and anti-HSP antibodies, children with autism and patients with autoimmune disease developed anti-dipeptidylpeptidase I (DPP I), anti-dipeptidylpeptidase IV (DPP IV [or CD26]) and anti-aminopeptidase N (CD13) autoantibodies. A significant percentage of autoimmune and autistic sera were associated with elevated immunoglobulin G (IgG), IgM, or IgA antibodies against three peptidases, gliadin, and HSP-60. These antibodies are specific, since immune absorption demonstrated that only specific antigens (e.g., DPP IV absorption of anti-DPP IV), significantly reduced IgG, IgM, and IgA antibody levels. For direct demonstration of SK, HSP-60, and gliadin peptide binding to DPP IV, microtiter wells coated with DPP IV were reacted with SK, HSP-60, and gliadin. They were then reacted with anti-DPP IV or anti-SK, anti-HSP, and antigliadin antibodies. Adding SK, HSP-60, and gliadin peptides to DPP IV resulted in 27 to 43% inhibition of the DPP IV-anti-DPP IV reaction, but DPP IV-positive peptides caused 18 to 20% enhancement of antigen-antibody reactions. We propose that (i) superantigens (e.g., SK and HSP-60) and dietary proteins (e.g., gliadin peptides) in individuals with predisposing HLA molecules bind to aminopeptidases and (ii) they induce autoantibodies to peptides and tissue antigens. Dysfunctional membrane peptidases and autoantibody production may result in neuroimmune dysregulation and autoimmunity.