Rollin Nagel

TELEPHONE-BASED TREATMENT FOR FAMILY PRACTICE PATIENTS WITH MILD DEPRESSION '

The need for treating milder forms of depression has recently been of increased interest. This was a randomized, controlled study to evaluate the effects of telephone-based problem-solving therapy for mild depression. Comparison groups were a treatment-as-usual group and another group receiving stress-management training by telephone. From 1,742 family practice patients screened for depression, 54 with mild depression entered the study. Treatment was provided by experienced family practice nurses, trained and supervised in the treatments. The Hamilton Rating Scale for Depression was administered before and after the intervention period, and the Beck Depression Inventory and Duke Health Profile were administered at the end of the intervention period. Of the 36 subjects assigned to the problem-solving and stress-management groups, half dropped out early in the study. Five from the treatment-as-usual group were lost to follow-up. In the remaining subjects, there was a significant decrease in depression scores. There were no significant differences in the amount of decrease between the groups on any scores. The small sample and high dropout rate limit the interpretation of the findings. However, since all subjects tended to improve, regardless of treatment received, mild levels of depression may generally remit even without focal intervention, and watchful waiting may be a reasonable alternative for management.

Coherence between physician diagnosis and patient self reports of anxiety and depression in primary care.

Mood and anxiety disorders complicate the care of patients with physical illness and pose challenges for primary care physicians. This study explored the coherence between a screening tool (PRIME-MD), a standardized questionnaire (Eysenck Personality Inventory), and physician diagnoses of anxiety and depression. Of 165 patients, 29% had diagnoses of depression, 21% had anxiety, and 59% had no mental health diagnosis. Patients who were younger, female, divorced/widowed, or unemployed with minimal education had highest prevalence of anxiety or depression. Scores on the self-report inventories were significantly higher in patients with physician-diagnosed anxiety or depression compared with those without these diagnoses. Medical use and chronic illness were highest in patients with anxiety or depression diagnoses. Despite the statistical agreement between the self-report inventories and physician diagnosis, the coherence among these measures was less than optimal. Use of self report tools is recommended to complement physician understanding of patient symptom description and management of anxiety and depression in primary care.

Primary Care Evaluation of Mental Disorders (PRIME-MD) Screening for Minor Depressive Disorder in Primary Care

OBJECTIVE Individuals visiting a primary care practice were screened to determine the prevalence of depressive disorders. The DSM-IV-TR research criteria for minor depressive disorder were used to standardize a definition for subthreshold symptoms. METHOD Outpatients waiting to see their physicians at 3 community family medicine sites were invited to complete a demographic survey and the Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD PQ). Those who screened positive for depression on the PRIME-MD PQ were administered both the PRIME-MD Clinician Evaluation Guide (CEG) mood module and the Hamilton Depression Rating Scale (HDRS) by telephone. Data were collected over a 2-year period (1996-1998). RESULTS 1,752 individuals completed the PRIME-MD PQ with 478 (27.3%) scoring positive for depression. Of these 478 patients, 321 received telephone follow-up using the PRIME-MD CEG mood module and the HDRS. PRIME-MD diagnoses were major depressive disorder (n = 85, 26.5%), dysthymia (n = 31, 9.6%), minor depressive disorder (n = 51, 15.9%), and no depression diagnosis (n = 154, 48.0%). The mean HDRS scores by diagnosis were major depressive disorder (20.3), dysthymia (12.9), minor depressive disorder (11.7), and no depression diagnosis (5.8). Post hoc analyses using Dunnetts C test indicated differences between each of the 4 groups at P ≤ .05, with the exception that dysthymia and minor depressive disorder were not significantly different. CONCLUSIONS Minor depressive disorder was more prevalent than dysthymia and had similar symptom severity to dysthymia as measured by the HDRS. More research using standardized definitions and longitudinal studies is needed to clarify the natural course and treatment indications for minor depressive disorder.

Siblings of Children with Mental Retardation: Family Characteristics and Adjustment

Siblings of children with mental retardation may be at greater risk for adjustment problems because of family stress related to the needs of the child with mental retardation. Family dimensions were investigated to determine their relationship to sibling adjustment. Adjustment of 12 siblings of children with mental retardation was examined in relationship to family dimensions. These relationships were compared to those for children from families without a disabled child. For both groups, self concept was positively associated with family cohesion, and social competence was positively associated with family promotion of independence. For only the siblings of the mentally retarded children, family conflict was inversely related to social competence, and family organization was positively related to sibling self concept. Our results suggest that family conflict and disorganization appear to have a more negative effect in families with a child with mental retardation.

Teaching interviewing skills: the effect of instructors' academic department.

This study examines student evaluations of an interviewing and communications skills course taught in small groups by members of psychiatry and family medicine departments. Student course evaluations for two academic years were analyzed by means of t-tests and multiple regression analyses to explore if the group leaders academic department affected the students learning experience. Students taught by family medicine instructors rated significantly higher three aspects of the course: the usefulness of the role playing session, the credibility and realism of the videotaping session, and the recommendation that the course be continued. This study found the family medicine instructors to be valued teachers of interviewing and communication skills.

Pediatric Resuscitation: Evaluation of a Clinical Curriculum

Abstract Objective: To assess the impact of a 6-hour pediatric resuscitation curriculum on the comfort levels of resident physicians’ evaluation and treatment of critically ill pediatric patients. Methods: An evaluation instrument assessed resident comfort levels, measured on a seven digit Likert scale ranging from significantly uncomfortable to significantly comfortable, in 13 areas of pediatric resuscitation. To complete the curriculum, residents had to demonstrate proficiency in knowledge and procedural skills during mock resuscitation scenarios and on both written and oral examinations. Results: Thirty-one residents participated in the study: 51.6% were pediatric, 12.9% were medicine/pediatric and 35.5% were emergency medicine residents. Participants in the curriculum had little previous experience with pediatric resuscitation (83% had been involved in five or fewer pediatric resuscitations). In all 13 areas of pediatric resuscitation tested, residents reported improvement in comfort levels following the course (p<0.002; Wilcoxon Signed Rank Tests). The most significant changes were observed for the following items: resuscitation of pulseless arrest, performance of cardioversion and defibrillation, performance of intraosseous needle insertion, and drug selection and dosing for rapid sequence intubation. Fewer than 48% of learners rated themselves as comfortable in these areas prior to training, but after completion, more than 80% rated themselves in the comfortable range. All residents but one received passing scores on their written examinations (97%). During the mock resuscitation scenarios and oral examination, 100% of the residents were assessed to have ‘completely’ met the learning objectives and critical actions Conclusion: Implementation of a pediatric resuscitation curriculum improves pediatric and emergency medicine residents’ comfort with the evaluation and treatment of critically ill pediatric patients. This curriculum can be used in residency training to document the acquisition of core competencies, knowledge and procedural skills needed for the evaluation and treatment of the critically ill child. The results reported in this study support using this model of instructional design to implement educational strategies, which will meet the requirements of graduate education.

Prediction of dietary adherence in cholesterol reduction: Relative contribution of personality variables and health attitudes

Abstract The purpose of this study was to identify personality and health attitude variables that might predict adherence to a cholesterol-reducing diet. After taking a battery of psychological inventories, 66 subjects entered a 26 week diet program. Adherence indices included attendance rate at scheduled appointments, changes in diet, and changes in serum cholesterol levels. Of the 55 subjects with complete data, 7 dropped out, 7 attended inconsistently, and 41 completed the program. Drop-outs scored significantly lower on the Health Belief measures of seriousness, susceptibility, and benefits. Improvement in serum cholesterol was positively correlated with the Health Belief Benefits Scale and negatively correlated with the Health Locus of Control chance scale. Dietary reduction in saturated fat was positively associated with the Health Belief Seriousness and Benefits Scales. Health attitudes and beliefs were better predictors of adherence than personality trait measures.

Evaluating empathy in interviewing: Comparing self‐report with actual behavior

The purpose of this study was to compare responses on the Medical Helping Relationship Inventory (MHRI), an instrument recently developed for evaluation of medical communications skills, with ratings of medical students’ videotaped interview behavior. Fifty videotapes of student interviews were evaluated by two trained raters, using the Carkhuff Empathic Understanding Scale, an adapted version of the Arizona Clinical Interview Rating scale, and additional items developed to measure specific interviewing behavior. Measures of empathy based on rated behavior were highly intercorrelated; however, expected positive relations between rated empathy and the MHRI Understanding subscale were not found. It would appear that preferences for Understanding responses on the MHRI multiple‐choice survey did not reflect the ratings of the students’ actual interview behavior.

Collaborative Goal Setting to Improve Lifestyle Behaviors: Lessons Learned From NOPCRN

ABSTRACT Angiosarcomas are a rare group of tumours which have poor prognosis and limited treatment options. The development of new therapies has been hampered by a lack of good preclinical models. Here, we describe the development of an autochthonous mouse model of angiosarcoma driven by loss of p53 in VE-cadherin-expressing endothelial cells. Using Cdh5-Cre to drive recombination in adult endothelial cells, mice developed angiosarcomas with 100% penetrance upon homozygous deletion of Trp53 with a median lifespan of 325 days. In contrast, expression of the R172H mutant p53 resulted in formation of thymic lymphomas with a more rapid onset (median lifespan 151 days). We also used Pdgfrb-Cre-expressing mice, allowing us to target predominantly pericytes, as these have been reported as the cell of origin for a number of soft tissue sarcomas. Pdgfrb-Cre also results in low levels of recombination in venous blood endothelial cells in multiple tissues during development. Upon deletion of Trp53 in Pdgfrb-Cre-expressing mice (Pdgfrb-Cre,Trp53fl/fl mice), 65% developed lymphomas and 21% developed pleomorphic undifferentiated soft tissue sarcomas. None developed angiosarcomas. In contrast, 75% of Pdgfrb-Cre,Trp53R172H/R172H mice developed angiosarcomas, with 60% of these mice also developing lymphomas. The median lifespan of the Pdgfrb-Cre,Trp53R172H/R172H mice was 151 days. Re-implantation of angiosarcoma tumour fragments from Cdh5-Cre, Trp53fl/fl mice provided a more consistent and rapid model of angiosarcoma than the two spontaneous models. The ability to passage tumour fragments through the mouse provides a novel model which is amenable to preclinical studies and will help the development of potential new therapies for angiosarcoma.

Application of the high risk model of threat perception to medical illness and service utilization in a family practice.

This study was designed to test the High Risk Model of Threat Perception in a family practice population. Predisposing, triggering, and buffering factors were assessed in 165 patients using psychological inventories. The relationship between these factors and self-reported symptoms, diagnosed chronic problems, and utilization was assessed. Negative affect and number and intensity of life events increased the risk for chronic illness and reported symptoms, while social support and approach style of coping decreased the apparent risk. The numbers of encounters and telephone calls to the office, obtained from the office database, were statistically correlated with negative affect and inversely with social support. The regression analysis predicted 27% of the variance in reported symptoms with negative affect, life events, and avoidance coping as significant predictors. Only 8% and 16% of the variance of telephone calls and office visits, respectively, could be predicted with a similar regression model. These results emphasize the importance of psychosocial factors in medical illness. Routine assessment of psychosocial risk factors in family practice patients is suggested.