Terry Bush

Adequacy and duration of antidepressant treatment in primary care.

Among a sample of 119 distressed high-utilizers of primary care, 45% of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination. However, only 11% of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy. In the year following the intervention, study patients whose physicians were advised regarding treatment during a psychiatric consultation were more likely to receive antidepressant medications (52.7%) relative to a randomized control group (36.1%). However, the intervention did not significantly increase the provision of adequate antidepressant therapy (37.1% vs 27.9%). Among study patients using antidepressants, patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not. Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20% of patients who had been given prescriptions for first-generation antidepressants (amitriptyline, imipramine, or doxepin) filled four or more prescriptions in the following six months, compared to 34% of patients who had prescriptions for newer antidepressants (nortriptyline, desipramine, trazodone and fluoxetine). Experimental research evaluating whether these newer medications (with more favorable side effect profiles) improve adherence, and thereby patient outcome, is needed.

The Role of the Primary Care Physician in Patientsʼ Adherence to Antidepressant Therapy

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages—1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants—were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression

Objective This report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. Study Design Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trial (N = 217), consulting psychiatrists provided enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153), Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologists provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. Results Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression, Collaborative Care was more costly and not more cost-effective than Usual Care. Conclusions Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.

An international comparison of back surgery rates.

Summary of Background Data. Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. Methods. The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: 1) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country‐specific rates of other surgical procedures were available from published sources. Results. The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. Conclusions. These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized. [Key words: back pain, surgery, geographic variation, utilization] Spine 1994;19:1201–1206

Achieving Guidelines for the Treatment of Depression in Primary Care Is Physician Education Enough

OBJECTIVES The authors examine whether physician education has enduring effects on treatment of depression. METHODS Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes. RESULTS No lasting educational effect was observed consistently in any of the outcomes measured. CONCLUSIONS There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.

Frustrating patients: physician and patient perspectives among distressed high users of medical services.

Objective:To identify differences between patients viewed as frustrating by their physicians and those considered typical and satisfying.Design:This cross-sectional observational study focused on psychologically distressed high users of medical services. Frustrating patients were compared with typical and satisfying patients, using data from patient questionnaires, physician assessments, structured psychiatric interviews, and computerized utilization records.Setting:Group Health Cooperative of Puget Sound, a large health maintenance organization.Patients/participants:Study patients were in the top decile for ambulatory visits, and had elevated scores for anxiety, depression, and somatization. Among the 339 patients invited to participate in the study, 251 agreed, and 228 were rated by their physicians.Main results:A substantial proportion (37%) of the high users were viewed as frustrating by their physicians. Physicians’ ratings of physical disease severity did not differ among the groups, but frustrating patients rated their own health status less favorably and reported more somatic symptoms and disabilities. The frustrating group utilized more medical services than did other distressed high utilizers. All three groups had a high prevalence of mental disorders. However, frustrating patients had higher rates of somatization and generalized anxiety disorder.Conclusions:Physicians and their frustrating patients had contrasting views of the patients’ illnesses. The best predictors of physician frustration were somatization and increased medical service utilization. There is need for further research and clinical attention concerning optimal clinical management for patients with somatization.

Quality of Depression Care in a Population-based Sample of Patients With Diabetes and Major Depression

Objectives:Major depression occurs in approximately 11% to 15% of patients with diabetes and is associated with poor glycemic control and adverse medical outcomes. This study examined the rates and predictors of recognition of depression among primary care patients with diabetes and comorbid major depression and the quality of depression care provided during a 12-month period. Methods:This study used automated utilization, pharmacy, and laboratory data from a health maintenance organization to describe the rate of recognition of depression and quality of care provided for patients with major depression and diabetes in the 12-month period before diagnosis. Major depression was diagnosed based on the Patient Health Questionnaire (PHQ-9) that was included in a mail survey sent to 9063 patients on the Group Health diabetes registry from 9 primary care clinics. Results:Approximately 51% of patients with major depression and diabetes were recognized as depressed by the health care system. Women were more likely to be recognized (odds ratio [OR] 1.58, 95% confidence interval [CI 1.26–1.97]), as were those with dysthymia (OR 3.44, 95% CI 2.08–5.72), panic attacks (OR 1.55, 95% CI 1.19–2.19), patients with more than 7 primary care visits (OR 1.42, 95% CI 1.06–1.91) and patients reporting poor health (OR 1.62, 95% CI 1.04–2.53). Of the 51% of patients with major depression who were recognized, 43% received 1 or more antidepressant prescriptions but only 6.7% received 4 or more psychotherapy sessions during a 12-month period. Discussion:There were large gaps in both recognition and quality of depression care provided to patients with major depression and diabetes within a health maintenance organization system.

Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms.

OBJECTIVE. The purpose of this work was to examine the relationship between youth-reported asthma symptoms, presence of anxiety or depressive disorders, and objective measures of asthma severity among a population-based sample of youth with asthma. METHODS. We conducted a telephone survey of 767 youth with asthma (aged 11–17 years) enrolled in a staff model health maintenance organization. The Diagnostic Interview Schedule for Children was used to diagnose Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, anxiety and depressive disorders; the Child Health Status-Asthma questionnaire (modified) was used to assess asthma symptoms; and automated administrative data were used to measure asthma treatment intensity and severity. Analyses of covariance were performed to determine whether the number of anxiety and depressive symptoms was related to the number of asthma symptoms. Logistic regression analyses were used to evaluate the strength of association between individual symptoms of asthma and the presence of an anxiety or depressive disorder and objective measures of asthma severity. RESULTS. After adjusting for demographic characteristics, objective measures of asthma severity, medical comorbidity, and asthma treatment intensity, youth with ≥1 anxiety or depressive disorder (N = 125) reported significantly more days of asthma symptoms over the previous 2 weeks than youth with no anxiety or depressive disorders. The overall number of reported asthma symptoms was significantly associated with the number of anxiety and depressive symptoms endorsed by youth. In logistic regression analyses, having an anxiety or depressive disorder was also strongly associated with each of the 6 asthma-specific symptoms, as well as the 5 related nonspecific somatic symptoms contained in the Child Health Status-Asthma questionnaire. CONCLUSIONS. The presence of an anxiety or depressive disorder is highly associated with increased asthma symptom burden for youth with asthma.

Influence of patient attachment style on self-care and outcomes in diabetes.

Objective: Difficulties collaborating with providers and important others may adversely influence self-management in patients with diabetes. We predicted that dismissing attachment style, characterized by high interpersonal self-reliance and low trust of others, would be associated with poorer self-management in patients with diabetes. Methods: A population-based mail survey was sent to all patients with diabetes from nine primary care clinics of a health maintenance organization. We collected data on attachment style, self-care behaviors, the patient provider relationship and depression status and accessed automated diagnostic, pharmacy, and laboratory data to measure diabetes treatment intensity, medical comorbidity, glycosylated hemoglobin levels, and diabetes complications. We used logistic regression to determine whether dismissing attachment style was associated with poorer diabetes self-care behaviors, adherence to medication, smoking status, and higher glycosylated hemoglobin. Results: In 4095 primary care patients with diabetes, prevalence rates for secure, dismissing, preoccupied, and fearful attachment styles were 44.2%, 35.8%, 7.9%, and 12.1%, respectively. When compared with secure attachment style, dismissing attachment style was associated with significantly lower levels of exercise (p = .005), foot care (p < .05), diet (p = .001), and adherence to oral hypoglycemic medications (p < .05), and with higher rates of smoking (p < .05), and these associations were mediated through the patient-provider relationship. Preoccupied attachment style, characterized by overreliance on others, was associated with a significantly lower risk of having glycosylated hemoglobin levels >8%, compared with secure attachment style. Conclusion: Attachment style is significantly associated with diabetes self-management and outcomes. HbA1c = glycosylated hemoglobin; GHC = Group Health Cooperative; BMI = body mass index; IV = independent variable; DV = dependent variable.

Long‐term Effects of a Collaborative Care Intervention in Persistently Depressed Primary Care Patients

AbstractOBJECTIVE: A previous study described the effect of a collaborative care intervention on improving adherence to antidepressant medications and depressive and functional outcomes of patients with persistent depressive symptoms 8 weeks after the primary care physician initiated treatment. This paper examined the 28-month effect of this intervention on adherence, depressive symptoms, functioning, and health care costs. DESIGN: Randomized trial of stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe and moderate depression groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and a primary care physician. MEASURES AND MAIN RESULTS: The collaborative care intervention was associated with continued improvement in depressive symptoms at 28 months in patients in the moderate-severity group (F1,87=8.65; P=.004), but not in patients in the high-severity group (F1,51=0.02; P=.88) Improvements in the intervention group in antidepressant adherence were found to occur for the first 6 months (χ2(1)=8.23; P<.01) and second 6-month period (χ2(1)=5.98; P<.05) after randomization in the high-severity group and for 6 months after randomization in the moderate-severity group(χ2(1)=6.10; P<.05). There were no significant differences in total ambulatory costs between intervention and control patients over the 28-month period (F1,180=0.77; P=.40). CONCLUSIONS: A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.