Thomas E. Oxman

Lack of Social Participation or Religious Strength and Comfort as Risk Factors for Death After Cardiac Surgery in the Elderly

The purpose of this study was to examine the relationship of social support and religion to mortality after elective open heart surgery in older patients.Of the 232 patients included in the study, 21 died within 6 months of surgery. Three biomedical variables were significant predictors of mortality and selected as adjustment variables for a multivariate analysis: history of previous cardiac surgery; greater impairment in presurgery basic activities of daily living; and older age. Among the social support and religion variables, two were consistent predictors of mortality in the multivariate analyses: lack of participation in social or community groups and absence of strength and comfort from religion. These results suggest that in older persons lack of participation in groups and absence of strength and comfort in religion are independently related to risk for death during the 6-month period after cardiac surgery.

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial

Abstract Objective To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. Design Cluster randomised controlled trial. Setting Five healthcare organisations in the United States and 60 affiliated practices. Patients 405 patients, aged ≥ 18 years, starting or changing treatment for depression. Intervention Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. Main outcome measures Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (≥ 50% decrease in scores) and remission (score of < 0.5). Results At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). Conclusion Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Suicidal and Death Ideation in Older Primary Care Patients With Depression, Anxiety, and At-Risk Alcohol Use

The authors identified correlates of active suicidal ideation and passive death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Participants included 2,240 older primary care patients (age 65+), who were identified in three mutually exclusive groups on the basis of responses to the Paykel suicide questions: No Ideation, Death Ideation, and Suicidal Ideation. Chi-square, ANOVA, and polytomous logistic regression analyses were used to identify characteristics associated with suicidal ideation. The highest amount of suicidal ideation was associated with co-occurring major depression and anxiety disorder (18%), and the lowest proportion occurred in at-risk alcohol use (3%). Asians have the highest (57%) and African Americans have the lowest (27%) proportion of suicidal or death ideation. Fewer social supports and more severe symptoms were associated with greater overall ideation. Death ideation was associated with the greatest medical comorbidity and highest service utilization. Contrary to previous reports, authors failed to find that active suicidal ideation was associated with increased contacts with healthcare providers. Accordingly, targeted assessment and preventive services should be emphasized for geriatric outpatients with co-occurring depression and anxiety, social isolation, younger age, and Asian or Caucasian race.

Interventions to Improve Provider Diagnosis and Treatment of Mental Disorders in Primary Care: A Critical Review of the Literature

The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.

Impact of pain on the outcomes of depression treatment: Results from the RESPECT trial

Objective: Pain is prevalent in patients with depression. The purpose of this study was to determine the impact of pain on depression treatment outcomes. Methods: Data was analyzed from a randomized controlled trial comparing a collaborative care intervention to usual care for the treatment of depression in 60 primary care practices. A total of 405 patients with either current major depressive disorder or dysthymia were enrolled, and assessed at baseline, 3, and 6 months. Main measures included the 20‐item Hopkins Symptom Check List (HSCL‐20) depression score, and the SF‐36 pain interference score. Results: Pain severe enough to produce at least moderate interference with daily activities was present in 42% of depressed patients at baseline. Pain outcomes did not differ between intervention and control groups but improved similarly in both over time. However, pain was still at least moderately severe in 32% of patients at 6 months. Both baseline pain and the amount of pain improvement over time were associated with depression remission and response rates. In a multivariate model controlling for age, gender, and medical co‐morbidity, depression severity increased with higher pain interference and decreased with the passage of time (p < .0001 for both). There was also a significant pain by time by treatment group interaction (p = .027). The beneficial effects of collaborative care on depression outcome persisted (p = .049) even after controlling for pain interference, time, covariates, and interaction effects. Conclusions: Pain has a strong negative impact on the response of depression to treatment. Recognizing and optimizing the management of comorbid pain that commonly coexists with depression may be important in enhancing depression response and remission rates.

The relationship of presenting physical complaints to depressive symptoms in primary care patients

Objective:To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice.Design:A cross-sectional study that was part of a larger prevalence study of depression in primary care.Setting:A general medical primary care practice in a teaching medical center in rural New England.Patients:1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification.Interventions:None.Results:Complaints that discriminated between depressed and non-depressed patients (at the p=0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%).Conclusions:Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms.

The Depression Care Manager and Mental Health Specialist as Collaborators Within Primary Care

OBJECTIVE The authors reviewed the implications of the latest generation of health services research studies on primary care practice system changes for depression management, especially in the roles of care managers and mental health specialists. METHODS Authors conducted a review of four large, related, multisite trials testing system changes in the delivery of care to depressed, mostly older, primary care patients. RESULTS These studies confirm that older patients are more likely to accept collaborative mental health treatment within primary care than within mental health specialty care. The study results published to date suggest that these system changes produce better outcomes than usual care for depression in a wide range of patients and healthcare organizations. Two key partners in implementing these system changes are a care manager to assist the primary care physician in patient education, treatment, and treatment monitoring, and a mental health specialist to provide care-manager consultation and collaborative care with the primary care physician for more complex cases. CONCLUSIONS Most patients with depression first seek attention for their symptoms in primary care, rather than in the mental health specialty sector. Since primary care visits are necessarily brief and pressured by competing demands to manage other medical problems, practice system changes are necessary. For mental health specialists, these studies emphasize the importance of joining and being integrated into primary care. Consultative and supervisory roles allow the specialist to indirectly but effectively serve a larger number of patients.

Rapport expressed through nonverbal behavior

Family Medicine residents were videotaped in interviews with a new and a return-visit patient. Two coders recorded nonverbal behavior performed by the residents for two, one-minute segments of each interview. Categories of movement included: proxemic behaviors of distance, orientation, and trunk lean, and head, hand/arm, and leg/foot movement, facial expression, and direction of gaze.Each of the 36 video segments were rated by a group of psychiatric nurses using bipolar adjective scales assessing dimensions of rapport. Significant differences in nonverbal behavior were found between high and low rapport doctors. Physicians were rated more positively when they sat directly facing the patient, with uncrossed legs, and arms in symmetrical, side-by-side positions. High rapport doctors also engaged in moderate, but less extensive eye contact, with the patient than low rapport doctors. Discussion focuses on the impact of nonverbal behavior on physician-patient communication and the establishment of rapport.

Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression

BACKGROUND Recent trials have shown improved depression outcomes with chronic care models. We report the methods of a project that assesses the sustainability and transportability of a chronic care model for depression and change strategy. METHODS In a randomized controlled trial (RCT), a clinical model for depression was implemented through a strategy supporting practice change. The clinical model is evidence based. The change strategy relies on established quality improvement programs and is informed by diffusion of innovations theory. Evaluation will address patient outcomes, as well as process of care and process of change. RESULTS Five medical groups and health plans are participating in the trial. The RCT involves 180 clinicians in 60 practices. All practices assigned to the clinical model have implemented it. Participating organizations have the potential to disseminate this clinical model of care to 700 practices and 1,700 clinicians. CONCLUSIONS It is feasible to implement the clinical model and change strategy in diverse practices. Follow-up evaluation will determine the impact, sustainability, and potential for dissemination. Materials are available through http://www.depression-primarycare.org; more in-depth descriptions of the clinical model and change strategy are available in the online-only appendixes to this article.

The treatment effectiveness project. A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients: background and research plan.

This report describes the background, rationale, and research plan for a comparative treatment trial of the effectiveness of paroxetine, problem-solving therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Patients were recruited from a variety of primary care practice settings in four separate geographic locations (Hanover, New Hampshire; Pittsburgh, Pennsylvania, San Antonio, Texas; and Seattle, Washington). Patients were randomly assigned to each of the three intervention conditions the medication/placebo conditions were double-blinded. The treatment trial was 11 weeks, with independent assessments of patient clinical status at baseline, 6 weeks, and 11 weeks. There was a follow-up at 25 weeks. Since there are relatively few placebo-controlled trials in primary care settings on patients with these disorders, the background of this project and a description of it are presented at this time, prior to the availability of outcome data, to provide methodological detail and to increase awareness in the research community of this treatment trial, with results to appear subsequently.