Wan Tang

Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers

OBJECTIVE: The goal was to describe the accuracy of the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory II (BDI-II), and Postpartum Depression Screening Scale (PDSS) in identifying major depressive disorder (MDD) or minor depressive disorder (MnDD) among low-income, urban mothers attending well-child care (WCC) visits during the postpartum year. METHODS: Mothers (N = 198) attending WCC visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools. The sensitivities and specificities of each screening tool were calculated in comparison with diagnoses of MDD or MDD/MnDD. Receiver operating characteristic curves were calculated and the areas under the curves for each tool were compared to assess accuracy for the entire sample (representing the postpartum year) and subsamples (representing early, middle, and late postpartum time frames). Optimal cutoff scores were calculated. RESULTS: At some point between 2 weeks and 14 months after delivery, 56% of mothers met criteria for either MDD (37%) or MnDD (19%). When used as continuous measures, all scales performed equally well (areas under the curves of ≥0.8). With traditional cutoff scores, the measures did not perform at the expected levels of sensitivity and specificity. Optimal cutoff scores for the BDI-II (≥14 for MDD and ≥11 for MDD/MnDD) and EPDS (≥9 for MDD and ≥7 for MDD/MnDD) were lower than currently recommended. For the PDSS, the optimal cutoff score was consistent with current guidelines for MDD (≥80) but higher than recommended for MDD/MnDD (≥77). CONCLUSIONS: Large proportions of low-income, urban mothers attending WCC visits experience MDD or MnDD during the postpartum year. The EPDS, BDI-II, and PDSS have high accuracy in identifying depression, but cutoff scores may need to be altered to identify depression more accurately among urban, low-income mothers.

Values and options in cancer care (VOICE): study design and rationale for a patient-centered communication and decision-making intervention for physicians, patients with advanced cancer, and their caregivers

BackgroundCommunication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers.Methods/designThe Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years.DiscussionThe intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes).Trial registrationClinical Trials Identifier: NCT01485627

Risks for Depression Onset in Primary Care Elderly Patients: Potential Targets for Preventive Interventions

OBJECTIVE Prevention of late-life depression, a common, disabling condition with often poor outcomes in primary care, requires identification of seniors at highest risk of incident episodes. The authors examined a broad range of clinical, functional, and psychosocial predictors of incident depressive episodes in a well-characterized cohort of older primary care patients. METHOD In this observational cohort study, patients age >/=65 years without current major depression, recruited from practices in general internal medicine, geriatrics, and family medicine, received annual follow-up assessments over a period of 1 to 4 years. Of 617 enrolled subjects, 405 completed the 1-year follow-up evaluation. The Structured Clinical Interview for DSM-IV (SCID) determined incident major depressive episodes. Each risk indicators predictive utility was examined by calculating the risk exposure rate, incident risk ratio, and population attributable fraction, leading to determination of the number needed to treat in order to prevent incident depression. RESULTS A combination of risks, including minor or subsyndromal depression, impaired functional status, and history of major or minor depression, identified a group in which fully effective treatment of five individuals would prevent one new case of incident depression. CONCLUSIONS Indicators routinely assessed in primary care identified a group at very high risk for onset of major depressive episodes. Such markers may inform current clinical care by fostering the early detection and intervention critical to improving patient outcomes and may serve as the basis for future studies refining the recommendations for screening and determining the effectiveness of preventive interventions.

Concomitant Forms of Abuse and Help-Seeking Behavior Among White, African American, and Latina Women Who Experience Intimate Partner Violence:

This study uses National Violence against Women Survey data to investigate the differential impact of concomitant forms of violence (sexual abuse, stalking, and psychological abuse) and ethnicity on help-seeking behaviors of women physically abused by an intimate partner (n = 1,756). Controlling for severity of the physical abuse, women who experienced concomitant sexual abuse are less likely to seek help, women who experienced concomitant stalking are more likely to seek help, whereas concomitant psychological abuse is not associated with help seeking. Ethnic differences are found in help seeking from friends, mental health professionals, police, and orders of protection. Implications for service outreach are discussed.

Validation of the simplified Chinese version of the FACT-B for measuring quality of life for patients with breast cancer.

The simplified Chinese version of the FACT-B was evaluated by QOL data measured from 376 patients with breast cancer. The results showed that test–retest reliability for five domains: physical well-being, social/family well-being, emotional well-being, functional well-being, additional concerns, and the overall scales and trial outcome index were 0.82, 0.85, 0.91, 0.86, 0.90, 0.84 and 0.91, 0.89 respectively. The internal consistency α for the five domains mentioned above were 0.85, 0.82, 0.84, 0.84 and 0.59 respectively. Correlation analysis, factor analysis and structural equation model showed good construct validity. Criterion-related validity was also confirmed using QLICP-BR as a criterion. The instrument can find the change of QOL for cancer patients after treatment. It’s concluded that the simplified Chinese version of FACT-B can be used to measure QOL for Chinese patients with breast cancer with good validity, reliability and responsiveness.

Outcomes of subsyndromal depression in older primary care patients.

OBJECTIVES Most older persons in primary care suffering clinically significant depressive symptoms do not meet criteria for major or minor depression. The authors tested the hypothesis that patients with subsyndromal depression (SSD) would have poorer psychiatric, medical, and functional outcomes at follow-up than nondepressed patients but not as poor as those with minor or major depression. The authors also explored the relative outcomes of three definitions of SSD to determine their relative prognostic value. DESIGN Prospective observational cohort study. SETTING Primary care practices in Monroe County, NY. PARTICIPANTS Four hundred eighty-one primary care patients aged 65 years and older who completed research assessments at intake and at least 1 year of follow-up evaluation. MEASUREMENTS Depression diagnoses and three definitions of SSD were determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the 24-item Hamilton Depression Rating Scale. Other validated measures assessed anxiety, cognition, medical burden, and functional status. RESULTS Patients with SSD had poorer 1-year lagged outcomes than nondepressed subjects in terms of psychiatric symptoms and functional status, often not significantly different than major or minor depression. Two of the SSD definitions identified subjects with poorer psychiatric and functional outcomes than the third SSD definition. CONCLUSIONS Clinicians should be vigilant in caring for patients with SSD, monitoring for persistent, or worsening depressive symptoms including suicidality, anxiety, cognitive impairment, and functional decline. Researchers may use particular SSD definitions to identify individuals at higher risk of poor outcomes, to better understand the relationships of SSD to functional disability, and to test innovative preventive and therapeutic interventions.

Study on the use of long-term urinary catheters in community-dwelling individuals.

PURPOSE The purpose of this study was to determine the incidence and distribution of catheter-related problems in long-term indwelling urinary catheter users. We also sought to assess appropriateness of catheter use and examine relationships among catheter complications and catheter care practices. DESIGN This repeated-measures study involved self-reported data collection by recall at intake and by prospective data collection at 2, 4, and 6 months in long-term urinary catheter users. SUBJECTS AND SETTING Two sampling arms were used: a home care (HC) agency with 10 individuals and the Internet with 33 people having spinal cord injury. METHODS Home visit and follow-up telephone call interviews were used with the participants from the HC agency. Data were self-administered through SurveyMonkey in the Internet sample, and communication was through e-mail, telephone, and postal mail. Analysis included descriptive statistics and generalized estimating equation techniques to adjust for within-subject variation over time. RESULTS All study participants had at least 1 catheter-related problem during 8 months, and many had multiple, recurring problems. Catheter-associated urinary tract infection (CAUTI) was reported by 70%, blockage by 74%, leakage by 79%, and accidental dislodgement by 33%. Key tests of associations (generalized estimating equation) predicted that catheter size contributed to CAUTI, with significant covariates of female gender and younger age. The presence of sediment in the urine on the day of the survey predicted catheter blockage. CONCLUSION The incidence of all complications was higher than expected. Problems associated with long-term indwelling catheter use may contribute to excess healthcare utilization adversely affecting both users and their families.

Co-Occurring Intimate Partner Violence and Mental Health Diagnoses in Perinatal Women

OBJECTIVES To describe the co-occurrence of intimate partner violence (IPV) and mental health burden among perinatal mothers attending well-baby visits with their infants in the first year of life. We compare rates of depression, anxiety disorder, and substance abuse diagnoses between mothers who reported IPV within the past year to those who did not. METHODS This cross-sectional study of 188 mothers of infants (under 14 months) was conducted in an urban hospital pediatric clinic. Participants reported demographics and IPV and completed a semistructured psychiatric diagnostic interview. RESULTS Mothers reporting IPV were more likely to be diagnosed with mood and/or anxiety diagnoses (p<0.05, Fishers exact test), specifically current depressive diagnoses (p<0.01, Fishers exact test) and panic disorder (p<0.05, Fishers exact test). There was a trend for more posttraumatic stress disorder (PTSD) (p<0.06) among abused mothers. Substance abuse and dependence, age, race, insurance status, employment, education, and family arrangements did not differ between groups. Prior major or minor depression increases the odds for perinatal depression threefold (OD 3.18). CONCLUSION These findings have implications for practitioners who encounter perinatal women. Findings suggest providers should explore signs and symptoms of depression and anxiety disorders among women reporting IPV. Similarly, when perinatal mothers report symptoms of depression, PTSD, or panic disorder, practitioners should be alert to the possible contributory role of IPV.

Distribution-free models for longitudinal count responses with overdispersion and structural zeros

Overdispersion and structural zeros are two major manifestations of departure from the Poisson assumption when modeling count responses using Poisson log-linear regression. As noted in a large body of literature, ignoring such departures could yield bias and lead to wrong conclusions. Different approaches have been developed to tackle these two major problems. In this paper, we review available methods for dealing with overdispersion and structural zeros within a longitudinal data setting and propose a distribution-free modeling approach to address the limitations of these methods by utilizing a new class of functional response models. We illustrate our approach with both simulated and real study data.

Modeling longitudinal binomial responses: implications from two dueling paradigms

The generalized estimating equations (GEEs) and generalized linear mixed-effects model (GLMM) are the two most popular paradigms to extend models for cross-sectional data to a longitudinal setting. Although the two approaches yield well-interpreted models for continuous outcomes, it is quite a different story when applied to binomial responses. We discuss major modeling differences between the GEE- and GLMM-derived models by presenting new results regarding the model-driven differences. Our results show that GLMM induces some artifacts in the marginal models at assessment times, making it inappropriate when applied to such responses from real study data. The different interpretations of parameters resulting from the conceptual difference between the two modeling approaches also carry quite significant implications and ramifications with respect to data and power analyses. Although a special case involving a scale difference in parameters between GEE and GLMM has been noted in the literature, its implications in real data analysis has not been thoroughly addressed. Further, this special case has a very limited covariate structure and does not apply to most real studies, especially multi-center clinical trials. The new results presented fill a substantial gap in the literature regarding the model-driven differences between the two dueling paradigms.