Disorders In Primary Care Settings Research Articles

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

Diagnosis and Treatment of Depression and Anxiety in Rural and Nonrural Primary Care: National Survey Results

The Conceptual Development of DSM-V

The Conceptual Development of DSM-V

Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings

This article describes a computer-assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced-based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary-care settings. The purpose of the current report is to (1) present the structure and format of the computer-assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. Thirteen clinicians using the computer-assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert-scale ratings and open-ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected. Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. Computer-assisted CBT programs provide a practice-based system for disseminating evidence-based mental health treatment in primary-care settings while maintaining treatment fidelity, even in the hands of novice clinicians.

P01-255 Detection and prevalence of depressive disorders in primary care settings in Hungary

Background:Although depressive disorders are common conditions in primary health care service, and many depressed patients consult their general practitioners, GPs have some difficulties in the detection and correct diagnosis of depression. Unrecognized and untreated depression causes great health and economic burden and also contributes to significant suffering, therefore the correct recognition of affective disorder in GP settings is an important healthcare target. The aim of our study was to assess the prevalence of depressive disorders in general practices in Hungary and also to assess the sensitivity and specificity of different depression screening instruments.Method:In the present study the current prevalence of DSM-IV depressive disorders were surveyed among 984 primary care attendees in 6 GP practices in Hungary, using the Beck Depression Inventory and the PRIME-MD screening instrument.Results:The current prevalence rate of any PRIME-MD DSM-IV depressive disorders, including symptomatic major depressive episode, were 18.5% and 7.3% respectively. Beck Depression Inventory identified any current depressive disorders with 95% sensitivity and 56% specificity and the same figures for current symptomatic major depressive episode were 83% and 23%, respectively.Discussion:Our results are similar to those reported previously from Hungary and from other countries. The findings also indicate that the Beck Depression Inventory and PRIME-MD can help in detecting depressive disorders in primary care.

Escitalopram in the treatment of major depressive disorder in primary-care settings: an open-label trial

The present trial was designed to assess the efficacy and safety of escitalopram prescribed to patients seeking treatment of major depressive disorder (MDD) in a Canadian primary-care setting. Investigators (mainly primary-care physicians) enrolled patients with MDD from their daily practice. Patients were treated with escitalopram (flexible dose 10-20 mg/day) for up to 24 weeks. Efficacy assessments included the Montgomery-Asberg Depression Rating Scale (MADRS), the Clinical Global Impression-Improvement and -Severity scales (CGI-I, CGI-S), the Patient Global Evaluation (PGE), and the Medical Outcome Study 36-item Short Form (SF-36). Out of the 647 patients enrolled, 461 (71%) completed 24 weeks of treatment. The most common reason for discontinuation was adverse events (10%). The mean MADRS score decreased from 30.7 at baseline to 10.9 at the end of 24 weeks (last observation carried forward, LOCF). Remission (MADRS<or=12) was achieved by 65.5% of patients (LOCF). Symptom improvements were confirmed by global ratings of improvement made by physicians (CGI-I) as well as patients PGE. There was improvement on all dimensions of the SF-36, suggesting an overall improvement in quality of life. Escitalopram was well tolerated, safe, and efficacious. Escitalopram can be used with confidence to treat patients with MDD in Canadian primary-care settings.

Screening for autism spectrum disorders in primary care settings

The need for autism-specific screening during pediatric well-child visits has been established. However, additional support for specific screening instruments is needed. The current study used the Modified Checklist for Autism in Toddlers (M-CHAT) and the M-CHAT Follow-Up Interview to screen 4797 children during toddler checkups. Of the 4797 cases, 466 screened positive on the M-CHAT; of the 362 who completed the follow-up interview, 61 continued to show risk for autism spectrum disorders (ASDs). A total of 41 children have been evaluated; 21 children have been diagnosed with ASD, 17 were classified with non-ASD delays, and three were typically developing. The PPV of M-CHAT plus interview was .57. It is notable that only four of the 21 cases of ASD were flagged by their pediatrician. These findings suggest that the M-CHAT is effective in identifying ASD in primary care settings. Future research will follow this sample longitudinally.

The Effect of Mental Illness, Substance Use, and Treatment for Depression on the Initiation of Highly Active Antiretroviral Therapy among HIV-Infected Individuals

Information regarding the prevalence of mental illness and substance use among HIV-infected patients and the effect of these problems on HIV treatment is needed. We conducted an observational study of patients in the University of Washington (UW) HIV Cohort to determine prevalence rates for mental illness and substance use. Cox regression analyses were used to examine the relationship between mental illness and substance use, pharmacologic treatment for depression/anxiety, and initiation of highly active antiretroviral therapy (HAART) within 9 months of becoming eligible for HAART. Among 1774 patients in the UW HIV cohort during 2004, 63% had a mental illness (including mood, anxiety, psychotic, or personality disorders), 45% had a substance use disorder, and 38% had both. There were 278 patients who met criteria for HAART eligibility. After controlling for other factors, patients with depression and/or anxiety were significantly less likely to initiate HAART compared with patients without a mental illness (hazard ratio [HR] 0.4, p = 0.02). However, patients with depression/anxiety who received antidepressant/antianxiety medications were equally likely to initiate HAART as patients without a mental illness (HR 0.9, p = 0.5). We found that patients with mental illness or substance use disorders receive HAART at lower CD4+ cell counts and higher HIV-1 RNA levels than patients without these disorders. However, HAART initiation among patients who receive treatment for depression/anxiety is associated with no delay. Screening for these disorders in primary care settings and access to appropriate treatment are increasingly important components of providing care to HIV-infected patients.

Practical guidelines for the biological treatment of unipolar depressive disorders in primary-care settings have been developed

Practical guidelines for the biological treatment of unipolar depressive disorders in primary-care settings have been developed

Using five questions to screen for five common mental disorders in primary care: diagnostic accuracy of the Anxiety and Depression Detector

Objective Primary care providers are increasingly taking on the role of ad hoc mental health provider. However, before patients in primary care can be treated, they must be identified. This study set out to validate a very brief screening instrument for identifying primary care patients with anxiety and depression. Method Eight hundred one primary care patients completed a questionnaire screening for (1) panic disorder, posttraumatic stress disorder (PTSD) and social phobia, or (2) panic disorder, generalized anxiety disorder (GAD) and major depression. Screening was followed by a diagnostic interview. The properties of the questionnaires were examined to identify a small set of items that effectively and efficiently screened for panic disorder, PTSD, social phobia, GAD and depression. Results Five items were selected across the two versions of the questionnaire, comprising the Anxiety and Depression Detector (the ADD). The sensitivities for the items ranged from 0.62 to 1.00, and the specificity values ranged from 0.56 to 0.83. When a “yes” answer to any of the screening questions was used to predict the presence of any diagnosis, sensitivity values were 0.92 to 0.96 and specificity values were 0.57 to 0.82. Sensitivity and specificity values varied little by gender, age or ethnicity. Conclusions The five items of the ADD appear to comprise a useful screening device for anxiety and depressive disorders in primary care settings.

Adherence to Treatment Among Economically Disadvantaged Patients With Panic Disorder

The purpose of this study was to examine the feelings of disadvantaged patients about and experiences of treatment for anxiety disorders in primary care settings. The patients had participated in the Collaborative Care for Anxiety and Panic study, which tested the effectiveness of an intervention to help primary care providers treat panic disorder. The treatment comprised cognitive behavioral therapy (CBT) combined with pharmacotherapy administered by primary care physicians with the expert advice of a psychiatrist. Post hoc semistructured interviews were conducted with 21 intervention participants who were classified according to adherence or nonadherence to treatment. The interview focused on reactions to CBT; reactions to the different features of the intervention, such as therapy sessions, demonstration videotapes, exercises, and a workbook; and comfort with the therapist. Two members of the research team independently coded, analyzed, and interpreted the data. Three themes emerged: information was empowering and reduced the sense of isolation experienced by participants, participants engaged in a dynamic and iterative personalized assessment of the intervention, and barriers to adherence were predominantly logistical. Results indicate that the extent to which patients chose to remain in treatment and follow treatment recommendations was rarely an all-or-nothing phenomenon. In a disadvantaged population such decisions seem to be influenced by the beliefs of the patient about what will and will not be effective in his or her individual case, an ongoing self-assessment of well-being, and the logistical barriers that come into play.

Perceived Unmet Need for Mental Health Treatment and Barriers to Care Among Patients With Panic Disorder

This study estimated the extent of perceived unmet need for mental health treatment among individuals with panic disorder in primary care settings, investigated the determinants of unmet need, and assessed barriers to care. Data were from baseline interviews in a clinical trial that investigated primary care treatment of panic disorder. Participants were asked whether there was any time in the past three months when they did not get as much care for emotional or personal problems as they needed or whether they had delays in getting care. Patients who endorsed unmet need were asked about specific perceived barriers. Logistic regression was used to investigate the determinants of unmet need. Of the 231 patients eligible for the study, 88 (38 percent) endorsed unmet need for emotional or mental health problems. Individuals with worse mental health, those who were more worried about panic, and those without sick pay were significantly more likely to report unmet need. Commonly reported barriers included being unable to find out where to go for help (43 percent), worry about cost (40 percent), lack of coverage by health plan (35 percent), and being unable to get an appointment soon enough (35 percent). The relatively low level of patient-reported unmet need for mental health treatment among primary care patients with panic disorder suggests that efforts to improve treatment of panic disorder should include patient education about mental illness and the effective treatments available. Although discussion of barriers to care has traditionally centered on stigma and economic factors, the results of this study suggest that simple logistic factors, such as not knowing whom to call for help, are also important barriers.

Paroxetine in the treatment of generalised anxiety disorder

Paroxetine is a selective serotonin re-uptake inhibitor useful in the treatment of a wide range of psychiatric disorders. Generalised anxiety disorder (GAD) is characterised by excessive persistent anxiety and worry about a number of events and activities occurring on more days than not for at least 6 months. GAD is the most common anxiety disorder in primary care settings. Paroxetine was the second antidepressant to receive an FDA indication for the treatment of GAD. In contrast to benzodiazepines, which had been the mainstay of treatment for anxiety disorders for many years, antidepressants, such as paroxetine, are more effective for the psychic symptoms of anxiety, which include worry, tension, irritability and concentration difficulties, and carry a more tolerable and safe side effect profile.

Factor Structure of the Center for Epidemiologic Studies Depression Scale in Low- Income Women Attending Primary Care Clinics

Given the high rates of major depressive disorder in primary care settings, routine use of screening measures to assist in identifying depressed individuals is warranted. The Center for Epidemiologic Studies Depression Scale (CES-D) ( Radloff, 1977 ) is a self-rated measure of distress commonly used to screen for depression in primary care settings. The present study was undertaken to confirm the original four-factor model in a sample of low-income women attending primary care clinics (N = 179). Although the original four-factor structure has been replicated in a variety of population groups, internal validity of the measure has not been previously examined in this population sample. A series of confirmatory factor analytic procedures failed to replicate the original four-factor structure or a second-order model. An exploratory analysis, using principal components and a VARIMAX rotation yielded three factors: Depressed Affect/Somatic Symptoms, Positive Affect, and Interpersonal Difficulties. Results of this study add support to previous research documenting an increased somatic presentation of depression in low-income samples. Implications for the use of the CES-D as a screening tool to identify depression in similar primary care samples are discussed.

The primary care PTSD screen (PC–PTSD): development and operating characteristics

Posttraumatic stress disorder (PTSD) is a frequently unrecognized anxiety disorder in primary care settings. This study reports on the development and operating characteristics of a brief 4-item screen for PTSD in primary care (PC-PTSD). 188 VA primary care patients completed the PC-PTSD, the PTSD Symptom Checklist (PCL) and the Clinician Administered Scale for PTSD (CAPS). The prevalence of PTSD was 24.5%. Signal detection analyses showed that with this base rate, the PC-PTSD had an optimally efficient cutoff score of 3 for both male and female patients. A cutoff score of 2 is recommended when sensitivity rather than efficiency is optimized. The PC-PTSD outperformed the PCL in terms of overall quality, sensitivity, specificity, efficiency, and quality of efficiency. The PC-PTSD appears to be a psychometrically sound screen for PTSD with comparable operating characteristtics to other screens for mental disorders.

Using the chronic care model to improve treatment of alcohol use disorders in primary care settings.

Alcohol use disorders (AUDs) are serious and often chronic medical conditions that present a significant public health concern. The Chronic Care Model (CCM), originally designed to improve care for patients with chronic conditions, is also applicable to a broad range of individuals with AUDs. In this article, we describe the CCM and discuss ways it can be adapted in primary care settings to improve care for AUDs. We review the evidence for considering the spectrum of AUDs as a chronic disease and discuss how the CCM might guide the reorganization of care to improve the delivery of effective interventions in primary care settings. We also solicited specific advice and feedback from an expert panel by means of a listserv. The CCM is a heuristic model that offers an approach to increase the ability of PCPs to identify, treat and effectively manage AUDs. Research suggests the model works well for a variety of chronic illnesses and across a number of different organizational settings. Implementation of the model in the case of AUDs has the potential to improve their care. Given the potentially chronic and relapsing nature of AUDs, it is important for the alcohol treatment community to be aware of the current research on improving care for chronic illnesses and to consider how the CCM might be adapted to improve care for AUDs. Further work is needed on developing tools, self-management support resources and training strategies before the CCM can be evaluated in real world settings.

Diagnosing depression and prescribing antidepressants by primary care physicians: the impact of practice style variations.

This study examined variations in the diagnosis of depressive disorders and prescription of antidepressant medications in primary care and the contribution of the physicians' practice styles to these variations. The analyses were based on visits to a representative sample of the U.S. office-based primary care physicians from the 1997 and 1998 National Ambulatory Medical Care Survey. In this sample, the propensities to give a diagnosis of depressive disorder and to prescribe antidepressants were operationalized as propensity variables. The association of these variables, obtained from a randomly selected subsample of visits to each physician, with the diagnoses and treatments of the other patients seen by the same physicians was examined. The results revealed considerable variations across practices in the percentages of patients who received diagnoses of depressive disorders (0-25%) and prescriptions for antidepressant medications (0-38%). Furthermore, the physicians' propensities to diagnose depressive disorders or to prescribe antidepressants were significantly associated with the diagnosis and treatment of individual patients. The large variations in diagnosis and treatment of depressive disorders and the significant impact of practice style variables on these variations highlight the need for implementation of uniform practice guidelines for diagnosis and treatment of depressive disorders in primary care settings.

Prevalence, recognition and management of depression in primary care in Germany: the Depression 2000 study.

'Depression 2000' is a major epidemiological study conducted in a representative sample of 412 primary care settings (which examined a total of 15,081 unselected patients) in Germany in order to address the current lack of information on the prevalence, recognition and treatment of depression in primary care. The study revealed that depression is a key challenge in primary care because of its prevalence (point prevalence according to ICD-10: 10.9%), type of presenting complaints and the time constraints of the doctors. Participating doctors had a very high workload (average of 62 patients per day) and perceived the management of depressed patients as a major burden. The majority of cases of depression identified met criteria for moderate or severe depression, and 51% had a chronic and/or recurrent course. A total of 55% of patients were correctly diagnosed as having a clinically significant depressive disorder, although only 21% received a diagnosis of 'definite' depression. In conclusion, these findings confirm the high prevalence of depressive disorders in primary care settings and underline the particular challenges posed by these patients. Although recognition rates among more severe major depressive patients, as well as treatments prescribed, appear to be more favourable than in previous studies, the high proportion of unrecognised patients with definite depression still raises significant concerns. It remains of continued prime importance to educate primary care doctors to better recognise depression in order to increase the patients' chances of receiving appropriate treatment.

WHO Annual Report Devoted To Mental Health Issues

WHO Annual Report Devoted To Mental Health Issues

DETECTION AND DIAGNOSIS OF PSYCHIATRIC DISORDERS IN PRIMARY MEDICAL CARE SETTINGS

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

Post-traumatic stress disorder in primary-care settings: prevalence and physicians' detection.

Little is known about the prevalence of PTSD in primary-care settings and regarding the ability of primary-care physicians to detect PTSD. The current study examines prevalence of PTSD in a national sample of primary-care attenders and primary-care physicians' detection of PTSD and general psychological distress in PTSD patients. Data are from a national study of 2975 primary-care attenders in Israel. Demographic data, responses to the GHQ-28, PTSD Inventory and physicians' diagnoses were examined. Twenty-three per cent of all patients who attended clinics (N = 684) reported traumatic events, 39% of whom (males 37%, females 40%) met criteria for PTSD on the PTSD Inventory. Eighty per cent of the males and 92% of the females with PTSD were distressed according to the GHQ. According to physicians, 37% of persons who reported trauma (40% of the women, 32% of the men) suffered from psychological distress. Only 2% of patients meeting PTSD criteria on the self-report measure were given a diagnoses of PTSD by physicians. Many primary-care patients suffer from PTSD, which is usually accompanied by major psychological distress. Attention by primary-care physicians to a history of trauma could improve physicians' detection of this disabling disorder.