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Biomedical subjects

Donald E Nease

Publications and source records attributed to Donald E Nease.

14 recordsLinked to original sources
PubMed2006

Depression case finding in primary care: a method for the mandates.

The current mandates for depression screening in primary care create a dilemma for clinicians. How should screening be implemented in the face of limited evidence for sustainable strategies for effective depression monitoring and management in primary care. In this article we review the issues surrounding primary care depression screening, and develop the argument for a case-finding strategy that includes careful choice of a single instrument, focused identification of high-risk patients, and systematic monitoring of outcomes. We believe this is a sustainable method that primary care clinicians can implement to address the spirit of current depression screening mandates.

Cross-Sectional Studies↗
PubMed2005

Severity and criteria based prompting for treatment of depressed patients.

PURPOSE: Primary care physicians (PCPs) often do not respond to prompts based upon criteria-based depression screens, perhaps because these prompts do not account for depression severity. We conducted this pilot study to determine the feasibility of prompting for both diagnostic criteria and severity and to assess whether depression would be more attended to with positive "dual prompts" than prompts based on either criteria or symptom severity alone. METHODS: Immediately prior to a routine care appointment, 87 adults from three primary care practices completed the PRIME-MD Clinician Evaluation Guide Mood Module (PRIME-MD; assesses depression criteria) and the Brief Depression Rating (BDR; assesses depressive symptom severity), and their results were issued in a salient PCP prompt on the chart. Immediately afterwards, patients reported the impact of the screening results upon treatment decisions during the encounter. Data were analyzed by X2, analysis of variance, and binomial regression. RESULTS: Compared to subjects screening positive on either depression criteria or severity alone (n = 10), those patients on both (n = 17) were more likely to report discussing depression, and agreement that the physician and patient decided treatment was needed and initiated or continued. There were no differences in patient satisfaction based on screening results. After accounting for PRIME-MD results, BDR scores predicted agreement with the physician and patient decided treatment was needed (OR = 22.03; 95% CI: 2.05-236.46). CONCLUSIONS: Supplementary severity-based depression screening is feasible, and might overcome the limitations of criteria-based screening alone. Future research could test this hypothesis in a large randomized trial.

Adolescent↗
PubMed2004

Essential characteristics of effective Balint group leadership.

OBJECTIVE: Balint work in the United States has suffered from a lack of written material on how Balint group leaders structure and guide group process. This study identified characteristics of effective Balint group leadership by gathering information from experienced Balint leaders. METHODS: We used evaluations of the leadership methods used by 21 Balint group leaders assembled at an American Balint Society workshop to pilot test the Society's credentialing process. Free text and rating data from leader evaluation forms were analyzed using qualitative text analysis and factor analysis. We also conducted focus groups. RESULTS: Convergence was seen on several characteristics across all sources of data. Effective Balint leaders operate to create a safe environment and move the group toward a new understanding of a specific doctor-patient relationship. Specific leader behaviors include protecting the presenter from interrogation, encouraging open speculation by group members, avoiding premature solutions, and tolerating silence and uncertainty. DISCUSSION: Although Balint group leaders rely on behaviors common to other small-group methods, they create a space and purpose markedly different from that seen in other small groups in medical education. Balint group leaders model and create a safe environment for shared, creative speculation and a more empathic experience of the doctor-patient relationship.

Behavior↗
PubMed2003

Depression screening: a practical strategy.

A 2-stage strategy, combining an assessment of severity with depression criteria, can help a physician focus on the most severe cases without missing less severe ones that still need treatment. Because of its brevity, relatively high positive predictive value, and ability to inform the clinician on both depression severity and diagnostic criteria, the PRIME-MD Patient Health Questionnaire (PHQ-9) is the best available depression screening tool for primary care. One-time screening is cost-effective; physicians may elect to screen more often based on risk factors.

Depression↗
PubMed2002

Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues.

Humans↗
PubMed2002

Improved detection of depression in primary care through severity evaluation.

OBJECTIVES: To determine whether the use of a symptom severity measure to augment an existing Diagnostic and Statistical Manual of Mental Disorders-Third Edition, Revised (DSM-III-R) criteria-based depression screener (PRIME-MD) would decrease the difficulties associated with depression screening in primary care by filtering out patients with minimal impairment. STUDY DESIGN: The study design was secondary data analysis. POPULATION: The study sample comprised 1317 patients, with intentional oversampling by ethnicity and sex, presenting for routine care at a university family practice center in Galveston, Texas. OUTCOMES MEASURED: The primary outcomes were cross-sectional, health-related quality-of-life outcomes of subjects who met symptom severity criteria as well as criteria for a DSM-III-R mood disorder. Health care utilization outcomes were examined as secondary outcomes. RESULTS: The combination of a 6-item depression severity instrument and the PRIME-MD resulted in 71% of depressed subjects being categorized as severely symptomatic and 29% as minimally symptomatic. Severely symptomatic subjects had significantly worse SF-36 Mental Health Component Summary scale (MCS) scores than did minimally symptomatic subjects (32.8 vs 43.5, P <.05). Minimally symptomatic subjects had MCS scores similar to those of a third group of subjects who did not meet DSM-III-R "threshold" criteria for mood disorder but who were severely symptomatic. Adjusted health care utilization was higher for the initial 3-month charge period in the severely symptomatic depressed subjects compared with minimally symptomatic depressed subjects ($679.20 vs $462.38, P <.05). CONCLUSIONS: The 6-item depression severity measure effectively separated patients meeting DSM-III-R "threshold" depression criteria into 2 groups: one presenting with severe symptoms and impairment and the other presenting with mild symptoms and significantly less impairment. A strategy of initial screening using a brief depression severity instrument, followed with a DSM criteria-based instrument, could decrease the immediate clinician workload by one third and focus treatment on those most likely to benefit.

Adult↗
PubMedDate not supplied

Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication.

PURPOSE: This study aimed to identify the demographic, psychiatric, and attitudinal predictors of treatment adherence during the maintenance phase of antidepressant treatment, ie, after symptoms and regimen are stabilized. METHODS: We surveyed 81 primary care patients given maintenance antidepressant medications regarding general adherence, recent missed doses, depression and treatment features, medication beliefs (necessity, concerns, harmfulness, and overprescription), and other variables. Additional data were collected from medical and payer records. RESULTS: Median treatment duration was 75 weeks. Adherence and beliefs were broadly dispersed and unrelated to treatment duration and type, physical functioning, and demographics. Multivariate analysis adjusting for social desirability, depression severity, and treatment duration indicated that an antidepressant-specific "necessity-minus-concerns" composite was strongly associated with both adherence outcomes. Specifically, adherence was highest when necessity exceeded concerns and lowest when concerns exceeded necessity. We crossed these 2 dimensions to characterize 4 patient attitudes toward antidepressants: skepticism, indifference, ambivalence, and acceptance. CONCLUSIONS: Patients given maintenance antidepressants vary widely in adherence. This variation is primarily explained by the balance between their perceptions of need and harmfulness of antidepressant medication, in that adherence is lowest when perceived harm exceeds perceived need, and highest when perceived need exceeds perceived harm. We speculate on ways to tailor adherence strategies to patient beliefs. Subsequent research should determine whether patients' perceptions about medication predict depression outcomes, can be used to improve clinical management, and respond to behavioral intervention.

Adult↗
PubMedDate not supplied

Infrastructure requirements for practice-based research networks.

BACKGROUND: The practice-based research network (PBRN) is the basic laboratory for primary care research. Although most PBRNs include some common elements, their infrastructures vary widely. We offer suggestions for developing and supporting infrastructures to enhance PBRN research success. METHODS: Information was compiled based on published articles, the PBRN Resource Center survey of 2003, our PBRN experiences, and discussions with directors and coordinators from other PBRNs. RESULTS: PBRN research ranges from observational studies, through intervention studies, clinical trials, and quality of care research, to large-scale practice change interventions. Basic infrastructure elements such as a membership roster, a board, a director, a coordinator, a news-sharing function, a means of addressing requirements of institutional review boards and the Health Insurance Portability and Accountability Act, and a network meeting must exist to support these initiatives. Desirable elements such as support staff, electronic medical records, multiuser databases, mentoring and development programs, mock study sections, and research training are costly and difficult to sustain through project grant funds. These infrastructure elements must be selected, configured, and sized according to the PBRN's self-defined research mission. Annual infrastructure costs are estimated to range from $69,700 for a basic network to $287,600 for a moderately complex network. CONCLUSIONS: Well-designed and properly supported PBRN infrastructures can support a wide range of research of great direct value to patients and society. Increased and more consistent infrastructure support could generate an explosion of pragmatic, generalizable knowledge about currently understudied populations, settings, and health care problems.

Biomedical Research↗
PubMedDate not supplied

ClinfoTracker: a generalizable prompting tool for primary care.

BACKGROUND: ClinfoTracker is a prompt and reminder system designed as a platform for the study of the cognitive aspects of prompting in primary care. We examined the impact of ClinfoTracker in three practices and its potential for studying primary care clinicians' use of prompt and reminder systems. METHODS: We studied ClinfoTracker in three practices using an observational design. We measured performance rates of three services during the course of 5 years in one practice and prompt response rates in all three practices for 5 months after implementation. We performed qualitative cognitive task analyses of ClinfoTracker use. RESULTS: Five-year compliance rates increased for fecal occult blood testing (1996-2000, 22.5%, P = .0037; 1997-2000, 23.5%, P = .0024) and type 2 diabetes retinopathy testing (1997-2000, 15.7%, P = .0004; 1998-2000, 16.9%, P = .0001; 1999-2000, 12.4%, P = .0048). ClinfoTracker response rates from the three practices showed significant increases during 5 months (P < .0001). Significant differences seen between practice response rates indicate variable success in ClinfoTracker implementation. Cognitive task analyses performed at site 1 indicate differences in how ClinfoTracker prompts are incorporated into practice. CONCLUSIONS: Improvements in preventive and disease management services after implementation show the potential of ClinfoTracker. Differences in implementation between practice sites and observations of individual clinicians show the promise ClinfoTracker holds for studying clinician use of prompt and reminder systems.

Analysis of Variance↗
PubMedDate not supplied

Assessment of depressive symptoms in deaf persons.

BACKGROUND: Evidence suggests that Deaf people may have a greater prevalence of depressive symptoms. However, it is unclear whether commonly used written screening instruments are accurate with this population because of their unique cultural and linguistic factors. SETTING: Deaf persons (n = 71) residing in southeastern Michigan. METHODS: Subjects completed the Zung Self-Rated Depression Scale in both the written (ZSDS-W) and American Sign Language (ZSDS-S) formats and the Hamilton Depression Scale (HAM-D) in American Sign Language in counterbalanced order, followed by a Test Of Reading Comprehension (TORC). They also provided extensive data on demographic, hearing loss, language use, social and health care use variables. RESULTS: Mean subject age was 52 years, 63% of subjects were women, 95% were Caucasian, and 47% were married (87% to another deaf/hard of hearing person). Thirty percent had a college degree and 20% had less than a 10th grade education. The ZSDS-W and ZSDS-S scores were highly correlated (r = +0.79), although the mean ZSDS-W score was 2.8 points higher (P = .001). The ZSDS-S correlated more highly (r = 0.80) with the HAM-D than the ZSDS-W (r = 0.71). There was a significant interaction effect (P < .001) such that the ZSDS-W and HAM-D were significantly associated among higher literacy subjects (beta = 0.80, P < .001) but not lower literacy subjects (beta = 0.20, P = .183). There were no other significant associations between depression scores and numerous demographic, educational, hearing loss, social or language variables. CONCLUSIONS: Compared with the conventional ZSDS-W, the ZSDS-S more accurately assesses depression severity among deaf persons with lower English literacy. However, given the greater sensitivity of the ZSDS-W and the practical barriers to ZSDS-S in physician practices, further research should determine which modality is best for routine depression screening.

Adult↗
PubMedDate not supplied

Information technology and cancer prevention.

Information technology is rapidly advancing and making its way into many primary care settings. The technology may provide the means to increase the delivery of cancer preventive services. The aim of this systematic review is to examine the literature on information technology impacts on the delivery of cancer preventive services in primary care offices. Thirty studies met our selection criteria. Technology interventions studied to date have been limited to some type of reminder to either patients or providers. Patient reminders have been mailed before appointments, mailed unrelated to an appointment, mailed after a missed appointment, or given at the time of an appointment. Telephone call interventions have not used technology to automate the calls. Provider interventions have been primarily computer-generated reminders at the time of an appointment. However, there has been limited use of computer-generated audits, feedback, or report cards. The effectiveness of information technology on increasing cancer screening was modest at best. The full potential of information technology to unload the provider-patient face-to-face encounter has not been examined. There is critical need to study these new technologic approaches to understand the impact and acceptance by providers and patients.

Humans↗