OBJECTIVE: To determine the clinical predictors and rate of relapse for major depression in primary care. DESIGN: A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted. SETTING: A large primary care clinic of a staff-model health maintenance organization. PATIENTS: Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months. MAIN OUTCOME MEASURES: Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist. RESULTS: Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither. CONCLUSIONS: The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

Adult↗

PubMedDate not supplied

Ophthalmic referral rates for patients with diabetes in primary-care clinics located in disadvantaged urban communities.

The level of adherence with recommended standards for ophthalmic examinations was assessed in a purposive sample of diabetic patient charts (n = 350) from four clinics in medically underserved areas. All of the clinics referred patients with diabetes to off-site services for comprehensive eye examinations (dilation, visual acuity, and intraocular pressure); adherence with the standard of care was defined as a chart note indicating a referral for an ophthalmic examination. Overall, 86% of the patients were from high-risk minority groups (black or Hispanic) for diabetes and its complications. Mean age and duration of diabetes were 57.7 and 8.8 years, respectively. Referrals for ophthalmic exams were noted in 18% of the charts during the year preceding the review and in 28.6% of the charts during the 2 preceding years. Annual referrals in the preceding 2 years were noted in 3.1% of the charts. Eye disease was noted as a diagnosis in 22%. Patients who had a diagnosis of eye disease noted in their charts had a 7.5-fold increase in the odds of having a referral noted. The increased likelihood of being referred in patients with known eye disease may be due to follow-up of current eye problems.

Black or African American↗

PubMedDate not supplied

Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain.

The authors evaluated 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) using structured psychiatric, family history, and sexual trauma interviews. Laparoscopy reports were blindly rated by a gynecologist. Compared with the nonpain group, the women with chronic pelvic pain had significantly higher current and lifetime rates of psychiatric disorders, as well as childhood and adult sexual victimization. They reported significantly higher mean numbers of somatization symptoms, but no significant differences in objective laparoscopic findings. Psychiatric disorders and sexual victimization are common in women with chronic pelvic pain and should be considered in the evaluation and treatment of these patients.

Adolescent↗

PubMedDate not supplied

Low-intensity treatment of depression in primary care: is it problematic?

The aim of this study was to examine patterns of care and outcomes of depressed patients under primary care during acute phase treatment. A cohort of depressed patients was assessed 6-8 weeks after starting pharmacotherapy in four large primary care clinics in a health maintenance organization. These patients (n = 1671) were receiving antidepressant treatment for a new episode of depression. To calculate main outcome measures, Structured Clinical Interview for Depression evaluated prior history and current depression status. Visit and pharmacy refill data described use of health services and antidepressant medication. Six to eight weeks after starting antidepressant therapy, 33.2% of patients had 0-3 depressive symptoms and no prior history of depression, an additional 42.3% also reported 0-3 symptoms but were at high risk of relapse, and 24. 5% were persistently depressed with 4 or more depressive symptoms. In the initial 6 weeks of treatment, these three groups showed similar use of antidepressant medication and health services. About 50% in each group had no follow-up visit for depression and 32%-42% had not refilled their antidepressant prescription. In general, depressed patients under primary care obtained low-intensity pharmacotherapy and inconsistent follow-up visits during initial acute phase treatment. Six weeks after starting antidepressant medicine, many were still symptomatic or recovered but had a high risk of depression relapse. Patients with unfavorable outcomes did not receive more intensive management than the one-third who had favorable outcomes.

Acute Disease↗

PubMedDate not supplied

Assessing the ethical costs and benefits of trauma-focused research.

Although scientists and members of Institutional Review Boards must balance the needs of investigators and participants in research, virtually no evidence is available to inform this decision making. This study examines the frequency and correlates of adverse reactions and adequacy of informed consent among 1174 women in an HMO who completed a trauma-focused health survey, and a subset of 252 women who later completed a trauma-focused research interview. Despite the sensitive content, the majority of women participants found participation in the interview and the questionnaire study to be a positive experience. Although a small number of women, particularly those with a history of maltreatment, underestimated the level of upset they would subsequently experience, the majority still did not regret participating, indicating that informed consent procedures were adequate, with a large proportion reporting immediate perceptions of personal gain. Finally, the cost-benefit ratio appears stable 48 hours post-interview, with some minor fluctuations. Overall, these results suggest that research on childhood victimization is well tolerated by women who participate. Though a small number of women may be disturbed by these investigations, in general, adverse reactions appear less common than previously anticipated.

Adult↗

PubMedDate not supplied

Incentives and barriers to retinopathy screening among African-Americans with diabetes.

Diabetes-related ophthalmic complications are the leading cause of newly diagnosed blindness among adults. These eye complications are often asymptomatic in the early stages, yet the majority of diabetes patients are not screened yearly. To develop a health promotion intervention to increase the rate of screening for diabetic retinopathy by dilated fundus exam (DFE), we assessed the knowledge and health beliefs related to preventing diabetic eye complications among a sample of African-Americans with diabetes. The study design was cross-sectional, using a telephone interview to collect data. From a random sample of 104 African-Americans with diabetes, 67 (64%) were completed: 54 women; mean age of 58 years. The telephone interview schedule contained items grouped into subscales for Perceived Incentives, Perceived Barriers to getting a DFE, Causes of Eye Problems, Risk of Eye Problems, and Effective Treatments for Eye Problems. Descriptive statistics were used to analyze the quantitative data. Transcribed qualitative responses to the open-ended questions were analyzed for themes. The incentives "having eye problems" and "doctor said it was important to go" each had 91% responding it was an incentive to go for a DFE. Only about one-third agreed that any particular item was a barrier to receiving a DFE (e.g., economic factors). In the subscale for Risk of Eye Problems, "retinopathy" had the lowest level of perceived risk (30%). Only 21% of the sample reported there were effective treatments for retinopathy. Eighty-seven percent reported the faulty belief that "diabetic eye problems have symptoms." Only 36% of the sample said they had heard of retinopathy and of those, only 8% could describe it correctly. Among general response themes were: fear, spirituality (faith and hope), priorities, economic or logistical factors, and external/internal motivation. Perceived incentives for receiving a DFE were acknowledged at far greater rates than perceived barriers. Having a yearly DFE in the absence of symptoms must be emphasized in health promotion materials. There are effective, early treatments for diabetic eye problems, and this information should be used to counter the fear of a dreaded diagnosis with the hope of treatment and cure. Ways of coping with fear of having the exam should be included in health education. DFEs must become a routine yearly exam and not just a reaction to recognized problems. Health education must address the specific needs of high-risk minority populations.

Adult↗

PubMedDate not supplied

The relationship between psychological distress and gastrointestinal symptoms in women with irritable bowel syndrome.

BACKGROUND: Individuals with irritable bowel syndrome (IBS) are reported to experience more symptoms compatible with psychopathologic disorders, abnormal personality traits, and psychological distress. Conversely, individuals with psychiatric disorders report higher levels of gastrointestinal (GI) symptoms compatible with IBS. Thus, psychological distress may contribute to GI symptoms in individuals with IBS. OBJECTIVES: To examine psychological distress in women with IBS, women with similar GI symptoms but not diagnosed (IBS nonpatients, IBS-NP), and asymptomatic Control women. METHODS: The women (N=97) were interviewed, completed questionnaires, and maintained daily diaries for 2 months. Across-women and within-woman analyses were used to calculate the results. RESULTS: The IBS and IBS-NP groups had a higher percentage of lifetime psychopathology and recalled psychological distress. At least 40% of the women in the IBS and IBS-NP groups had positive relationships between daily psychological distress and daily GI symptoms. CONCLUSIONS: Psychological distress is an important component of the IBS symptom experience and should be considered when treatment strategies are designed.

Adult↗