Biomedical subjects

G E Simon

Publications and source records attributed to G E Simon.

At least 37 records · Page 2Linked to original sources

PubMed1999

The natural history of somatization in primary care.

BACKGROUND: Somatization is often regarded as a chronic disorder. However, empirical studies to support this view and to determine its natural history in primary care are lacking. This paper provides data on the incidence and persistence of current somatization syndrome in a large cross-national sample drawn from 15 sites in 14 countries. METHODS: After screening with the General Health Questionnaire, a stratified sample of 5438 primary care patients was interviewed with the Composite International Diagnostic Interview and evaluated for physical health status, self-rated overall health and for occupational disability. Twelve months later, 3204 of the patients completed follow-up interviews. RESULTS: Over a 12-month period, an abridged form of somatization defined as four current symptoms in males and six in females was persistent in 45.9% of the patients. Persistence of syndrome was related to age and to subjective indices of psychological distress at baseline. Persistence was unrelated to depression. The 12-month incidence of the abridged somatization syndrome was 7.1% (95% CI, 6.1-8.3%). Individuals with depression at baseline and those with poor view of their health were more likely to develop new episodes of somatization 12-months later. CONCLUSION: Somatization syndrome showed considerable change over time. Persistence and onset of somatization were related to both level of psychopathology and health beliefs.

Adolescent↗

PubMed1999

Depression among high utilizers of medical care.

OBJECTIVE: To determine the prevalence of unrecognized or unsuccessfully treated depression among high utilizers of medical care, and to describe the relation between depression, medical comorbidities, and resource utilization. DESIGN: Survey. SETTING: Three HMOs located in different geographic regions of the United States. PATIENTS: A total of 12,773 HMO members were identified as high utilizers. Eligibility criteria for depression screening were met by 10,461 patients. MEASUREMENTS AND MAIN RESULTS: Depression status was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Depression screening was completed in 7,203 patients who were high utilizers of medical care, of whom 1,465 (20.3%) screened positive for current major depression or major depression in partial remission. Among depressed patients, 621 (42.4%) had had a visit with a mental health specialist or a diagnosis of depression or both within the previous 2 years. The prevalence of well-defined medical conditions was the same in patients with and patients without evidence of depression (41.5% vs 41.5%, p = .87). However, high-utilizing patients who had not made a visit for a nonspecific complaint during the previous 2 years were at significantly lower risk of depression (13.1% vs 22.4%, p < .001). Patients with current depression or depression in partial remission had significantly higher numbers of annual office visits and hospital days per 1,000 than patients without depression. CONCLUSIONS: Although there was evidence that mental health problems had previously been recognized in many of the patients, a large percentage of high utilizers still suffered from active depression that either went unrecognized or was not being treated successfully. Patients who had not made visits for nonspecific complaints were at significantly lower risk of depression. Depression among high utilizers was associated with higher resource utilization.

Comorbidity↗

PubMed1999

Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care.

OBJECTIVE: The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted. METHOD: They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy. RESULTS: At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy. CONCLUSIONS: Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

Adult↗

PubMed1999

Health care utilization and costs among patients treated for bipolar disorder in an insured population.

OBJECTIVE: The study examined health care utilization and costs among patients treated for bipolar-spectrum disorders in an insured population. METHODS: Computerized data on prescriptions and on outpatient and inpatient diagnoses from a large health plan were used to identify patients treated for cyclothymia, bipolar disorder, or schizoaffective disorder. Three age- and sex-matched comparison groups consisting of general medical outpatients, patients treated for depression, and patients treated for diabetes were selected from health plan members. Utilization and cost of health services for the four groups over a six-month period were assessed using computerized accounting records. RESULTS: Total mean+/-SD costs for patients in the bipolar disorder group ($3,416+/-$6,862) were significantly higher than those in any of the comparison groups. Specialty mental health and substance abuse services accounted for 45 percent of total costs in the group with bipolar disorder (mean+/-SD=$1, 566+/-$3,243), compared with 10 percent in the group with depression. Among patients treated for bipolar disorder, 5 percent of patients accounted for approximately 40 percent of costs for specialty mental health and substance abuse services, 90 percent of inpatient costs for specialty mental health and substance abuse services, and 95 percent of out-of-pocket costs for inpatient care. In the bipolar disorder group, parity coverage of inpatient mental health and substance abuse services would increase overall health care costs by 6 percent. CONCLUSIONS: Health care costs for patients with bipolar disorder exceed those for patients treated for depression or diabetes, and specialty mental health and substance abuse treatment costs account for this difference. Costs to the insurer and costs borne by patients are accounted for by a small proportion of patients. Elimination of discriminatory mental health coverage would have a small effect on overall health care costs.

Adolescent↗

PubMed1999

Best clinical practice: guidelines for managing major depression in primary medical care.

Practice guidelines such as those of the United States Public Health Service Agency for Health Care Policy and Research have been instrumental in addressing the significant problem of how best to manage major depression in primary medical care settings. Since this set of guidelines was published in 1993, new findings from randomized clinical trials and extensive clinical experience permit us to reevaluate trends in treatment of major depression in primary medical care. This review suggests guidelines for achieving best clinical practice given current knowledge.

Antidepressive Agents↗

PubMed1998

Persistent pain and well-being: a World Health Organization Study in Primary Care.

CONTEXT: There is little information on the extent of persistent pain across cultures. Even though pain is a common reason for seeking health care, information on the frequency and impacts of persistent pain among primary care patients is inadequate. OBJECTIVE: To assess the prevalence and impact of persistent pain among primary care patients. DESIGN AND SETTING: Survey data were collected from representative samples of primary care patients as part of the World Health Organization Collaborative Study of Psychological Problems in General Health Care, conducted in 15 centers in Asia, Africa, Europe, and the Americas. PARTICIPANTS: Consecutive primary care attendees between the age of majority (typically 18 years) and 65 years were screened (n = 25 916) and stratified random samples interviewed (n = 5438). MAIN OUTCOME MEASURES: Persistent pain, defined as pain present most of the time for a period of 6 months or more during the prior year, and psychological illness were assessed by the Composite International Diagnostic Interview. Disability was assessed by the Groningen Social Disability Schedule and by activity-limitation days in the prior month. RESULTS: Across all 15 centers, 22% of primary care patients reported persistent pain, but there was wide variation in prevalence rates across centers (range, 5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41 -1.89), and to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological disorder and persistent pain was observed in every center, while the relationship between disability and persistent pain was inconsistent across centers. CONCLUSIONS: Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers. Large variation in frequency and the inconsistent relationship between persistent pain and disability across centers suggests caution in drawing conclusions about the role of culture in shaping responses to persistent pain when comparisons are based on patient samples drawn from a limited number of health care settings in each culture.

Adult↗

PubMed1998

Suicide mortality among patients treated for depression in an insured population.

Studies of inpatient and specialty samples have estimated that 15% of depressed patients eventually die by suicide. This report examines suicide mortality among members of Group Health Cooperative of Puget Sound, a large health plan in western Washington state, who were treated for depression. Computerized discharge diagnoses, outpatient visit diagnoses, and outpatient prescription records were used to identify all enrollees who received treatment for depression during 1992, 1993, and 1994. Computerized death certificate data were used to identify all deaths and all suicide deaths in this sample before January 1, 1995. During the study period, 35,546 individuals received some treatment for depression and accounted for 62,159 person-years of follow-up. Of 850 deaths, 36 (4.2%) were classified as definite or possible suicides. Overall suicide mortality rate was 59 per 100,000 person-years, and was significantly higher among men than women (118 vs. 36 per 100,000 person-years, respectively). Risk per 100,000 person-years declined from 224 among patients who received any inpatient psychiatric treatment to 64 among those who received outpatient specialty mental health treatment to 43 among those treated with antidepressant medications in primary care to 0 among those treated in primary care without antidepressants. These data suggest that overall suicide risk among patients treated for depression is considerably lower than previous estimates based on specialty and inpatient samples. Risk is strongly related to treatment history--a likely indicator of illness severity.

Adult↗

PubMed1998

Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines.

The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.

Antidepressive Agents↗

PubMed1998

Impact of improved depression treatment in primary care on daily functioning and disability.

BACKGROUND: Few data are available regarding the impact of improved depression treatment on daily functioning and disability. METHODS: In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability: self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days. RESULTS: Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0.68, 95% CI 0.46, 0.99) and more favourable overall health (OR 0.50, 95% CI 0.28, 0.91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance. CONCLUSIONS: More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability.

Absenteeism↗

PubMed1998

SF-36 summary scores: are physical and mental health truly distinct?

OBJECTIVES: Data from 536 primary care patients initiating antidepressant treatment were used to examine the performance of the Medical Outcomes Study SF-36 Physical Component and Mental Component summary scores. METHODS: The SF-36 was administered at baseline and readministered after 1 month and 3 months (n = 482). RESULTS: At the baseline assessment, patients reported modest impairment on the Physical Function, Role--Physical, Bodily Pain, and General Health Perceptions subscales (0.10 to 0.68 standard deviations below national norms), but the Physical Component summary (mean = 51) indicated no impairment based on a population norm of 50. During 3 months of follow-up evaluation, the Physical Function, Role--Physical, Bodily Pain, and General Health Perceptions subscales all showed moderate and statistically significant improvement (range from 0.28 to 0.49 standard deviation units), whereas the Physical Component summary score was essentially unchanged (mean = 50 at both 1-month and 3-month assessments). This pattern of results is a natural consequence of the assumptions and methods used to calculate these summary scores-orthogonal factor rotation and negative scoring coefficients. CONCLUSIONS: These findings suggest caution in the interpretation of Mental Component Summary and Physical Component Summary scores when the condition or treatment of interest has strong effects on scales with negative scoring coefficients (Mental Health and Role--Emotional for the Physical Component; Physical Function, Role--Physical, and Bodily Pain for the Mental Component).

Adolescent↗

PubMed1998

Cost implications of initial antidepressant selection in primary care.

While fluoxetine is considerably more expensive than tricyclic antidepressants (TCAs), some previous studies have suggested that general medical expenditures are lower among patients treated with fluoxetine. In this study, computerised pharmacy and cost-accounting records of a large health plan were used to examine overall treatment costs for 5169 primary-care patients beginning antidepressant treatment with fluoxetine or one of 2 TCAs, imipramine or desipramine. Comparison was based on initial medication prescribed, regardless of subsequent switches or discontinuation. Patients treated with fluoxetine were older, with a higher burden of medical illness and higher overall health-service costs before starting antidepressant treatment, compared with patients receiving the other 2 drugs. Initial choice of fluoxetine was associated with approximately $US140 higher mean antidepressant costs and approximately $US300 higher mean costs for all other health services (1995 costs). Alternative methods of accounting for baseline differences (age, medical comorbidity, prior costs) indicated that adjusted 'non-antidepressant' costs (total costs minus costs of antidepressant therapy) in the fluoxetine group were $US75 to $US300 lower than in either of the TCA groups, but these differences were not statistically significant. Subgroup analyses suggested that the use of fluoxetine was associated with lower overall costs only among those incurring high costs in the pretreatment period. These findings support earlier studies suggesting that the use of fluoxetine as a first-line antidepressant in primary care will increase antidepressant drug costs, but will not significantly increase total treatment costs.

Adult↗

PubMed1998

Should anxiety and insomnia influence antidepressant selection: a randomized comparison of fluoxetine and imipramine.

BACKGROUND: The more sedating antidepressants are often recommended for patients presenting with anxiety or insomnia. We examine whether baseline anxiety or insomnia symptoms (1) show differential response to fluoxetine or imipramine or (2) predict differences between drugs in overall clinical response or likelihood of medication discontinuation. METHOD: 336 health maintenance organization primary care patients beginning antidepressant treatment for depression were randomly assigned to an initial prescription for fluoxetine or imipramine. All subsequent care (medication dosage, change, or discontinuation) was managed as usual by the primary care physician. The 17-item Hamilton Rating Scale for Depression (HAM-D) and the Hopkins Symptom Checklist (SCL) anxiety and depression subscales were administered prior to randomization and 1 month later. RESULTS: Rates of improvement in insomnia (HAM-D insomnia items), agitation (HAM-D agitation item), and anxiety (SCL anxiety subscale) were essentially identical in the two treatment groups. Baseline level of insomnia did not predict significant differences between randomization groups in improvement in overall HAM-D score (p = .44) or SCL depression subscale (p = .44). Similarly, baseline level of anxiety did not predict significant differences in improvement in HAM-D (p = .19) or SCL depression subscale (p = .31). Patients assigned to fluoxetine were significantly less likely to change or discontinue antidepressant medication during the first month, but this difference did not vary according to baseline level of insomnia (p = .68) or anxiety (p = .25). CONCLUSION: Among patients with moderate depression, baseline levels of insomnia or anxiety should not influence the choice of fluoxetine or imipramine as an initial antidepressant.

Adult↗

PubMed1998

Can depression be managed appropriately in primary care?

This review considers the necessary conditions for appropriate management of depression in primary care. While discussion of primary care management has often focused on the recognition of depression, recognition alone is not sufficient. Recent research demonstrates that primary care management of depression frequently fails to meet recommended standards for intensity of treatment and follow-up. Several recent randomized trials show that effective treatment of depression in primary care is possible but will require significant changes in current practice. Prerequisites for more effective management of depression in primary care include appropriate patient education, systematic monitoring of care processes and outcomes, and easy access to the full range of psychiatric consultation services.

Antidepressive Agents↗

PubMed1998

Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment.

BACKGROUND: We evaluated depression severity, health-related quality of life (HRQL), and medical cost outcomes of primary care patients receiving recommended and less-than-recommended levels of antidepressant treatment. METHODS: We performed a secondary analysis of clinical trial data from primary care clinics in a staff-model managed care organization. The trial included patients with Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depression who were starting antidepressant treatment. The primary outcomes measures used were the 17-item Hamilton Depression Rating Scale (HDRS), Hopkins Symptom Checklist depression scores, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) mental and physical component summary scores, and the total outpatient and inpatient medical costs. RESULTS: Of 358 patients starting antidepressant treatment, 195 (54.5%) received doses recommended by the Agency for Health Care Policy and Research for 90 days or more. Mean HDRS score decreased from 14.1 to 8.8 in patients receiving less-than-recommended treatment and decreased from 13.8 to 8.9 in patients with minimum recommended treatment (P = .761). No significant differences in improvement of HRQL outcomes during 6 months were observed between patients receiving recommended or less-than-recommended antidepressant therapy. Mean total medical costs over 6 months for patients taking the recommended levels of antidepressant treatment were $1872 +/- 140 compared with $2622 +/- 413 for patients taking less-than-recommended treatment (P = .032). The differences in total medical costs were attributable to significantly lower nonmental health-related inpatient costs in the recommended antidepressant treatment group ($104 vs $785, P = .004). CONCLUSIONS: Patients receiving minimum recommended levels of antidepressant therapy for 3 months showed improvement in depression severity and HRQL comparable with patients receiving less-than-recommended treatment. Patients receiving minimum recommended treatment had lower total costs and nonmental health-related inpatient costs. Antidepressant treatment in primary care patients may have the greatest impact on the frequency of health care visits and on costs for medical conditions and impairments.

Adult↗

PubMed1997

Depression, use of medical services and cost-offset effects.

This review considers evidence that depression is associated with increased use of general medical services and that more intensive treatment of depression might be expected to reduce medical expenditures. Cross-sectional studies strongly support an association between depression and medical utilization, but cannot establish a causal relationship. Available longitudinal studies lack the sample size and duration of follow-up necessary to examine how changes in depression influence utilization. Some quasi-experimental and experimental studies support a "cost-offset" effect due to mental health treatment, but no experimental data directly address the specific impact of depression treatment on medical utilization. The available data identify the potential for large cost savings through improved treatment of depression but do not clearly establish that such savings can be realized. Definitive proof of a cost-offset due to depression treatment will require a new generation of experimental studies adapted to assess economic outcomes.

Cost-Benefit Analysis↗

PubMed1997

The syndrome of hypochondriasis: a cross-national study in primary care.

BACKGROUND: The nature and correlates of hypochondriasis are still poorly understood, especially in settings other than those in North America and Western Europe. METHODS: A total of 25,916 consecutive patients making ambulatory visits to primary care clinics at 15 sites in 14 countries were screened using the 12-item General Health Questionnaire (GHQ-12). Based on the screen-score performance, a stratified sample of 5447 of respondents was evaluated at the second-stage (response rate: 62%). Evaluation consisted of physician-rated physical and psychological health status and self-ratings of overall health, physical disability and GHQ-28. Interviewers conducted assessment of psychiatric status, using the Composite International Diagnostic Interview (CIDI) and occupational disability. RESULTS: Across the sites, the occurrence of ICD-10 hypochondriasis was 0.8% (95% Confidence Interval, 0.5-1.0%) and over 1.5% at only two sites. A less restrictively-defined form of the disorder had a pooled frequency of 2.2% (95% Confidence Interval, 1.8-2.6%) across the sites. Patients with this abridged hypochondriasis were more likely than those without to have co-morbid major depression and generalized anxiety disorder. They had a poorer perception of their health, were more physically disabled, were more impaired in the performance of occupational role, and were above-average utilizers of health service. Patients with ICD-10 hypochondriasis were no more impaired than those with abridged hypochondriasis. CONCLUSION: Even though the ICD-10-defined hypochondriasis is rare, a form consisting of the triad of disease conviction, associated distress and medical help-seeking is present in primary-care settings in different cultures. This syndrome is associated with considerable psychiatric ill-health and functional disability.

Adolescent↗

PubMed1997

Achieving guidelines for the treatment of depression in primary care: is physician education enough?

OBJECTIVES: The authors examine whether physician education has enduring effects on treatment of depression. METHODS: Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction; and (6) depression outcomes. RESULTS: No lasting educational effect was observed consistently in any of the outcomes measured. CONCLUSIONS: There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.

Depressive Disorder↗

PubMed1997

Prevalence, burden, and treatment of insomnia in primary care.

OBJECTIVE: The prevalence, burden, and management of insomnia among primary care patients were evaluated. METHOD: Consecutive patients aged 18 to 65 years in primary care clinics of a staff-model health maintenance organization (N = 1,962) were screened with the 12-item General Health Questionnaire. A stratified random sample (N = 373) completed face-to-face diagnostic assessments including the Composite International Diagnostic Interview, a brief self-rated disability questionnaire (Brief Disability Questionnaire), and the interviewer-rated Social Disability Schedule. A telephone follow-up survey was completed 3 months later. Use of psychotropic drugs, use of mental health services, and direct health care costs were assessed by using the health plan's automated data systems. RESULTS: Approximately 10% of the primary care patients reported major current insomnia (e.g., taking at least 2 hours to fall asleep nearly every night). Current insomnia was associated with significantly greater functional impairment (according to both Brief Disability Questionnaire and Social Disability Schedule), more days of disability due to health problems, and greater general medical service utilization. While insomnia was associated with depressive disorder and chronic medical illness, adjustment for these factors only partially accounted for the association of insomnia with disability and with health care utilization. Of the patients with current insomnia, 28% received any psychotropic drug; 14% received benzodiazepines and 19% received antidepressants. CONCLUSIONS: Insomnia among primary care patients is associated with greater functional impairment, lost productivity, and excess health care utilization.

Adult↗