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Biomedical subjects

G E Simon

Publications and source records attributed to G E Simon.

At least 73 records · Page 4Linked to original sources
PubMed1994

Predictors of outpatient mental health utilization by primary care patients in a health maintenance organization.

OBJECTIVE: The authors examined the volume and predictors of outpatient mental health utilization among primary care patients in a large staff-model health maintenance organization (HMO). METHOD: Consecutive primary care patients (N = 1,810) were screened by using the 12-item General Health Questionnaire, and a stratified random sample (N = 373) completed the 28-item General Health Questionnaire and Composite International Diagnostic Interview. Telephone interviews and computerized records were used to examine use of mental health services inside and outside the HMO over the following 3 months. RESULTS: Over 3 months, 6.7% of the screened patients used mental health services within the HMO. Utilization increased with higher General Health Questionnaire score (2.9% among those scoring 0, 22.3% among those scoring 8 or more) and decreased with higher out-of-pocket cost for mental health visits (7.5% for those with no change, 3.3% for those paying $30/visit). Among the interviewed subjects, 5.1% used mental health services within the HMO (mean = 2.92 visits) and 8.9% used outside mental health services (mean = 8.86 visits). Use of outside services was more strongly related to sociodemographic factors, and use of inside services was more related to severity of psychological disorder. CONCLUSIONS: Among these subjects, use of mental health care was high and services purchased outside the HMO exceeded those inside the HMO. Increasing copayment levels progressively reduced demand without respect to severity of illness. Attempts to control outpatient mental health costs must address equity and clinical need.

Adolescent↗
PubMed1994

Multiple chemical sensitivity syndrome: a clinical perspective. I. Case definition, theories of pathogenesis, and research needs.

Multiple chemical sensitivity syndrome (MCS) does not appear to fit established principles of toxicology. Yet social, political, and economic forces are demanding that MCS be defined medically, even though to date scientific studies have not identified pathogenic mechanisms for the condition or any objective diagnostic criteria. Consequently, a working definition of MCS can rely only on an individual's subjective symptoms of distress and attribution to environmental exposures rather than currently measurable objective evidence of disease. Nevertheless, patients labeled with MCS are clearly distressed and many are functionally disabled. In this review, four theories of causation are explored: (1) MCS is a purely biologic/physical or psychophysiologic reaction to low-level chemical exposures. (2) MCS symptoms may be elicited by low-level environmental chemical exposures, but the sensitivity is initiated by psychologic stress. (3) MCS is a misdiagnosis and chemical exposure is not the cause. The symptoms may be due to misdiagnosed physical or psychologic illness. (4) MCS is an illness belief system manifest by culturally shaped illness behavior. Areas for further research regarding the etiologies of MCS are suggested. Recognizing that the cause of the syndrome may be multifactorial, strategies are proposed for clinical evaluation and management in Part II of this manuscript using a biopsychosocial model of illness.

Humans↗
PubMed1994

Multiple chemical sensitivity syndrome: a clinical perspective. II. Evaluation, diagnostic testing, treatment, and social considerations.

Multiple chemical sensitivity syndrome (MCS) does not appear to fit established principles of toxicology. Social, political, and economic forces are demanding that MCS be defined medically, even though scientific studies have failed as yet to identify pathogenic mechanisms for the condition or any objective diagnostic criteria. Consequently, a working definition of MCS can only rely on a person's subjective symptoms of distress and attribution to environmental exposures rather than currently measurable objective evidence of disease. Nevertheless, patients labeled with MCS are clearly distressed and many are functionally disabled. Without reconciling the different theories of etiology of MCS discussed in Part I of this report, and recognizing that the cause of the syndrome may be multifactorial, strategies are proposed for clinical evaluation and management of patients with MCS using a biopsychosocial model of illness. The social implications of this illness are also discussed.

Health Policy↗
PubMed1993

Immunologic, psychological, and neuropsychological factors in multiple chemical sensitivity. A controlled study.

OBJECTIVE: To examine the role of immunologic, psychological, and neuropsychological factors in multiple chemical sensitivity. DESIGN: Case-control comparison. SETTING: Community allergy practice (cases), university-based clinics for musculoskeletal injuries (controls). PARTICIPANTS: Forty-one patients with chemical sensitivity and 34 control patients with chronic musculoskeletal injuries. MAIN OUTCOME MEASURES: Immunologic measures included autoantibody titers, lymphocyte surface markers, and interleukin-1 generation by monocytes. Psychological evaluation included standardized measures of anxiety, depression, and somatization. RESULTS: Immunologic testing did not differentiate patients with chemical sensitivity from controls. The only difference noted (lower interleukin-1 generation among cases) appeared attributable to laboratory methods. Patients with chemical sensitivity reported greater prevalence of current anxiety or depressive disorder (44% versus 15%, P = 0.006). This difference, however, did not appear to precede the onset of chemical sensitivity, and 25% of chemically sensitive patients showed no significant current psychological disturbance. Cases reported significantly more "medically unexplained" physical symptoms before and after the onset of chemical sensitivity. When considering only symptoms that preceded chemical sensitivity, 25% of cases (and no controls) satisfied criteria for somatization disorder. Neuropsychological testing revealed no significant case-control differences. CONCLUSIONS: Immunologic testing failed to confirm findings from earlier uncontrolled studies, militating against proposed immunologic mechanisms. The decreased memory and concentration frequently described in multiple chemical sensitivity were not confirmed by brief neuropsychological testing. Psychological symptoms, although not necessarily etiologic, are a central component of chemical sensitivity.

Adult↗
PubMed1993

Patterns of antidepressant use in community practice.

Computerized pharmacy records from a large staff-model health maintenance organization were used to examine patterns of antidepressant use by primary care physicians and psychiatrists. Based on timing of prescription refills, patients treated by psychiatrists were more likely than those treated in primary care to continue medication for more than 30 days (35% vs 25%, p < 0.00001) and more likely to reach a prescribed daily dose of 100 mg of imipramine or the equivalent (48% vs 40%, p < 0.00001). Patients treated with newer antidepressants were significantly more likely to continue treatment past 30 days (range from 75% for fluoxetine to 54% for doxepin, p < 0.00001) and to reach an adequate daily dose (range from 51% for fluoxetine to 26% for doxepin, p < 0.00001). Psychiatrists more often prescribed newer antidepressants, and much of the difference between specialties could be explained by drug selection. These findings suggest more intensive antidepressant treatment than in earlier reports, especially in primary care. More intensive treatment with newer antidepressants may reflect more tolerable side effects, but these observational data are liable to selection bias. Any potential advantages of newer antidepressant medications must be balanced against significantly higher costs.

Adolescent↗
PubMed1992

Reevaluation of secular trends in depression rates.

Results of numerous community surveys of psychiatric illness suggest a striking change in the occurrence of depression, with younger generations experiencing higher lifetime risk and earlier age of onset. Data from the National Institute of Mental Health Epidemiologic Catchment Area Survey (a cross-sectional survey of psychiatric morbidity in five US communities conducted between 1980 and 1984) were reexamined for evidence of methods effects which might contribute to these unexpected findings. A pattern of higher lifetime risk and earlier age of onset among recent birth cohorts was observed for every psychiatric disorder examined, with schizophrenia, major depression, and panic disorder showing equally strong trends. For respondents of all ages, reported first onset of major depression clustered in the 10-year period prior to the study interview, in contrast to the expectation that older respondents would report onset in early adulthood. Examination of individual psychiatric symptoms revealed a nearly universal pattern of decreasing lifetime prevalence among older respondents, a reversal of the expected accumulation of lifetime symptoms with age. These findings suggest that effects of study methods may contribute to the apparent temporal trends in prevalence of depression and that cross-sectional surveys may underestimate lifetime psychiatric morbidity among older respondents. Generational changes in the lifetime risk of depression or other psychiatric disorders may not be reliably assessed by cross-sectional survey data.

Adolescent↗
PubMed1992

Psychiatric disorder and functional somatic symptoms as predictors of health care use.

Data from Wave 1 of the National Institute of Mental Health Epidemiologic Catchment Area study were used to examine how functional somatic symptoms and other psychiatric disorders relate to use of health care. Panic disorder and functional somatic symptoms were strongly linked to use of general medical services while depression showed such a relationship only among females. Panic disorder and depression also showed strong association with use of mental health services, but functional somatic symptoms showed only a weak relationship. Multivariable models suggest that functional somatic symptoms lead to selective use of general medical services over mental health services.

Adult↗
PubMed1991

Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study.

OBJECTIVE: Somatization has often been viewed as a defense against awareness of emotional distress or as a masked version of depression. This report examines whether community residents with high levels of functional somatic symptoms also report overt psychological distress and whether somatization is associated with any specific psychiatric disorder. METHOD: Analyses used data from the community sample of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study, a population-based survey of psychiatric morbidity among more than 18,000 residents of five U.S. communities. RESULTS: Increasing number of somatization symptoms was strongly associated with overt expression of psychological distress and psychiatric symptoms. Among ECA respondents with five or more current functional somatic symptoms, 63% reported current psychological symptoms and 50% met criteria for a current psychiatric diagnosis (compared to 7% and 6%, respectively, among those with no current somatization symptoms). Somatization symptoms showed strongest associations with anxiety and depressive symptoms, intermediate association with symptoms of psychotic disorders, and weakest associations with symptoms of substance abuse and antisocial personality. CONCLUSIONS: ECA study respondents with high levels of somatization symptoms typically reported overt psychological distress, especially anxiety and depression. Patterns of response do not support a dissociation between physical and emotional symptoms. Functional somatic symptoms appear to be common expressions of distress instead of defenses against awareness.

Adolescent↗
PubMed1990

Allergic to life: psychological factors in environmental illness.

Environmental illness is an increasingly frequent and medically unexplained syndrome of "allergy" to common environmental agents. A recent outbreak of chemical-induced illness allowed study of psychological factors in environmental illness. Thirty-seven symptomatic plastics workers completed structured diagnostic interviews and self-report measures of somatization and psychopathology. The 13 subjects who developed environmental illness scored higher on all measures than those who did not. The greatest differences were in prior history of anxiety or depressive disorder (54% versus 4%) and number of medically unexplained physical symptoms before exposure (6.2 versus 2.9). These findings suggest that psychological vulnerability strongly influences chemical sensitivity following chemical exposure.

Anxiety Disorders↗
PubMed1990

An outbreak of illness among aerospace workers.

A multispecialty panel of physicians evaluated a case series of 53 composite-materials workers in a large aircraft manufacturing facility who filed workers' compensation claims for illness labeled by the media as the "aerospace syndrome." Possible skin and respiratory tract exposures included formaldehyde, phenol, particulates, epoxy resins, and trace organic solvents, but measured concentrations were well below all regulatory and consensus standards. Most workers had histories of transient skin or respiratory tract irritation consistent with the known potential toxicity of these materials. None of the workers tested had immunoglobulin IgG or IgE antibodies to human serum albumin complexed with formaldehyde. A majority (74%) met DSM-III-R [Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised] criteria for major depression, panic disorder, or both. Most of these psychiatric disorders were of a recent onset, correlating in time with the use of phenol- and formaldehyde-impregnated composite material. Psychosocial factors were thought to have played a major role in the high prevalence of illness in this group and should be evaluated directly in well-controlled epidemiologic studies of similar crisis-building situations in the future.

Air Pollutants, Occupational↗
PubMed1975

The measurement of free erythrocyte porphyrin (FEP) as a simple means of distinguishing iron deficiency from beta-thalassemia trait in subjects with microcytosis.

Assay of free erythrocyte porphyrin (FEP) and measurement of red cell indices were obtained in a group of subjects with iron deficiency and beta-thalassemia trait to determine if these studies cound detect these disorders and discriminate bbetween them. FEP values were increased in 90.2 per cent of subjects with iron deficiency but were within the normal range in 96.6 per cent of subjects with beta-thalassemia trait. Mean FEP values increased sligtly as transferrin saturation fell but became abnormally elevated when the transferrin saturation fell but became abnormally elevated when the transferrin saturation was less than 15 per cent. Unlike subjecs with iron deficiency in whom the mean corpuscular volume varied from 46 to 84, all individuals with beta-thalassermia trait exhibited microcytosis. In most instances, determination of FEP appears to distinguish beta-thalassemia trait from iron deficiency in patients with microcytosis.

Anemia, Hypochromic↗
PubMedDate not supplied

Relapse of depression in primary care. Rate and clinical predictors.

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

Long-term outcomes of initial antidepressant drug choice in a "real world" randomized trial.

OBJECTIVE: To compare the long-term clinical, quality-of-life, and economic outcomes after an initial prescription for fluoxetine, imipramine hydrochloride, or desipramine hydrochloride. DESIGN: Randomized, controlled trial. SETTING: Primary care clinics of a staff-model health maintenance organization in the Seattle, Wash, area. PATIENTS: Four hundred seventy-one adults beginning antidepressant drug treatment for depression. INTERVENTION: Random assignment of initial medication (desipramine, fluoxetine, or imipramine), with treatment (dosing, medication changes or discontinuation, and follow-up visits) managed by a primary care physician. MEASUREMENTS: Interviews at baseline and at 6, 9, 12, 18, and 24 months examined medication use, clinical outcomes (Hamilton Depression Rating Scale and depression subscale of the Hopkins Symptom Checklist), and quality of life (Medical Outcomes Study SF-36 Health Survey). Medical costs were assessed using the health maintenance organization's accounting data. RESULTS: Patients assigned to fluoxetine therapy were significantly more likely to continue taking the initial antidepressant but no more likely to continue any antidepressant therapy. The fluoxetine group did not differ significantly from either tricyclic drug group on any measure of depression severity or quality of life. For 24 months, antidepressant drug costs were approximately $250 higher for patients assigned to fluoxetine therapy, but total medical costs were essentially identical. CONCLUSIONS: Initial selection of fluoxetine or a tricyclic antidepressant drug should lead to similar clinical outcomes, functional outcomes, and overall costs. Differences in antidepressant prescription costs are blunted by the large minority of tricyclic-treated patients who switch to use of more expensive medications. Restrictions on first-line use of fluoxetine in primary care will probably not reduce overall treatment costs.

Adrenergic Uptake Inhibitors↗
PubMedDate not supplied

Can depression treatment in primary care reduce disability? A stepped care approach.

OBJECTIVE: To assess effects of stepped collaborative care depression intervention on disability. DESIGN: Randomized controlled trial. SETTING: Four primary care clinics of a large health maintenance organization. PATIENTS: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication. INTERVENTION: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes. MAIN OUTCOME MEASURES: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94). CONCLUSIONS: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058

Data Collection↗