Will sharing uncertainty reduce physician effectiveness?
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Communication↗
Biomedical subjects
G E Simon
Publications and source records attributed to G E Simon.
Depression in medical patients.
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Cross-Sectional Studies↗
Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis.
OBJECTIVES: To identify psychiatric differences between patients with chronic fatigue and those with rheumatoid arthritis and to investigate whether patients meeting Centers for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS) can be differentiated from patients with chronic fatigue on measures of disability and psychosocial distress. DESIGN: Cross-sectional study comparing 98 patients with chronic fatigue with 31 patients with rheumatoid arthritis on structured psychiatric interviews and patient questionnaires. Nineteen patients meeting CDC criteria for CFS were compared with 79 patients with chronic fatigue not meeting CDC criteria on questionnaires measuring disability and psychosocial distress. SETTING: Consecutive patients with chronic fatigue were selected from a chronic fatigue clinic at the University of Washington, and 31 consecutive patients with rheumatoid arthritis were sampled from a private rheumatology practice. MAIN RESULTS: Patients with chronic fatigue had a significantly higher prevalence of lifetime major depression and somatization disorder than did patients with rheumatoid arthritis. Patients with chronic fatigue also had a significantly higher prevalence of current and lifetime psychiatric diagnoses. Only 19 of 98 patients with chronic fatigue met CDC criteria for CFS. Patients meeting CDC criteria for CFS could not be differentiated from the larger group of patients with chronic fatigue on any study variable. CONCLUSIONS: Patients with chronic fatigue have a significantly higher burden of psychiatric illness than do patients with rheumatoid arthritis. The psychiatric illness preceded the development of chronic fatigue in over half the patients. Centers for Disease Control criteria for CFS did not select a subset of chronic fatigue patients who could be differentiated on disability or psychosocial parameters from patients with chronic fatigue who did not meet CDC criteria.
Adult↗
Panic disorder and misdiagnosis of mitral valve prolapse.
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Diagnosis, Differential↗
Telephone assessment of depression severity.
This report describes the adaptation of three common measures of depression severity, the Hamilton Depression Rating Scale, the Structured Clinical Interview for DSM-III-R, and selected items of the Symptom Checklist-90 for follow-up assessment by telephone. In a sample of 30 patients beginning antidepressant treatment, telephone and in-person assessment of current symptom severity produced nearly identical results for all three instruments.
Adult↗
Research diagnosis of current depressive disorder: a comparison of methods using current symptoms and lifetime history.
Data from the WHO international study of Psychological Problems in General Health Care were used to compare two alternative algorithms for diagnosing current major depression using the Composite International Diagnostic Interview: the traditional method based on lifetime diagnosis and an alternative method based on number of current symptoms. Using DSM-IV criteria for current major depression, 6.2% of 5394 primary care patients were diagnosed by both methods, 2.0% by the lifetime-based method only, and 1.9% by the current symptom method only. Measures of severity (current symptoms, lifetime symptoms, disability, and comorbid anxiety) indicated that those diagnosed by only one method were only slightly less ill than those diagnosed by both. While the symptom-based method identifies a slightly more ill group, use of either method alone may exclude many who differ little from those classified as cases.
Adult↗
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↗
Recovery from depression, work productivity, and health care costs among primary care patients.
We describe a secondary analysis of data from a randomized trial conducted at seven primary care clinics of a Seattle area HMO. Adults with major depression (n=290) beginning antidepressant treatment completed structured interviews at baseline, 1, 3, 6, 9, 12, 18, and 24 months. Interviews examined clinical outcomes (Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-IIIR), employment status, and work days missed due to illness. Medical comorbidity was assessed using computerized pharmacy data, and medical costs were assessed using the HMO's computerized accounting data. Using data from the 12-month assessment, patients were classified as remitted (41%), improved but not remitted (47%), and persistently depressed (12%). After adjustment for depression severity and medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain paid employment (P=.007) and reported fewer days missed from work due to illness (P<.001). Patients with better 12-month clinical outcomes had marginally lower health care costs during the second year of follow-up (P=.06). We conclude that recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs. Although observational data cannot definitively prove any causal relationships, these longitudinal results strengthen previous findings regarding the economic burden of depression on employers and health insurers.
Adolescent↗
Course of hypochondriasis in an international primary care study.
Hypochondriasis is frequently defined as a chronic condition distinct from anxiety and depressive disorders. Consecutive primary care attenders (n=25,916) were screened using the General Health Questionnaire and a stratified random sample (n=5447) completed a baseline diagnostic assessment. All patients with significant psychiatric symptoms and a random sample of remaining patients (n=3201) were asked to complete a follow-up diagnostic assessment 12 months later. Of patients meeting an abridged definition of hypochondriasis at baseline, 18% continued to do so at follow-up and an additional 16% continued to report hypochondriacal worries. 45% of those with hypochondriasis at follow-up also met criteria for DSM-IV anxiety or depressive disorder. Follow-up anxiety or depressive disorder was significantly associated with both onset and persistence of hypochondriasis. Hypochondriasis is moderately stable over time. The clear distinction between hypochondriasis and anxiety/depressive disorders suggested by ICD-10 and DSM-IV may be difficult to accomplish in practice.
Adolescent↗
Outcomes of recognized and unrecognized depression in an international primary care study.
Longitudinal data from the World Health Organization Psychological Problems in General Health Care study were used to examine the relationship between recognition and outcomes among depressed primary care patients. A representative sample of primary care patients at 15 sites completed a baseline assessment including the Composite International Diagnostic Interview (CIDI), the 28-item General Health Questionnaire (GHQ), and the Brief Disability Questionnaire (BDQ). The GHQ and BDQ were readministered after 3 months, and the GHQ, BDQ, and CIDI were readministered after 12 months. Of 948 patients with major depression at the baseline assessment, 42% were recognized by the primary care physician and given an appropriate diagnosis. Recognized patients were more severely ill (mean GHQ score 16.2 vs. 12.9, t = 5.44, p < 0.001) and more disabled (mean BDQ score 9.8 vs 8.2, t = 3.22, p < 0.001) at baseline. Recognized patients showed a significantly greater decrease in GHQ score at the 3-month assessment (6.1 vs 4.1, F = 5.33, df = 1, p = 0.02). At 12 months, recognized and unrecognized groups did not differ in either change in GHQ score or change in diagnostic status from baseline. Results were consistent across study sites. Our data suggest that recognition and appropriate diagnosis of depression in primary care is associated with significantly greater short-term improvement. The absence of a relationship between recognition and long-term outcomes may reflect limitations of this observational study. When considered along with other recent studies, these findings suggest that increasing recognition of depression in primary care is only a first step toward more appropriate treatment.
Adult↗
Lessons from recent research on depression in primary care.
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Depression↗
Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression.
OBJECTIVE: The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. STUDY DESIGN: Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trail (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. RESULTS: Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression. Collaborative Care was more costly and not more cost-effective than Usual Care. CONCLUSIONS: Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.
Adult↗
Depression in the workplace: effects on short-term disability.
We analyzed data from two national surveys to estimate the short-term work disability associated with thirty-day major depression. Depressed workers were found to have between 1.5 and 3.2 more short-term work-disability days in a thirty-day period than other workers had, with a salary-equivalent productivity loss averaging between $182 and $395. These workplace costs are nearly as large as the direct costs of successful depression treatment, which suggests that encouraging depressed workers to obtain treatment might be cost-effective for some employers.
Absenteeism↗
Depression and panic attacks related to phenol-formaldehyde composite material exposure in an aerospace manufacturing plant.
In a case series study we evaluated 53 composite-materials workers in an aerospace plant who filed workers' compensation claims for illness allegedly related to phenol-formaldehyde resin exposure. Symptoms ranged from mucosal and skin irritation to depression and cognitive impairment. Certain health practitioners implying they had immunologic dysfunction and organic brain injury, led workers to believe they were chemically poisoned. Industrial hygiene evaluation failed to show levels of chemicals above permissible levels. Thorough evaluation by our multidisciplinary panel failed to find significant objective abnormalities by physical exam and laboratory testing. Thirty-nine percent of the workers had sensory irritation and/or skin complaints that generally resolved rapidly with removal from exposure. Psychiatric diagnoses (including major depression and/or panic attacks) were made in 74% of the workers, but only 26% of these had antecedent disease. Fourteen (26%) had multiple somatic complaints that generally persisted despite removal from exposure, but they also had long histories of significant pre-existing psychological illness. Detailed neuropsychologic testing failed to show any definite evidence or organic brain dysfunction in any of the workers tested. We speculate that sensory irritation from low-level volatile organic compounds with autonomic arousal, reinforced by the belief they were "chemically poisoned," led to psychogenic illness.
Aircraft↗
Case report: Unusual location of Dirofilaria immitis in a 28-year-old man necessitates orchiectomy.
The fourth case of zoonotic Dirofilaria immitis infection in a California resident is reported. This case was unique in that it involved the spermatic cord, produced significant symptoms, and upon physical examination was suspected of being an incarcerated inguinal hernia. At surgery frozen sections were inconclusive regarding neoplasia and cord involvement precluded removal of the mass without orchiectomy, which was done. Histopathology revealed a well-preserved immature male D. immitis, the canine heartworm, in a branch of the spermatic artery. The morphological identification of the worm was confirmed by polymerase chain reaction (PCR) studies. This case illustrates that D. immitis infections can complicate differential diagnosis of extrapulmonary lesions and suggests that the public health significance of this vector-borne filarial worm needs to be evaluated through appropriate epidemiological studies in enzootic areas.
Adult↗
Psychiatric treatments in multiple chemical sensitivity.
Despite the controversy and uncertainty surrounding the causes of the MCS syndrome, psychiatric treatments may provide some relief to MCS patients. These approaches may help patient and physician focus on the most important goals: relief of symptoms and improvement of function. Success requires that physician and patient establish a collaborative relationship and negotiate a treatment plan. Behavioral treatments are most effective at reducing disability and promoting a return to active life. When directed at appropriate target symptoms, psychopharmacologic treatments may reduce some of the most distressing symptoms of chemical sensitivity.
Anti-Anxiety Agents↗
Epidemic multiple chemical sensitivity in an industrial setting.
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Depression↗
Psychiatric symptoms in multiple chemical sensitivity.
Neuropsychiatric symptoms are among the most prominent manifestations of generalized chemical sensitivity. Patients, clinicians, and researchers are in agreement that symptoms such as depression, irritability, and mood instability are prominent among the distressing and disabling symptoms occurring in response to low-level chemical exposure. Beyond that point, however, agreement is difficult. The pathophysiology and clinical management of these symptoms remain quite controversial. This paper will review available data on the prevalence and form of psychiatric symptoms among those suffering from multiple chemical sensitivity. Various models explaining the relationship of psychiatric symptoms to chemical sensitivity will be discussed. Finally, the implications of these models for clinical management and future research will be reviewed.
Humans↗