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Biomedical subjects

W Katon

Publications and source records attributed to W Katon.

At least 37 records · Page 2Linked to original sources
PubMed1999

Costs of health care use by women HMO members with a history of childhood abuse and neglect.

BACKGROUND: Early childhood maltreatment has been associated with adverse adult health outcomes, but little is known about the magnitude of adult health care use and costs that accompany maltreatment. We examined differences in annual health care use and costs in women with and without histories of childhood sexual, emotional, or physical abuse or neglect. METHODS: A random sample of 1225 women members of a health maintenance organization completed a 22-page questionnaire inquiring into childhood maltreatment experiences as measured by the Childhood Trauma Questionnaire. Health care costs and use data were obtained from the automated cost-accounting system of the health maintenance organization, including total costs, outpatient and primary care costs, and emergency department visits. RESULTS: Women who reported any abuse or neglect had median annual health care costs that were $97 (95% confidence interval, $0.47-$188.26) greater than women who did not report maltreatment. Women who reported sexual abuse had median annual health care costs that were $245 (95% confidence interval, $132.32-$381.93) greater than costs among women who did not report abuse. Women with sexual abuse histories had significantly higher primary care and outpatient costs and more frequent emergency department visits than women without these histories. CONCLUSION: Although the absolute cost differences per year per woman were relatively modest, the large number of women in the population with these experiences suggests that the total costs to society are substantial.

Adolescent↗
PubMed1999

Patterns of care for depressed older adults in a large-staff model HMO.

The authors examined automated pharmacy and visit data for 502 members of a large-staff model health maintenance organization (HMO) who had been diagnosed with depression and started on antidepressants by their primary-care providers. Older patients (age >/=60; n=110) were less likely than younger adults (age 18-59, n=110) to receive adequate doses of antidepressant medications for 30 or 90 days. Older adults were also less likely than younger adults to receive more than two primary-care visits for depression in the 12 weeks after receiving a new antidepressant prescription and were less likely to receive specialty mental health care in the 6 months after receiving a new antidepressant prescription.

Adolescent↗
PubMed1999

Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness.

There is a gap between the efficacy of treatments for late-life depression under research conditions and the effectiveness of treatments as they occur in the "real world" of primary care. Considerable evidence supports the efficacy of treatments for late-life depression, but many depressed older adults either are not recognized or do not receive effective treatment for depression in primary care. Older adults face a range of special treatment barriers: knowledge deficits; losses and social isolation; multiple medical problems; and lack of financial resources. More research is needed to understand these barriers and to study the effectiveness of multifaceted, population-based disease management interventions for late-life depression in primary care.

Aged↗
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

Panic disorder in the general medical setting.

There is a high prevalence of panic disorder in medical patients, as well as an association between panic disorder and high rates of utilization of medical services and excessive medical costs incurred from extensive medical workups. The association between panic disorder and specific cardiac, gastrointestinal, respiratory, and neurologic symptoms and disorders are described, and psychophysiological models attempting to account for the medical comorbidity associated with panic disorder are addressed. Finally, clinical trials investigating pharmacological and psychological interventions to treat the somatic symptoms with which patients with panic disorder often present are reviewed and critiqued, and productive avenues for further research on panic disorder in medical patients are recommended.

Comorbidity↗
PubMed1998

Longitudinal changes associated with improvement in chronic fatigue patients.

Tertiary care patients with chronic fatigue were followed for 2.5 years to determine if changes in physical and psychological status were associated with improvements in chronic fatigue, physical functioning, and return to work. Results indicated that improvement in psychological symptoms, DSM-III-R disorders, physical examination signs, and changes in whether the patient continued to meet criteria for chronic fatigue syndrome (CFS) were associated with recovery from fatigue, improved functioning, and return to work. Patients who never met CFS criteria or only met criteria at the initial assessment, reported improved physical functioning. Patients whose psychiatric disorders and physical examination signs were still present at a mean follow-up time of 2.5 years were more likely to have persistent fatigue and work disability. Loss of physical examination signs was a significant independent predictor of improved functioning and return to work. These results suggest that psychiatric status, as well as physical status, are associated with recovery from chronic fatigue.

Adult↗
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

The treated prevalence of bipolar disorder in a large staff-model HMO.

OBJECTIVE: The treated prevalence of bipolar disorder was examined in a large staff-model health maintenance organization (HMO) in western Washington state. METHODS: Automated data for all 294,284 adults enrolled in the HMO or treated by HMO providers were used to determine the number of patients treated for bipolar disorder between July 1, 1995, and June 30, 1996. Patients with bipolar disorder were identified using computerized records of inpatient diagnoses, outpatient visit diagnoses, and outpatient prescriptions of mood stabilizers. Validity of the identification procedure was confirmed by review of a random sample of outpatient records. RESULTS: The treated prevalence of bipolar disorder in the HMO was .42 percent. Somewhat higher treated-prevalence rates were found for women, younger enrollees, family members of HMO subscribers, enrollees in some of the individual plans within the HMO, and enrollees in the state's Basic Health Plan program for low-income residents. Of the 1,236 adults treated for bipolar disorder, 93 percent made at least one visit to specialty mental health services, and 86 percent received mood-stabilizing medications. Only a small percentage of the 1,236 patients received treatment with an antidepressant, an antipsychotic, or a benzodiazepine without having a mood stabilizer prescribed. CONCLUSIONS: The treated-prevalence rate found in this HMO population is higher than rates previously reported for prepaid health plans and lower than estimates from large population surveys. The majority of treated patients received specialty mental health services and treatment with mood-stabilizing medications.

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

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

Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study.

OBJECTIVE: To examine whether depressive symptoms in older adults contribute to increased cost of general medical services. DESIGN: A 4-year prospective cohort study. SETTING: Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash. PATIENTS: A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Non-participants were somewhat older and had a higher level of chronic medical illness. MAIN OUTCOME MEASURES: Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO. RESULTS: In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness. CONCLUSIONS: Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.

Aged↗
PubMed1997

Screening for psychiatric disorders in chronic fatigue and chronic fatigue syndrome.

Psychiatric disorders are common in chronic fatigue (CF) and chronic fatigue syndrome (CFS). To determine the usefulness of the General Health Questionnaire (GHQ), a self-report measure of psychological distress, in identifying those with psychiatric illnesses, a structured psychiatric interview and the GHQ were administered to 120 CF and 161 CFS patients seen in a referral clinic. Overall, 87 (35%) patients had a current and 210 (82%) a lifetime psychiatric disorder. Compared to patients without psychiatric disorders, GHQ scores above the threshold (> or = 12) were more frequent among patients with current (p < 0.001) and lifetime (p < 0.05) diagnoses; scores among patients with CF and CFS were similar. Longer illness duration, greater fatigue severity, and current psychiatric disorders were significant predictors of the GHQ score. In CF and CFS, the best sensitivity (0.69-0.76) and specificity (0.51-0.62) were achieved for current psychiatric diagnoses using a threshold score of > or = 12. Thus, patients scoring < 12 on the GHQ are significantly less likely to have a psychiatric disorder.

Adult↗
PubMed1997

Population-based care of depression: effective disease management strategies to decrease prevalence.

This paper reviews the concepts of population-based care and disease management of major depression. Population-based care and disease management strategies motivated by health care reform provide approaches for organizing health services to lower the prevalence of common medical and psychiatric illnesses in primary care populations. We apply these concepts to the organization of services for patients with major depression.

Cross-Sectional Studies↗
PubMed1997

Panic disorder and quality of life: variables predictive of functional impairment.

OBJECTIVE: The authors sought to characterize the functional impairment in patients with panic disorder, specifically the variance in impairment explained by demographic and clinical variables. METHOD: Sixty-two patients with panic disorder and 61 comparison subjects from three primary care clinic sites were assessed with an adapted form of the Structured Clinical Interview for DSM-III-R. Impairment was assessed according to three measures from the 36-item Short-Form Health Survey (general health perception, mental health, and physical functioning) as well as a principal component factor of the survey. Subjects were also compared with respect to personality variables, presence and severity of chronic medical illness, and demographic characteristics. Stepwise multiple regressions with and without pairwise interactions were used to construct models of disability in the patients with panic disorder. RESULTS: The patients with panic disorder were more impaired than comparison subjects on each measure of the Short-Form Health Survey. The panic disorder diagnosis combined with major depression, increasing neuroticism and age, less education, and an interaction between panic disorder and age accounted for 48%-77% of the variance in impairment scores. Gender and ethnicity contributed modestly to the variance in impairment in physical functioning, whereas no contribution was demonstrated for chronic medical illness or city of residence. CONCLUSIONS: Factors in addition to panic phenomena contribute to the severe impairment seen in patients with panic disorder. Further research about factors that affect impairment may help improve clinical approaches to this illness.

Adult↗
PubMed1997

The effect of panic disorder in the managed care setting.

Panic disorder is significantly overrepresented in the primary care setting, compared with the general population. Patients with panic disorder are expensive to treat because they tend to be high utilizers of health care and are more likely to suffer recurrent psychiatric and physical disorders, present with unexplained somatic symptoms, and attempt suicide. Most primary care physicians receive little training in accurately recognizing and effectively treating panic disorder. The overutilization of primary care services by, and frequent misdiagnosis of, patients with panic disorder indicates a need for managed care systems to develop guidelines for diagnosing and managing panic disorder.

Algorithms↗
PubMed1997

Collaborative management to achieve depression treatment guidelines.

Two models that integrate the psychiatrist into treatment of depression in primary care have been evaluated in randomized controlled trials. In the psychiatrist/primary care model, a psychiatrist alternated visits with a primary care physician to assist in the education and pharmacologic treatment of the patient. In the psychiatrist/psychologist team model, the psychiatrist worked with a team of psychologists to improve adherence to and effectiveness of antidepressant treatment, with psychologists also providing brief behavioral treatment in the primary care clinic. Findings with the psychiatry/primary care model are reported. It was found that the collaborative model was associated with improved adherence to treatment, increased patient satisfaction with depression care, and improved depression outcome compared with usual care by primary care physicians alone. Similar results were found in the study of the psychiatrist/psychologist collaborative care model. The success of these models indicates the appropriateness of a novel role for the psychiatrist and psychologist, i.e., that of collaboration with primary care physicians in care of the depressed patient in the primary care setting.

Antidepressive Agents↗