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Biomedical subjects

W Katon

Publications and source records attributed to W Katon.

At least 55 records · Page 3Linked to original sources
PubMed1997

Generalized anxiety disorder in primary care: the precursor/modifier pathway to increased health care utilization.

Generalized anxiety disorder (GAD) is commonly seen in the primary care setting and is associated with disability, medically unexplained symptoms, and over utilization of health care resources. The authors review the rare occurrence of GAD uncomplicated by other psychiatric illness and the important relationship between GAD and depression. They suggest that GAD may exert its major effect on health care utilization not by a direct path, but by acting as a precursor or concurrent modifier of other psychiatric disorders that more directly affect health care costs.

Anxiety Disorders↗
PubMed1997

The education of depressed primary care patients: what do patients think of interactive booklets and a video?

BACKGROUND: Clinicians, policy makers, and health care administrators are attempting to improve depression outcomes in the primary care setting. Despite positive evidence about the efficacy of self-help materials and psychoeducational interventions, use of educational materials designed for the primary care patient are receiving little attention in present depression initiatives. The present study describes the use and evaluation of three educational materials by depressed primary care patients. METHODS: As a part of a randomized control trial, depressed primary care patients were identified by primary care physicians and randomized to a clinical trial exploring a new method of treating depression. Patients assigned to the new method of treatment received a package of educational materials at the time of the baseline interview. These materials included two brief interactive booklets (medication booklet, behavioral health booklet) and a short video. The present analysis concerns data obtained from 108 intervention patients in a telephone survey conducted 1 week after they received the package of educational materials. RESULTS: Approximately three quarters of the subjects reported that they read or viewed all of the educational products. The majority rated the products as somewhat to significantly helpful: medication booklet 81%; behavioral health booklet 82%; and video 69%. Previously reported results include findings of significantly better medication adherence and improved clinical outcomes by patients with major depression who received a primary care intervention that included the educational products discussed in this paper. CONCLUSIONS: Educational materials may play a significant role in improving depression treatment outcomes in the primary care setting.

Adaptation, Psychological↗
PubMed1996

Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants.

OBJECTIVE: To compare the clinical, functional, and economic outcomes of initially prescribing fluoxetine with outcomes of initially selecting imipramine or desipramine. DESIGN: Randomized controlled trial. SETTING: Primary care clinics of a Seattle, Wash, area staff-model health maintenance organization from 1992 through 1994. PATIENTS: A total of 536 adults beginning antidepressant treatment for depression. INTERVENTION: Random assignment of initial antidepressant prescription (desipramine, fluoxetine, or imipramine). Subsequent antidepressant treatment (doses, medication changes or discontinuation, specialty referral) was managed by the primary care physician. MAIN OUTCOME MEASURES: Assessments after 1, 3, and 6 months examined clinical outcomes (Hamilton Depression Rating Scale and the depression subscale of the Hopkins Symptom Checklist) and quality-of-life outcomes (Medical Outcomes Study SF-36). Medication use and health care costs were assessed using the health maintenance organization's computerized data. RESULTS: Patients assigned to receive fluoxetine reported fewer adverse effects, were more likely to continue the original medication, and were more likely to reach adequate doses than patients beginning treatment with either tricyclic drug. The fluoxetine group reported marginally better clinical outcomes after 1 month, but these differences were not statistically significant and disappeared by the 3-month assessment. Quality-of-life outcomes in the 3 groups did not differ. Total health care costs over 6 months were approximately equal for the 3 groups, with higher antidepressant costs in the fluoxetine group balanced by lower outpatient visit and inpatient costs. CONCLUSIONS: Clinical outcomes, quality-of-life outcomes, and overall treatment costs provide no clear guidance on initial selection of fluoxetine or tricyclic drugs. Thus, patients' and physicians' preferences are an appropriate basis for treatment selection.

Adult↗
PubMed1996

A multifaceted intervention to improve treatment of depression in primary care.

BACKGROUND: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. METHODS: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. RESULTS: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. CONCLUSION: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Adult↗
PubMed1996

The DSM-IV panic disorder field trial: panic attack frequency and functional disability.

The goal of the DSM-IV panic disorder field trial was to provide an empirical basis for choosing between alternate proposals (DSM-III-R and proposed DSM-IV) for the diagnostic threshold for panic disorder, in particular the number and frequency of panic attacks required for diagnosis. The two criteria sets were compared with respect to their ability to identify individuals whose panic attacks were associated with distress, impairment, or help-seeking. Subjects were a convenience sample screened in three geographically diverse primary care clinics for presence (past 6 months) or absence (lifetime) of panic attacks. Each underwent a clinician-administered semistructured interview which included assessment of panic frequency, panic-related impairment, psychiatric diagnosis, health services utilization, and medical illness. Self-perceived health-related quality of life was assessed using the Medical Outcome Study SF-36 Health Survey Questionnaire. Although both proposals diagnosed the same proportion of panic-impaired individuals, they were not completely overlapping. Twenty percent of subjects diagnosed by each criteria set were excluded by the other. Subjects who had been excluded by the DSM-III-R but included by the DSM-IV proposal were those with fewer than 4 attacks in 4 weeks who also denied worry about the "next" attack. Broadening the worry criterion to include concerns about the health implications of attacks enabled diagnosis of this group. Subjects who met DSM-III-R, but not the proposed DSM-IV criteria, had 4 attacks in 4 weeks but denied any panic related worry. Modification of the DSM-IV proposal to include a month of worry or "a significant change in behavior related to the attacks" allowed inclusion of this group in the diagnostic category. These data suggest that the finalized DSM-IV panic disorder criteria will diagnose a greater proportion of individuals whose panic attacks are associated with impairment without inflating the diagnostic category or significantly reducing specificity.

Adult↗
PubMed1996

Functional status in patients with chronic fatigue syndrome, other fatiguing illnesses, and healthy individuals.

BACKGROUND: Chronic fatigue syndrome (CFS) is a condition that may be associated with substantial disability. The Medical Outcomes Study Short-Form General Health Survey (SF-36) is an instrument that has been widely used in outpatient populations to determine functional status. Our objectives were to describe the usefulness of the SF-36 in CFS patients and to determine if subscale scores could distinguish patients with CFS from subjects with unexplained chronic fatigue (CF), major depression (MD), or acute infectious mononucleosis (AIM), and from healthy control subjects (HC). An additional goal was to ascertain if subscale scores correlated with the signs and symptoms of CFS or the presence of psychiatric disorders and fibromyalgia. DESIGN: Prospectively collected case series. SETTING: Patients with CFS and CF were seen in a university-based referral clinic and had undergone a complete medical and psychiatric evaluation. Other study subjects were recruited from the community to participate in research studies. PARTICIPANTS: The study included 185 patients with CFS, 246 with CF, 111 with AIM, and 25 with MD. There were 99 HC subjects. MEASURES: The SF-36 and a structured psychiatric interview were used. The SF-36 contains 8 subscales: physical, emotional, social, and role functioning, body pain, mental health, vitality, and general health- and a structured psychiatric interview. RESULTS: Performance characteristics (internal reliability coefficients, convergent validity) of the SF-36 were excellent. A strikingly consistent pattern was found for the physical functioning, role functioning, social functioning, general health, and body pain subscales, with the lowest scores in CFS patients, intermediate scores in AIM patients, and the highest scores in the HC subjects. The CFS patients had significantly lower scores than patients with CF alone on the physical functioning (P < or = 0.01), role functioning (P < or = 0.01), and body pain (P < or = 0.001) subscales. The emotional functioning and mental health scores were worst among those with MD. The presence of fibromyalgia, being unemployed, and increasing fatigue severity all were associated with additional functional limitations across multiple functional domains, with increasing fatigue appearing to have the greatest effect. CONCLUSIONS: The SF-36 is useful in assessing functional status in patients with fatiguing illnesses. Patients with CFS and CF have marked impairment of their functional status. The severity and pattern of impairment as documented by the SF-36 distinguishes patients with CFS and CF from those with MD and AIM, and from HC, but does not discriminate between CF and CFS.

Adult↗
PubMed1996

Panic disorder and medical comorbidity: a review of the medical and psychiatric literature.

Epidemiological studies have found significant comorbidity between panic disorder and many medical illnesses. The authors discuss the accumulating psychiatric and medical literature addressing comorbidity between panic disorder and cardiac, respiratory, gastrointestinal, and neurological illnesses. Cardiac symptoms such as chest pain and palpitations, as well as certain disorders such as mitral valve prolapse, hypertension, and cardiomyopathy, share significant comorbidity with panic disorder. Researchers have also shown significant comorbidity between panic disorder and chronic obstructive pulmonary disease, irritable bowel syndrome, and migraine headache. Pathophysiological mechanisms that may explain the association between panic disorder and comorbid medical illnesses, such as autonomic dysregulation of cardiac activity and smooth muscle tone and dynamic abnormalities of the coronary microvasculature, are discussed as well.

Adult↗
PubMed1996

Panic disorder: relationship to high medical utilization, unexplained physical symptoms, and medical costs.

Epidemiologic surveys and retrospective studies in the primary care setting have demonstrated that panic disorder is a primary cause of morbidity and increased utilization of medical services. Half of all visits to a primary care provider are precipitated by the somatic symptoms that are often associated with this anxiety disorder, including chest pain, dyspnea, tachycardia, dizziness, and abdominal discomfort. Since many of these symptoms resemble those of clinical diseases, patients frequently undergo extensive and costly diagnostic procedures to rule out conditions such as coronary artery disease, inflammatory bowel disorder, and asthma. Persistent, unexplained medical symptoms not only place an undue financial burden on outpatient services and hospitals, but also have a negative impact on social and vocational function. The primary care physician is in a unique position to recognize patients who may be at risk for panic disorder and to initiate appropriate treatment, preventing prolonged functional impairment and unnecessary cost to the patient and the health care system.

Adult↗
PubMed1995

Collaborative management to achieve treatment guidelines. Impact on depression in primary care.

OBJECTIVE: To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician. DESIGN: A randomized controlled trial among primary care patients with major depression or minor depression. PATIENTS: Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression. INTERVENTIONS: Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials. MAIN OUTCOME MEASURES: Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms. RESULTS: In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P < .01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < .03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < .001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P < .02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time. CONCLUSION: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression.

Adult↗
PubMed1995

Outcomes of "inadequate" antidepressant treatment.

OBJECTIVE: To examine outcomes of primary care patients receiving low levels of antidepressant treatment. DESIGN: Cohort study comparing patients receiving anti-depressant treatment within and below the recommended dosing range. SETTING: Primary care clinics of a staff-model health maintenance organization. PATIENTS: Primary care patients initiating antidepressant treatment for depression. MEASUREMENTS AND MAIN RESULTS: Of 88 patients beginning antidepressant treatment, 49 (56%) used "adequate" doses for 30 days or more. Likelihood of "adequate" pharmacotherapy was not related to patient age, gender, medical comorbidity, or baseline depression severity. All the patients showed substantial clinical improvement after four months. Compared with those using "adequate" pharmacotherapy, the patients receiving low-intensity treatment had lower likelihood of clinical response (64% vs 84%; chi-square = 4.44; df = 1; p = 0.035). At four months, however, those receiving low-intensity and those receiving higher-intensity treatment did not differ significantly in either the score on the 20-item Symptom Checklist depression scale (18.91 and 15.72, respectively; F = 1.45; df = 1.86; p = 0.23) or the proportion with persistence of major depression (10% and 4%, respectively; chi-square = 1.30; df = 1; p = 0.25). A replication sample of 157 patients (assessed only at baseline and four months) yielded similar results. CONCLUSIONS: While the patients receiving recommended levels of pharmacotherapy showed somewhat higher improvement rates, many of the patients receiving "inadequate" treatment experienced good short-term outcomes. Efforts to increase the intensity of depression treatment in primary care should focus on the subgroup of patients who fail to respond to initial treatment.

Adult↗
PubMed1995

Chronic fatigue: risk factors for symptom persistence in a 2 1/2-year follow-up study.

BACKGROUND: The prolonged disability of patients suffering from chronic fatigue may be due to sustaining factors that are independent of the cause and subject to intervention. This study reexamined a cohort of patients with chronic fatigue to define medical and psychiatric predictors of persistent symptoms. METHODS: Seventy-eight patients with chronic fatigue present for 6 months or more (not required to meet the Centers for Disease Control case definition for chronic fatigue syndrome [CFS]) completed a self-report, follow-up questionnaire to measure the overall improvement or worsening of their condition at a mean of 2.5 years after their initial examination. At the time of initial evaluation, patients underwent a structured psychiatric examination, physical examination, laboratory studies, and self-report measures of psychological distress and functional disability. The psychiatric examination queried the patient about 28 somatic symptoms that are separate from those associated with CFS. Discriminant analysis was used to determine which variables present at the initial examination were significant predictors of persistent symptoms and disability at 2.5 years. RESULTS: The factors most important at the time of initial presentation in predicting persistent illness were: (1) more than eight medically unexplained physical symptoms separate from those associated with CFS case definition; (2) lifetime history of dysthymia; (3) duration of chronic fatigue symptoms greater than 1.5 years; (4) less than 16 years of formal education; and (5) age older than 38 years. None of the results of the initial physical examination, or immunologic, general laboratory, or viral antibody measurements were significant in predicting persistence of symptoms. Recovery rates for those who met the criteria for CFS by either of two case definitions were lower than the rate of noncases, but the differences were not statistically significant. The five aforementioned variables formed a significant discriminative function, correctly classifying 78% of those who recovered and 74% of those with persistent symptoms. CONCLUSIONS: At initial examination, patients with chronic fatigue, more than eight medically unexplained physical symptoms (excluding symptoms in the case criteria for CFS), a lifetime history of dysthymic disorder, longer than 1.5 years of chronic fatigue, less than 16 years of formal education, and who were older than 38 years were the most likely to have persistence of symptoms of chronic fatigue at the 2.5-year follow-up.

Adult↗
PubMed1995

Psychiatric disorders in spouse caregivers of care recipients with Alzheimer's disease and matched controls: a diathesis-stress model of psychopathology.

To test a diathesis-stress model of psychopathology, the authors examined the rates of current and lifetime psychiatric disorders in 82 spouse caregivers of Alzheimer's disease (AD) patients and 86 demographically matched controls. Caregivers and controls did not differ in the prevalence of disorders before the onset of care recipients' AD (or during a similar time period for the controls); caregivers experienced more depressive-anxiety disorders after the onset of patient's AD than controls. This study strongly supported the 3 key components of a diathesis-stress interaction. First, caregivers with a psychiatric history prior to the onset of patient's AD were more likely than caregivers with no history to receive a diagnosis after the onset of AD. Second, a similar relationship existed for controls. Finally, caregivers with a psychiatric history were more likely to experience a recurrence after the onset of AD than controls with a psychiatric history. These findings indicate that the diathesis of psychiatric history and the stress of caregiving interact, resulting in the observed group differences in the prevalence of psychiatric disorders.

Aged↗
PubMed1995

Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees.

This study was designed to determine the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders among a community sample of adolescent and young adult refugees from Afghanistan. The study also measured the correlation of their current psychiatric disorders with the number of traumatic events experienced, parental acculturation and distress, and other important demographic factors. Thirty-eight refugees between 12 and 24 years of age were interviewed with the Structured Clinical Interview for DSM-III-R. Five subjects met DSM-III-R criteria for PTSD, 11 subjects met the criteria for major depression, and 13 had either PTSD or major depression or both. Significant positive correlations were found between the subjects' psychiatric diagnosis and the total number of traumatic events experienced and the parental level of psychological distress (especially maternal distress). There were negative correlations between children's symptomatology and a measure of maternal acculturation. These results suggest that a significant proportion of adolescent and young adult Afghan refugees in the community suffer from severe but undiagnosed psychiatric disorders.

Acculturation↗
PubMed1995

The role of the primary care physician in patients' adherence to antidepressant therapy.

In this study, the authors attempted to determine predictors of adherence to antidepressant therapy and to identify specific educational messages, side effects, and features of doctor-patient collaboration that influence adherence. Patients newly prescribed antidepressants for depression at a health maintenance organization were identified by using automated pharmacy data and medical records review. Patients (n = 155) were interviewed 1 and 4 months after starting antidepressant medication. Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy. Patients who received the following five specific educational messages--1) take the medication daily; 2) antidepressants must be taken for 2 to 4 weeks for a noticeable effect; 3) continue to take medicine even if feeling better; 4) do not stop taking antidepressant without checking with the physician; and 5) specific instructions regarding what to do to resolve questions regarding antidepressants--were more likely to comply during the first month of antidepressant therapy. Asking about prior experience with antidepressants and discussions about scheduling pleasant activities also were related to early adherence. Side effects, only at severe levels, were associated with early noncompliance. Neuroticism, depression severity, and other patient characteristics did not predict adherence. Primary care physicians may be able to enhance adherence to antidepressant therapy by simple and specific educational messages easily integrated into primary care visits.

Adult↗
PubMed1995

Primary care physician use of cognitive behavioral techniques with depressed patients.

BACKGROUND: Although researchers are paying more attention to the treatment of depression in the primary care setting, little is known about the nature of psychotherapeutic interactions that occur between primary care physicians and their patients in the context of a visit for depression. In recent years, brief cognitive behavioral therapy has been demonstrated to be efficacious, and the public has become more familiar with these techniques through media exposure and self-help books. METHODS: Depressed primary care patients were surveyed regarding the extent to which cognitive behavioral (CB) techniques were suggested during the primary care visit in which antidepressant medication was initially prescribed. One hundred fifty-five patients completed responses to phone surveys 1 month and 4 months after the visit. Patients were also surveyed regarding the recommendation of counseling by the primary care physician. RESULTS: The majority of patients (61%) reported that their physician advised them to identify activities they were already doing that helped them feel better. Physician recommendations regarding planning pleasurable activities, problem solving, challenging depressive thoughts, and planning activities that boost confidence were reported by 22% to 40% of study patients. Older patients reported fewer interactions about CB strategies. Primary care physicians' suggestion of CB strategies was associated with both patient use of CB strategies in the months following the visit and better adherence to recommended medication therapy during the first month of treatment. CONCLUSIONS: Many patients seem to recognize the occurrence of psychotherapeutic interactions during visits to their primary care physician in which an antidepressant medication was prescribed, and patients' recognition of these interactions is associated with increased adherence to the recommended course of antidepressant prescriptions.

Adaptation, Psychological↗