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Biomedical subjects

W Katon

Publications and source records attributed to W Katon.

At least 145 records · Page 8Linked to original sources
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Severity of somatization and its relationship to psychiatric disorders and personality.

Medical patients' (75 with chronic fatigue complaints, 61 with dizziness, and 88 with disabling tinnitus; N = 224) current and past psychiatric diagnoses and personality characteristics were assessed to determine if they could independently explain the number of medically unexplained physical symptoms that the patients had experienced. Cloninger's Tridimensional Personality Questionnaire (TPQ) and the Diagnostic Interview Schedule based on DSM-III-R were used to assess the personality and psychiatric diagnoses, respectively. The results revealed that the number of lifetime medically unexplained symptoms were significantly, independently, and positively related to increasing numbers of current and past anxiety and depressive disorders and to the harm avoidance dimension of the TPQ. In a second analysis, the "worry/pessimism" and "impulsiveness" subscales were positively related to the number of medically unexplained symptoms. The results suggest that somatization is associated with current and past history of psychiatric illnesses and harm avoidance in this sample of medical patients.

Adult↗
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A review of randomized trials of psychiatric consultation-liaison studies in primary care.

The field of consultation-liaison (C-L) psychiatry has developed a variety of research interventions to try to improve the recognition and treatment of mental disorders in primary care. The authors review the results of three generations of randomized trials of mental health interventions developed by C-L psychiatrists. In general, these trials have been more successful in improving detection of mental illness and increasing the application of mental health treatments by primary care physicians than in changing patient outcomes. The results of these randomized trials are interpreted by using models developed in the health services field.

Clinical Trials as Topic↗
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Neuroticism and extraversion as predictors of health outcomes in depressed primary care patients.

Depressed primary care patients (N = 217) were assessed to determine if certain personality characteristics predict health domains independent of chronic disease, demographics, depression, and psychiatric diagnoses. Eleven health variables were used to create three outcome factor scores: disability (e.g., days missed work); somatization (e.g., medically unexplained symptoms); and subjective pain (severity, interference). Neuroticism explained significant variance in all health outcomes independent of the other predictors. Depression and neuroticism interacted in the disability and pain models. Depression was related to health in neurotic patients, while in the absence of neuroticism, little relation between depression and health was observed. Neuroticism may explain why persons with similar health problems have differing levels of disability, pain, and somatization.

Depressive Disorder↗
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Depression in coronary heart disease. What is the appropriate diagnostic threshold?

The purpose of this study was to determine the threshold at which depression becomes important for the daily functioning of patients with heart disease. Data from a 1-year prospective cohort study of health maintenance organization patients undergoing coronary angiography for coronary heart disease were analyzed for differences in a standardized composite measure of functioning. Patients with major depression (N = 19) and patients with minor depression (N = 28) were significantly more functionally impaired at baseline and at 1-year follow-up than those with no depression (N = 110). The major and minor depression groups did not differ significantly. The significance of the depression group differences was reduced, but not eliminated, when controlling for differences in reported heart symptoms.

Activities of Daily Living↗
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Panic disorder in primary care: biopsychosocial differences between recognized and unrecognized patients.

Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in more symptomatic and impaired patients. As part of a randomized effectiveness study in primary care patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a significantly higher frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with more prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However, the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care.

Adolescent↗
PubMedDate not supplied

The association between depressive symptoms and health status in patients with chronic pulmonary disease.

This study evaluated the association between depressive symptoms and health related quality of life (HRQoL) in patients with chronic pulmonary disease using both general and disease-specific HRQoL measures. A cross-sectional analysis of HRQoL measures completed by patients enrolled in the Department of Veteran Affairs Ambulatory Care Quality Improvement Project. 1252 patients with chronic pulmonary disease screened positive for emotional distress and returned the Hopkins Symptom Checklist-20 (SCL-20). 733 of 1252 had a score of 1.75 or greater on the SCL-20 indicating significant depressive symptoms. Depressive symptoms were associated with statistically significantly worse general and pulmonary health as reflected by lower scores on all sub-scales of both the Medical Outcomes Short Form-36 and the Seattle Obstructive Lung Disease Questionnaire. In fact, 11% to 18% of the variance in physical function sub-scales was attributed to depressive symptoms alone. Patients with chronic pulmonary disease and depressive symptoms reported significantly more impaired functioning and worse health status when compared to those patients without depressive symptoms. Because there are highly effective treatments for depression, selective screening of patients with chronic pulmonary disease for depression may identify a group that could potentially benefit from treatment interventions.

Adaptation, Psychological↗
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Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited?

Despite the extensive research documenting the significance of medically unexplained somatic symptoms in primary care patients, few studies have examined somatic symptoms as a predictor of depressive and anxiety disorders among pregnant women cared for in Obstetrics. We utilized the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) to assess current depressive and anxiety disorders and self-reported somatic symptoms among 186 women receiving prenatal care. We examined the bivariate relationships between depressive and anxiety disorders and mean number of somatic symptoms. Linear regression analyses assessed the unique association between maternal depression, anxiety and somatic symptoms, while controlling for selected demographics and maternal medical risk. Twenty three percent (N=43) of women met screening criteria for depressive and/or anxiety disorders. Women with depression and/or anxiety were significantly more likely to report somatic symptoms (mean=7.1, SD=2.6) compared to women without depression or anxiety (mean=5.0, SD=2.6) [t(df)=4.54(184), P<.001]. This association persisted in multivariate models. Our findings suggest that antenatal depressive and anxiety disorders are associated with an amplification of physical symptoms of pregnancy. Eliciting and tracking somatic symptoms during prenatal visits could potentially improve detection of depressive and anxiety disorders in the obstetrical sector.

Adult↗
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Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse.

In this article, we describe an evidence-based stepped care approach to improving the care of chronic illness in organized health care systems. We review the common principles that have been found to improve the management and outcomes of patients with major depression, asthma, diabetes, and congestive heart failure. These population-based methods to improve care of chronic illness require reorganizing the roles of specialists, primary care physicians, and nurses.

Asthma↗
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Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial.

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

Adult↗
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Status of minor depression or dysthymia in primary care following a randomized controlled treatment.

This report describes the rates of recovery and remission from minor depression or dysthymia in primary care patients three months after completing a randomized controlled treatment trial. The subjects were primary care patients who received > or =4 treatment sessions with Problem-Solving Treatment, paroxetine, or placebo and who completed an independent assessment 3 months after the study (201 with minor depression, 229 with dysthymia). The 17-item Hamilton Rating Scale for Depression (HAMD), semistructured questions about postintervention depression treatments, and baseline medical comorbidity, neuroticism, and social function were the primary measures. For minor depression 76% and for dysthymia 68% of subjects who were in remission at the end of the 11-week treatment trial were recovered (HAMD < or =6) three months after the treatment trial. Of patients who were not in remission at 11 weeks, for minor depression 37% and for dysthymia 31% went on to achieve remission at 25 weeks. The majority of patients chose not to use antidepressants or psychotherapy after the trial. Patients with minor depression that had greater baseline social function and lower neuroticism scores were more likely to be recovered. For patients with minor depression, these findings suggest a need for some matching of continuation and maintenance treatment to patient characteristics rather than uniform, automatic treatment recommendations. Because of the chronic, relapsing nature of dysthymia, practical improvements in encouraging effective continuation and maintenance phases of treatment are indicated.

Adolescent↗
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Infectious mononucleosis: psychological symptoms during acute and subacute phases of illness.

Although anecdotal reports suggest that anxiety and depressive disorders may be precipitated by acute infectious mononucleosis (AIM), there are few population-based studies measuring distress and psychiatric disorder during and after infection. The purpose of this research was to study the prevalence of psychiatric disorders and psychological distress in patients with AIM at initial infection and over the subsequent 6 months. In addition, we examined the correlation of baseline biopsychosocial factors with distress at 2 and 6 months postillness. A population-based cohort with AIM was surveyed at initial infection and at 2- and 6-month follow-up visits. Measures included physical and laboratory examinations, trait and state measures of psychological and somatic distress, locus of control, social support, and functioning. Patients also received a structured psychiatric interview during the initial infection. Although transient psychological distress was common during acute infection, few patients met criteria for DSM-III-R psychiatric illness. Greater distress at 2 months was associated with significantly lower social functioning in the month prior to diagnosis and higher aspartate aminotransferase (SGOT/AST) levels, less confidence in the physician and health care system (locus of control), and less severe physical symptoms of AIM at baseline. Greater distress at 6 months was associated with an increased number of adverse life events in the 6 months after developing AIM and more days of reduced activity in the 2 weeks prior to the onset of AIM. This population-based study suggests that few subjects develop DSM-III-R psychiatric disorders with AIM. Both biological and psychosocial factors are highly correlated with psychosocial distress at 2 months, whereas psychosocial factors are more important at 6-month follow-up.

Activities of Daily Living↗
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The treatment effectiveness project. A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients: background and research plan.

This report describes the background, rationale, and research plan for a comparative treatment trial of the effectiveness of paroxetine, problem-solving therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Patients were recruited from a variety of primary care practice settings in four separate geographic locations (Hanover, New Hampshire; Pittsburgh, Pennsylvania, San Antonio, Texas; and Seattle, Washington). Patients were randomly assigned to each of the three intervention conditions the medication/placebo conditions were double-blinded. The treatment trial was 11 weeks, with independent assessments of patient clinical status at baseline, 6 weeks, and 11 weeks. There was a follow-up at 25 weeks. Since there are relatively few placebo-controlled trials in primary care settings on patients with these disorders, the background of this project and a description of it are presented at this time, prior to the availability of outcome data, to provide methodological detail and to increase awareness in the research community of this treatment trial, with results to appear subsequently.

Antidepressive Agents↗
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Effectiveness research and implications for study design: sample size and statistical power.

Most clinical trials have started to incorporate more broadly defined outcome measures, such as health-related quality of life, to complement clinical status measures as well as direct costs and cost-effectiveness analyses. Contrasting a broad range of outcome and cost measures, we analyze the implications for sample sizes and study design using data from prior mental health and primary care studies that span a wide range of practice settings, patient populations, and geographic areas. While meaningful clinical symptomatic differences are often detectable with sample sizes of well under 100 per cell, detecting even large changes in health-related quality of life generally requires several hundred observations per cell. Reasonable precision in cost estimates usually requires sample sizes in the thousands. Very few clinical trials or observational effectiveness studies that incorporate quality of life or cost measures have such sample sizes, resulting in many (unreported) null findings and, due to publication biases favoring significant results, scientific publications that exaggerate true effects. It raises issues for the general direction of clinical trials and effectiveness studies, as well as for how cost and health-related quality of life results based on small studies should be dealt with in publications.

Clinical Trials as Topic↗
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The use of administrative data to assess quality of care for bipolar disorder in a large staff model HMO.

We examined patterns of care for 1246 adults treated for bipolar disorder in a large health maintenance organization. Computerized pharmacy and visit data were used to identify patients treated for bipolar disorder. Automated medical records for the following year were used to assess continuity and dosing of treatment with mood stabilizers, laboratory monitoring for adverse effects and therapeutic serum levels, and frequency of follow-up visits. Of our 1246 subjects 83% filled a mood stabilizer prescription during the 1-year study period, and doses were within recommended ranges 80% of the time. Over 75% of the patients on mood stabilizers had at least one apparent interruption in medication use. Approximately half of the long-term users of mood stabilizers had at least one 7-month period without a recorded blood level and approximately half had a similar period without monitoring for adverse medication effects. Of the 116 subjects discharged from a psychiatric hospitalization 58% had a visit with a psychiatrist or a psychiatric nurse practitioner within 30 days. Of those discontinuing mood stabilizer treatment 68% made a mental health visit within 90 days. Our findings demonstrate the feasibility of using administrative data systems for population-based quality of care assessment and suggest opportunities for improving the care of bipolar patients.

Adolescent↗
PubMedDate not supplied

Methodologic issues in randomized trials of liaison psychiatry in primary care.

Most anxiety, depressive, and substance abuse disorders are treated exclusively in the primary care health system. However, recognition and treatment of these disorders in primary care is deficient. Psychopharmacologic and psychotherapeutic interventions have been developed and proven effective in randomized trials in specialty care. However, the results of successful trials of mental health interventions in specialty settings may not generalize to primary care settings because of epidemiologic differences in patients, differences in skills of providers, as well as differences in the very structure of care. The importance of the development of innovative randomized trials to improve recognition and treatment of mental illness in primary care is emphasized, as well as the methodologic problems inherent in carrying out these trials.

Humans↗
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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↗