Screening older adults for depression in primary care settings.

Primary care is a logical environment for depression recognition in older adults. Most older adults are diagnosed and treated for depression by primary care providers. Recognition systems for depression in this setting are particularly needed because the prevalence of depression in older primary care patients may range from 7% to 36%, depending on the instrument and diagnostic criteria used. Implementing systematic detection systems in primary care settings has proven difficult. In one study, only one third of all physicians surveyed used any formal screening tool. Though a number of barriers to recognition of depression have been identified, the authors focus their discussion in this article on two, time and patient factors, and review two screening instruments, the Geriatric Depression Scale--Short Form and the Center for Epidemiologic Studies Depression Scale, that may be able to address these factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The treatment of depression in older adults in the primary care setting: An evidence-based review.

The objective of this study was to conduct an evidence-based review of treatments for depression in older adults in the primary care setting. A literature search was conducted using PsycINFO and Medline to identify relevant, English language studies published from January 1994 to April 2004 with samples aged 55 and older. Studies were required to be randomized controlled trials that compared psychosocial interventions conducted within the primary care setting with "usual care" conditions. Eight studies with older adult samples met inclusion criteria and were included in the review. Two treatment models were evident: Geriatric Evaluation Management (GEM) clinics and an approach labeled integrated health care models. Support was found for each model, with improvement in depressive symptoms and better outcomes than usual care; however, findings varied by depression severity, and interventions were difficult to compare. Further efforts to improve research and clinical care of depression in the primary care setting for older adults are needed. The authors recommend the use of interdisciplinary teams and more implementation of psychosocial treatments shown to be effective for older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Numeric terminology of erythrocyte blood group antigens

BACKGROUND: Depression in late life is a significant health problem in the United States. This study examined the relationship between depression and alcohol, cigarette use, family history, and sociodemographic factors in older adult primary care patients. METHODS: As part of a larger clinical trial, 2,732 patients in 24 primary care offices were recruited to complete a self-administered health screening survey. Depression was assessed using Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for lifetime and current depression. RESULTS: A total of 17.8% of females and 9.4% of males age 60 and over met DSM-III-R criteria for lifetime depression; 10.6% of the females and 5.7% of the males met current depression criteria. Depression was significantly and positively correlated with female gender and family history of mental health problems and negatively correlated with social contact. CONCLUSIONS: Older adults, especially women, should be considered at elevated risk for depression when a family history of mental health problems and self-report of inadequate social connection can be established.     

Comparison between the dynamics of lipid/gramicidin A systems in the lamellar and hexagonal phases: a solid-state 13C NMR study

Adolescence is a developmental period marked by multiple challenges and demands which create a heightened vulnerability to the development of emotional disorders. Primary care physicians are in an ideal position to intervene in the early stages and prevent the tragic consequences which can occur with an untreated mental health disorder. This article reviews the assessment and treatment of adolescent mental health in the primary care medical setting. Knowledge of these disorders and their manifestations in the primary care environment will enable clinicians to provide higher quality medical care and will reduce the potential for continual life disruptions into the adult years.     

Characteristics of Israeli primary health care physicians who treat depression

Primary health care physicians have a pivotal role in treating mental health problems. We determined the proportion of primary care physicians in Israel who treat depression and their characteristics. The study was based on a stratified national random sample of primary care physicians (n677, response rate 78%). From these physicians' reports 22% always treat depression, 36.6% usually, 28.6% sometimes, and 12.6% never. Based on a logistic regression model the physicians who always or usually treated depression were distinguished from the other physicians by their treating more medical conditions on their own, seeing themselves as having more first contact for psychosocial problems, having frequent contact with social workers and specializing in family medicine. Primary health care physicians play a major role in treating depression on their own. This raises new questions about how they treat depression themselves, and under what circumstances they treat or refer to a specialist.     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.     

Untreated anxiety among adult primary care patients in a Health Maintenance Organization

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.     

Physician management preferences and barriers to care for rural patients with depression

OBJECTIVE: To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. DESIGN: Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. SETTING: Primary care practices in nonmetropolitan counties. PARTICIPANTS: Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. MAIN OUTCOME MEASURES: Physician preferences for and barriers to the effective management of depression. RESULTS: An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. CONCLUSIONS: The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.     

Women's mental health in primary care. Depression, anxiety, somatization, eating disorders, and substance abuse

Primary care physicians can improve the care of women patients by applying new concepts of women's physiology and psychosocial development. New developmental models that emphasize the importance of relationships in women's self-concept and well-being have led to effective psychotherapies for depression, eating disorders, anxiety and substance abuse. Many of these therapies can be offered in brief formats suitable to primary care settings. New biological treatments including the use of estrogen, thyroid hormone and bright light for depression and refeeding to increase metabolic rate in eating disorders also promise to expand the range of mental health problems that generalist physicians can treat successfully.     

Health care for the whole person: Research update.

Quality health care must be informed by the best available scientific knowledge. This article offers research evidence supporting "health care for the whole person." We present an integrative biopsychosocial framework that can serve as a useful foundation for translational research endeavors and the development, evaluation, and dissemination of evidence-based health and mental health interventions. Pain and depression are used as exemplars of the biopsychosocial model. Empirical support for mental health interventions in primary care settings is highlighted, with particular emphasis on the treatment of depression across the life span. Research, practice, and policy implications based on the extant evidence base for health care for the whole person are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

PRIME-MD and rural primary care: Detecting depression in a low-income rural population.

An efficient method for screening depression in primary care may ultimately facilitate referrals to and collaboration with psychologists. The current study extends previous research on the validity of the Mood Module of the Primary Care Evaluation of Mental Disorders (PRIME-MD; R. L. Spitzer et al, 1995) and used nurses as administrators in two rural public health units. Participants were 136 predominantly female (59% Caucasian, 38% African American) primary care patients. Results indicated that 40% were classified as depressed. Depressed participants reported significantly worse mental and physical functioning, even after controlling for age, severity of illness, and tobacco use. Routine screenings for mood disorders in rural primary care could serve as a means of facilitating collaboration between primary care physicians and psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Promoting adolescent mental health in primary care: a review of the literature

High levels of psychological disturbance amongst adolescents have been linked to behaviours which can damage physical health, and with mental health problems in adulthood. The aim of this review was to see if published literature supports the hypothesis that primary care is a suitable setting in which mental health problems in adolescents can be prevented by early detection and treatment. Medline, BIDS, SIGLE and Psychlit databases (January 1990-February 1997) were systematically searched for English language studies on adolescent health promotion and mental health in primary care; reference sections were checked for earlier work. When offered, adolescent health checks and clinics have been well received with attendance rates of 73% and 83% reported, respectively. Primary care offers a setting for the prevention and detection of mental health problems in adolescents. Further research is needed to determine cost effective ways of using these opportunities.     

Initial management of the patient with altered mental status

Primary care physicians may encounter patients with altered mental status or neurologic deficit. Because the differential diagnosis for altered mental status includes conditions with significant morbidity and mortality, care of these patients must be rapid and thorough. The resources required to ensure and maintain cardiopulmonary stabilization and to perform the initial workup are often unavailable in the primary care office setting. Therefore, these patients often require immediate referral to an emergency department. Proper evaluation and initial management include evaluation of metabolic factors, assessment for toxic ingestions and a thorough neurologic assessment.     

Older adults, reimbursement, and referrals: Implications for psychologists after Medicare reimbursement changes and before health care reform.

Psychologists' current provision of mental health services to older adults was investigated by a mail survey. One half of licensed psychologists in a metropolitan region in the Northeast were randomly sampled, with a return rate of 61% (n?=?37). 75% saw older adult clients (aged 65 and over), and 72% accepted Medicare payments. Older adults composed 8% of their practice. Solopracticing physicians were the chief referral link to and from the medical community. Barriers to providing mental health services included client's lack of social support network and low levels of reimbursement. The challenges of continuing psychologists' recent advances in serving the mental health needs of older adults in an era of health care reform and managed care are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social and mental health needs of the aged.

Argues that in the 1980s, an increase in life expectancy of older adults will have a significant impact on the cultural, social, economic, and political life of the country. As the 75+ yr old population increases, the need for comprehensive, community-based care for those persons will increase. Mental and physical health problems confronting the elderly include depression, mental disorder or senility, and chronic illness, such as hypertension and heart disease. The Older Americans Act of 1965 and the role of the Administration on Aging in providing for the mental health needs of the aged are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Public policy and the provision of psychological services to older adults.

Public policy shapes who delivers health care, how care is delivered, and how much providers are paid. The impact of public policy will become even more important to psychologists who serve older adults as 76 million members of the so called “baby boom” generation enter their later years. Armed with basic public policy facts, psychologists can better maneuver the systems created by public policy and even change policy. This article reviews how Medicare works since it is the primary payer of mental health services for older adults. The article then turns to the question of how many health care professionals (including psychologists) will be required to meet the needs of a rapidly growing older population and concurrent challenges of training and building that work force. Finally, different policy visions for a better mental health care system for older adults are summarized since they may be roadmaps to what the future of mental health care will look like. The article closes with practical recommendations on how psychologists can influence mental health and aging public policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Activity Counseling Trial (ACT): rationale, design, and methods. Activity Counseling Trial Research Group

The Activity Counseling Trial (ACT) is a multicenter, randomized controlled trial to evaluate the effectiveness of interventions to promote physical activity in the primary health care setting. ACT has recruited, evaluated, and randomized 874 men and women 35-75 yr of age who are patients of primary care physicians. Participants were assigned to one of three educational interventions that differ in amount of interpersonal contact and resources required: standard care control, staff-assisted intervention, or staff-counseling intervention. The study is designed to provide 90% power in both men and women to detect a 1.1 kcal.kg-1.day-1 difference in total daily energy expenditure between any two treatment groups, and over 90% power to detect a 7% increase in maximal oxygen uptake, the two primary outcomes. Primary analyses will compare study groups on mean outcome measures at 24 months post-randomization, be adjusted for the baseline value of the outcome measure and for multiple comparisons, and be conducted separately for men and women. Secondary outcomes include comparisons between interventions at 24 months of factors related to cardiovascular disease (blood lipids/lipoproteins, blood pressure, body composition, plasma insulin, fibrinogen, dietary intake, smoking, heart rate variability), psychosocial effect, and cost-effectiveness, and at 6 months for primary outcome measures. ACT is the first large-scale behavioral intervention study of physical activity counseling in a clinical setting, includes a generalizable sample of adult men and women and of clinical setting, and examines long-term (24 months) effects. ACT has the potential to make substantial contributions to the understanding of how to promote physical activity in the primary health care setting.     

Integrating mental health services into primary medical care

Primary care clinicians occupy a strategic position in relation to the emotional problems of their patients. Integrating mental health and primary medical services promotes available, coordinated, accessible, and less stigmatizing treatment by recognizing an indivisibility of the total person in illness and in health. Federal efforts to encourage Health Maintenance Organization (HMO) development as part of a national health program prompts serious attention to organizational arrangements for developing such an integrated program for medical-mental health care. We have found a team collaborative model in which mental health providers are members of a primary care team to be useful and promising. Supportive services are provided on a continuing basis through patterned relationships. Shared responsibility for patient care between physicians, nurse practitioners, physician assistants, and mental health workers provides built-in peer review and encourages intrateam consultation.     

Patients' perspectives on the management of emotional distress in primary care settings

OBJECTIVE: To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire. DESIGN: Patient surveys. SETTING: Five private primary care practices. MEASUREMENTS AND MAIN RESULTS: Patients' desire for treatment of emotional distress and for specific types of mental health interventions were measured, as well as patients' ratings of the impact of emotional distress, the frequency of depressive symptoms, and mental health functioning. Of the 403 patients, 33% felt that it was "somewhat important" and 30% thought it was "extremely important" that their physician tries to help them with their emotional distress. Patient desire for this help was significantly related to a diagnosis of depression (p < .001), perceptions about the impact of emotional distress (p < .001), and mental health functioning (p < .001). Among patients with presumptive diagnoses of major and minor depression, 84% and 79%, respectively, felt that it was at least somewhat important that they receive this help from their physician. Sixty-one percent of all primary care patients surveyed and 69% of depressed patients desired counseling: 23% of all patients and 33% of depressed patients wanted a medication: and 11% of all patients and 5% of depressed patients desired a referral to a mental health specialist. CONCLUSIONS: A majority of these primary care patients and almost all of the depressed patients felt that it was at least somewhat important to receive help from their physician for emotional distress. The desire for this help seems to be related to the severity of the mental health problem. Most of the patients wanted counseling, but relatively few desired a referral to a mental health specialist.     

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.