Clinical relevance of thiamine status amongst hospitalized elderly patients

BACKGROUND: The prevalence and the consequences of thiamine deficiency among elderly patients admitted to acute geriatric wards are not known. OBJECTIVES: (1) To assess the prevalence of thiamine deficiency in patients admitted to a geriatric ward compared to age-matched ambulatory outpatients; (2) to identify their diseases and problems associated with thiamine deficiency, and (3) to determine the relationship between the thiamine status and the cognitive and functional status of these patients. MATERIALS AND METHODS: 118 aged hospitalized patients (83 +/- 7 years; mean age +/- SD) were prospectively enrolled on admission to the geriatric ward. Their cognitive status was assessed using the Mini-Mental State Examination (MMSE) and their ability to perform their activities of daily living (ADL) using ADL scales. The effect of exogenous thiamine pyrophosphate (TPP) addition on the blood transketolase (TK) activity (TPP TK effect) served to estimate thiamine deficiency. Socioeconomic data, diseases and treatment were identified as potential associated risk factors. This group of hospitalized patients was divided according to their thiamine status to characterize the conditions associated with thiamine deficiency. Thirty-five outpatients without any functional or cognitive impairment served as a control group. RESULTS: Of 118 inpatients, 46 (39%) presented with a TPP TK effect of >15%, and 6 with values of >22%, indicating moderate and severe thiamine deficiency, respectively. Only 6 of 30 outpatients (20%) exhibited a TPP TK effect of >15% and none of them reached values of >18%. Although it tended to be lower in outpatients, the mean TPP TK effect did not statistically differ from the mean of inpatients. Thiamine-deficient inpatients comprised a larger proportion of institutionalized subjects than nondeficient inpatients (87 versus 47%, p < 0.001). Functional status, cognitive functions and the occurrence of delirium did not differ according to their thiamine status. By contrast, thiamine-deficient inpatients exhibited a higher proportion of Alzheimer's disease, depression, cardiac failure and falls. Furosemide was more frequently taken by thiamine-deficient patients. CONCLUSIONS: Severe thiamine deficiency remained quite low among the hospitalized elderly. The prevalence of moderate thiamine deficiency approached 40%. Institutionalized subjects were at particular risk of developing thiamine deficiency. Its clinical relevance on functional status and on cognitive function remained not significant. By contrast, a high proportion of falls, Alzheimer's disease, depression, cardiac failure and furosemide use could have been related to thiamine deficiency.     

Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse and dependence in primary care patients: Findings of the PRIME MD-1000 study.

The psychiatric comorbidity, health, and functioning of primary care patients with alcohol abuse and dependence (AAD) was investigated in a sample of 1,000 patients. Psychiatric symptomatology was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic system. Health and functional status was assessed with the Medical Outcomes Study Short Form General Health Survey (SF-20). Results indicated that use of the PRIME-MD system brought about a 71% increase in physician recognition of AAD. AAD patients were diagnosed with substantial psychiatric comorbidity, and they reported poorer health and functioning than did patients without any psychiatric disorders. However, they reported less impairment and psychiatric comorbidity than did patients with other psychiatric disorders. Results also indicated that AAD patients' health and functioning were associated with the presence or absence of psychiatric comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective 4- to 5-year study of DSM-III-R hypochondriasis

BACKGROUND: Although hypochondriasis is generally thought to be a chronic and stable condition with a relatively low remission rate, this disorder remains understudied. METHODS: This is a 4- to 5-year prospective case-control study of DSM-III-R hypochondriasis. Medical outpatients meeting DSM diagnostic criteria for hypochondriasis completed an extensive research battery assessing hypochondriacal symptoms, medical and psychiatric comorbidity, functional status and role impairment, and medical care. A comparison group of nonhypochondriacal patients from the same setting underwent the same battery. Four to 5 years later, both cohorts were re-interviewed. RESULTS: One hundred twenty hypochondriacal and 133 nonhypochondriacal comparison patients were originally studied. Follow-up was obtained on 73.5% (n = 186) of all patients. At follow-up, the hypochondriacal sample was significantly (P<.001) less hypochondriacal and had less somatization (P<.001) and disability than at inception, but 63.5% (n = 54) still met DSM-III-R diagnostic criteria. When compared with the comparison group using repeated measures multivariate analysis of variance, these changes remained statistically significant (P<.0001). Changes in medical and psychiatric comorbidity did not differ between the 2 groups. When hypochondriacal patients who did and did not meet diagnostic criteria at follow-up were compared, the latter had significantly less disease conviction (P<.05) and somatization (P<.01) at inception, and their incidence of major medical illness during the follow-up period was significantly (P<.05) greater. CONCLUSIONS: Hypochondriacal patients show a considerable decline in symptoms and improvement in role functioning over 4 to 5 years but two thirds of them still meet diagnostic criteria. Hypochondriasis, therefore, carries a very substantial, long-term burden of morbidity, functional impairment, and personal distress.     

Adverse perinatal outcomes in young adolescents

BACKGROUND: Identification of psychiatric patients with severe and persisting impairments can facilitate treatment, aid in program planning, and provide data for cost-of-care projections. METHODS: In this prospective study of patient outcomes, 1,679 inpatients were classified on admission using a functional status measure developed by the authors. Consenting subjects were reassessed at discharge and at 3, 6, and 12 months postdischarge to determine what proportion of patients classified as low functioning on admission remained so at follow-up. RESULTS: Patients classified as low functioning on admission represented 23.4% of the sample; the proportion that remained low functioning at the follow-ups ranged from 56.1% to 65.2%. Compared to the high functioning group, three times more low functioning patients were rehospitalized within 12 months of discharge (9.4% vs 32%). CONCLUSIONS: Patients with increased risk of persisting disability can be identified on admission using commonly available clinical measures. Of patients with low functioning on admission, more than half will have long-term impairment.     

The renal medullary thick ascending limb as a model for understanding lipid mediators in sepsis

OBJECTIVE: To evaluate the impact of HIV illness on psychiatric and psychosocial functioning over 3 years in a sample of male and female HIV-positive injecting drug users (IDU), with a comparison group of HIV-negative male and female IDU. DESIGN: As part of a multidisciplinary study, 121 men (69 HIV-positive, 52 HIV-negative) and 66 women (36 HIV-positive, 30 HIV-negative) were evaluated semiannually for seven visits. Attrition, unrelated to sex or serostatus, was 33%. RESULTS: At baseline, rates of major depression and dysthymia ranged from 15% (HIV-negative men) to 33% (HIV-positive men and HIV-negative women). Global impairment was in the range found in psychiatric patients (mean Global Assessment of Functioning scores, 46-51). Higher levels of social support and less social conflict were independently associated with decreased distress and improved global functioning among both men and women. For both HIV-positive groups, degree of improvement over time was related to degree to HIV progression: those who remained healthier in terms of CD4 count and illness stage showed more improvement. HIV-seronegative status was associated with less distress for men but not for women. Overall, women reported higher levels of psychiatric distress than men. CONCLUSIONS: High rates of psychopathology were found in this IDU cohort, independent of HIV status and sex. Although rates of psychopathology, injecting drug use and distress declined slightly during the study, they remained elevated; accordingly, psychiatric services are indicated for this population.     

Mood improvement in elderly women after in-hospital physical rehabilitation

OBJECTIVE: To evaluate the relationship between change in depressive symptoms and in-hospital physical rehabilitation in elderly women. DESIGN: Longitudinal study. SETTING: Hospital facility (geriatric evaluation and rehabilitation unit). PATIENTS: One hundred twenty-three elderly inpatient women (mean age: 78.4+/-6.9 years, range 60 to 93) with good cognitive status (Mini Mental State Examination: 23.1+/-5.1) consecutively admitted over a 7-month period. INTERVENTION: Physical therapy tailored to individual needs (five sessions a week of 30 to 45 minutes each). MAIN OUTCOMES MEASURES: On admission: cognition (MMSE), depressive symptoms (Geriatric Depression Scale [GDS]), functional status (basic and instrumental activities of daily living [BADL, IADL], Tinetti scale), and somatic health. On discharge: depressive symptoms and gait and balance performances (Tinetti scale). RESULTS: Seventy-five patients (61%) did not show changes on Tinetti scale over the hospitalization period and 48(39%) had a change of 3 or more points. Nonresponders had no change of GDS over the hospitalization period for all levels of physical disability on admission, whereas responders had relevant improvement of depressive symptoms when markedly disabled on admission, and progressively smaller improvements of depressive symptoms with increasing function on admission. CONCLUSIONS: The study provides evidence that mood status changes synchronically with disability.     

Aortic and lower-extremity arterial disease: evaluation with MR angiography versus conventional angiography

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.     

Home alone: the role of cognition in return to independent living

OBJECTIVE: To identify unique predictors of the ability to return to living alone in geriatric patients undergoing medical rehabilitation. DESIGN: Of 900 consecutive geriatric patients entering medical rehabilitation, 372 were identified as living alone before admission. Data were collected on functional status, cognition, demographics, and discharge disposition. SETTING: A freestanding medical rehabilitation facility. All patients were admitted to a geriatric rehabilitation unit. PATIENTS: Patients aged 60 to 99, identified as having lived alone before admission, were included. As standard procedure, patients underwent functional and cognitive assessment, and medical records were reviewed. MAIN OUTCOME MEASURE: Logistic regression analysis was used to evaluate predictors of discharge disposition, including demographic variables, medical burden, the Functional Independence Measure (FIM), and the Dementia Rating Scale (DRS). RESULTS: Both the FIM and DRS provided significant and unique variance in prediction of discharge disposition. Patients discharged home alone performed similarly to those discharged with supervision on FIM motor items but higher on FIM social cognition items, emphasizing the strong role of cognition in discharge disposition. Patients discharged home alone scored above suggested cutoff scores on the DRS, indicating generally intact cognitive functioning, whereas those discharged with supervision scored below suggested cutoffs. CONCLUSION: Results emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients.     

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE: Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints. DESIGN: A point prevalence study of patients cared for in various types of geriatric settings. SETTING: Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden. PARTICIPANTS: A total of 1325 patients, mean age 82 years, 64% of whom were women. MEASUREMENTS: The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument. RESULTS: Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances. CONCLUSIONS: This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.     

Assessment of functional abilities among geriatric patients: A MIMIC model of the functional independence measure.

Objective: To investigate the influence of population heterogeneity among geriatric patients on the factor structure and differential item functioning on the Functional Independence Measure (FIM) and thereby evaluate the appropriateness of using 2 factor composite scores (FIM motor and FIM cognition) among geriatric patients. Design: A specific application of structural equation modeling (i.e., multiple indicators, multiple causes [MIMIC] model) was conducted on FIM admission scores from 718 geriatric rehabilitation patients. Setting: A large urban rehabilitation hospital. Participants: 718 inpatients referred for medical rehabilitation (M?=?77.5 yrs; 62% African American; 68% female). Measurements: All participants' functional abilities were rated on the FIM by trained physical and occupational therapists on admission to the rehabilitation hospital. In addition, all patients completed the Geriatric Depression Scale. Results: Three motor functioning items and 3 cognitive functioning items differed systematically across groups within this geriatric sample (i.e., young-old vs old-old, male vs female, depressed vs nondepressed) even after controlling for group differences on levels of overall motor and cognitive functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The informed consent process in older patients who developed delirium: a clinical epidemiologic study

PURPOSE: Delirium, defined as an acute, fluctuating disorder of attention and cognition, is a serious and increasingly common problem for hospitalized older persons. Delirium poses unique ethical challenges for the informed consent process, notably the preservation of patient autonomy in the face of potentially fluctuating decision-making capacity. To clarify these issues, we examined the informed consent process in a group of hospitalized older patients who developed delirium. PATIENTS: Eighty-four hospitalized patients aged >70 years who developed delirium during hospitalization at a large urban teaching hospital. METHODS: We conducted a clinical epidemiologic investigation of informed consent in 173 medical and surgical procedures performed in 84 patients. Clinical researchers carried out detailed cognitive evaluation of patients on or near the consent date. A separate blinded researcher extracted medical record information on the procedures and informed consent process variables. RESULTS: Of 173 procedures, 33 (19%) had no documentation of any consent, and 34 (20%) used surrogate consent. There were no documented assessments of competency/ decisional capacity; cognitive assessments were done in 7 (4%) cases, and legal consults in 2 (1%) cases. Discussion of potential risks of the procedure with patient or surrogate were documented in 61 (35%) cases. In multivariable analysis, independent predictors for failure to obtain consent were presence of delirium (adjusted odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.3, 5.3) and less invasive procedure (OR = 5.0, CI 2.0, 12.8). Although cognitive impairment predicted surrogate use, we found that 47% of cases with substantial impairment did not involve use of a surrogate, whereas surrogates signed for 4% of cases with normal mental status near the time of consent. CONCLUSIONS: Our results highlight the ethical challenges that delirium poses for the informed consent process, including the high rate of no consent, lack of cognitive and decisional capacity assessment, and inconsistent surrogate use.     

The trauma patient: open hospital choice?

Mental-health service utilization among elderly people has been shown to be low relative to younger age groups. This study was done to determine the current proportion of elderly persons served in a university-affiliated psychiatry outpatient clinic, and to better characterize elderly patients who receive specialized mental-health care in this setting. The proportion of visits from elderly patients (aged 60 and over) was found to be 16%. Demographic and clinical characteristics of a sample of 140 consecutive geriatric patients evaluated at the clinic were obtained. The data revealed that the patients had a mean age of 74.7+/-7.5 (SD) years, and were mostly female (72.1%) and white (78.6%). Surprisingly, the age distribution was found to be bell shaped, with a small upper tail. The three most prevalent psychiatric diagnoses were depression (56.4%), dementia (35.7%), and substance use disorder (20%). Overall, 59.3% of geriatric patients had a history of prior psychiatric treatment. Females were significantly more likely than males to have a psychiatric history (69.3% vs. 33.3%, P = .0001). Among patients with a psychiatric history, females were more likely to have a current diagnosis of major depression (P = .0006), while males were more likely to have a current substance use disorder (P = .03). The prevalence of dementia increased with each successive decade above 60, while the occurrence of bipolar and adjustment disorders was confined to younger geriatric patients. Elderly patients receiving psychiatric treatment in the clinic thus formed a heterogeneous group. Gender, age, and presence of a psychiatric history were all associated with differences in prevalence and distribution of various mental disorders in this geriatric psychiatry outpatient clinic.     

Changes in mental status of elderly patients in age-integrated and age-segregated hospital milieus.

Studied the effects of age-segregated hospital environments on cognitive functioning of 55 aged, male psychiatric patients. Changes in performance on mental status and responsiveness measures during the 1st 3 wk. after admission were compared for patients randomly assigned to an age-segregated custodial, age-integrated custodial, and a therapy ward. Ss placed in the age-integrated custodial ward and in the therapy ward showed significantly greater improvement in responsiveness and mental status than Ss placed in the age-segragated custodial ward. Effects of ward placement cut across all diagnostic groups. The therapeutic potential of age-integrated patient environments is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A symptom profile of hospitalization-requiring depression among the elderly related to clinical subgroups. A way to improve diagnostics

The objectives were to study clinical symptoms of major depression in later life by using relevant assessment scales of psychopathology, behavioural disorders, and physical functioning. The evaluations on admission and at discharge were based on interdisciplinary observations and interview of patients. The study was carried out during twelve months in a psychogeriatric university department and encompassed 202 patients. All (N = 80) (40%) patients who had a principal diagnosis of major depression are accounted for. Mean age was 79.5 years. Results of the assessments all showed significant improvements (p = 0.0000-0.0024). The overall results of the assessments show that the key symptom of sadness is often missing, muted, or overshadowed by other symptoms, and that behavioural disturbancies and functional disability may be important symptoms in geriatric depression. In conclusion: adequate treatment of major depression in the elderly significantly improves psychopathology, behavioural disorders and physical functioning. When dealing with mental disorders in this age group, awareness of the five clinical presentations in major geriatric depression, i.e. dementoform, somatoform neurotiform, eretic and classic geriatric depression, may target the diagnostic procedure.     

Physical and mental comorbidity of substance use disorders in psychiatric consultations. European Consultation-Liaison Workgroup

Comorbidity of substance use disorders with physical and mental disorders was investigated among 1249 consecutive psychiatric consultation patients admitted to six general hospitals in Finland. Of the patients 354 (28%) were diagnosed with substance use disorders (ICD-10), of which 22% were due to use of at least two different types of psychoactive substances. Alcohol dependence (117/226) in male patients and acute drug intoxication (49/128) at a similar rate as alcohol dependence (44/128) in female patients were the most common clinical conditions. With few exceptions, all substance use disorders were comorbid and in 63% of affected patients comprised a "triple diagnosis" (i.e., physical, mental, and substance use diagnoses concurrently). Poisonings and personality disorders in both sexes, digestive system diseases in men, and injuries in women were related to substance use disorders. Conclusions for service provision were: (1) the high level of co-occurrence of physical and mental disorders with substance use disorders calls for comprehensive, multi-disciplinary assessment of any substance use problems ascertained in psychiatric consultations; (2) poisoning with substance use involvement and mental comorbidity was the most common combined clinical condition justifying provision of addiction psychiatric emergency consultations in general hospitals; (3) polydrug use indicating severe problems and complex treatment needs should be identified; and (4) psychiatric referrals of patients with physical alcohol-related disorders should be ensured in general hospitals.     

Social role functioning by adolescents with psychiatric disorders

OBJECTIVE: To identify aspects of social role functioning that are impaired in adolescents with specific psychiatric disorders in order to improve the psychiatric taxonomy and clinical knowledge base. METHOD: Adolescents in four urban public schools were screened for mental health problems. Structured psychiatric interviews (National Institute of Mental Health Diagnostic Interview Schedule for Children Version 2.2) with 288 adolescents and their mothers were used to identify youths with psychiatric disorders, and 10 aspects of social role functioning were assessed. Aspects of social role functioning that discriminated between youths with and without psychiatric disorders and between those with emotional disorders and those with disruptive disorders were identified for boys and for girls. RESULTS: Boys with any type of disorder and all youths with disruptive disorders had significant, consistent impairment in academic performance and several other areas of functioning. Youths with emotional disorders, especially girls, demonstrated impairment in social activity participation and peer acceptance, but girls with disorders were not as consistently different from those without as were the boys with emotional disorders. CONCLUSIONS: Role functioning differs in important ways between youths with and without psychiatric disorders and between girls and boys with disorders. The results underscore the importance of investigating observable aspects of role behavior in order to improve the timely detection and effective management of psychiatric disorders in youth.     

Relationship between self-rated functional status and psychosocial stress in patients suffering from rheumatoid arthritis

BACKGROUND: To assess relationship between psychosocial factors and self-rated functioning in rheumatoid arthritis (RA). METHODS: In 66 RA patients (mean age +/- SD = 50.8 +/- 12.6 years, women 49 (74%), illness duration mean +/- SD = 13.4 +/- 10.5 years) aspects of developmental psychosocial stress thought to influence human behavior were assessed in an in depth interview using structured biographical history. Furthermore evaluation included Trait anxiety, global functional status according to the ACR criteria, radiological staging of illness and patients' self-ratings of functioning obtained by the Health Assessment Questionnaire (HAQ). Bivariate correlations were performed using psychosocial and somatic factors and self-rated functional status. RESULTS: Scores of developmental psychosocial stress significantly correlated with interviewers scoring of nurture (r = -0.722, p < 0.001) indicating good internal consistency of interview data. Significant correlations were found between patients' scoring of functional status (HAQ) and (i) ACR criteria (r = 0.490, p < 0.0001) and (ii) score of Trait anxiety (r = 0.367, p < 0.003). There was no significant correlation between developmental psychosocial stress and HAQ score. CONCLUSION: Developmental psychosocial stress does not significantly contribute as to how RA patients perceive their functional ability. In a proportion of RA patients self-rated functional status may depend on the patients disposition (e.g. neuroticism) probably promoting impaired illness behavior (e.g. regressive tendencies) which should be considered in assessing treatment procedures.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

Treating depressed primary care patients improves their physical, mental, and social functioning

BACKGROUND: This study describes the functioning of primary care patients with major depressive disorder, the relationship of medical comorbidity to functional status, and the effects of depression-specific treatment on functional status after 8 months. METHODS: Patients were randomized to a protocol intervention (nortriptyline hydrochloride or interpersonal psychotherapy) or to usual care with the patient's physician in a clinical trial of primary care treatments of depression. Their functional status was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Global Assessment Scale. Medical comorbidity was assessed with the Duke Severity of Illness Checklist. The Hamilton Rating Scale for Depression and Beck Depression Inventory were used to measure depressive severity. Assessments were conducted at baseline and at 1, 2, 4, and 8 months after randomization. RESULTS: At baseline, patients reported substantial impairments in the functional domains as assessed by the SF-36 and Global Assessment Scale. Severity of general medical illness and depression were not correlated. Greater medical comorbidity was associated with diminished physical, but not psychological, functioning. Mean scores on SF-36 scales and the Global Assessment Scale improved significantly during the 8 months of follow-up. Patients assigned to protocol treatments showed greater improvement, compared with those assigned to usual care, on the SF-36 mental summary scale and most individual scales but not on the SF-36 physical summary scale. However, patients who completed protocol treatment also experienced significant improvement on the physical summary scale. Medical comorbidity was only a weak predictor of outcome. CONCLUSIONS: Primary care patients with major depressive disorder report substantial impairments in physical, psychological, and social functioning on initial assessment. Severity of baseline medical comorbidity did not correlate with severity of depression and only weakly correlated with functional status at 8 months. Functional impairments improve with time, but standardized depression-specific treatment is associated with greater improvement in more domains of functioning than is a physician's usual care.