The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms.

BACKGROUND: Measurement-based care is an effective clinical strategy underutilized for bipolar disorder partly due to lacking a widely adopted patient-reported manic symptom measure. OBJECTIVE: To report development and psychometric properties of a brief patient-reported manic symptom measure. DESIGN: Secondary analysis of data collected in a randomized effectiveness trial comparing two treatments for 1004 primary care patients screening positive for bipolar disorder and/or PTSD. PARTICIPANTS: Two analytic samples included 114 participants with varied diagnoses and test-retest data, and 179 participants with psychiatrist-diagnosed bipolar disorder who had two or more assessments with the nine-item Patient Mania Questionnaire-9 [PMQ-9]). MAIN MEASURES: Internal and test-retest reliability, concurrent validity, and sensitivity to change were assessed. Minimally important difference (MID) was estimated by standard error of measurement (SEM) and by standard deviation (SD) effect sizes. KEY RESULTS: The PMQ-9 had high internal reliability (Cronbach's alpha = 0.88) and test-retest reliability (0.85). Concurrent validity correlation with manic symptom measures was high for the Internal State Scale-Activation Subscale (0.70; p<0.0001), and lower for the Altman Mania Rating Scale (0.26; p=0.007). Longitudinally, PMQ-9 was completed at 1511 clinical encounters in 179 patients with bipolar disorder. Mean PMQ-9 score at first and last encounters was 14.5 (SD 6.5) and 10.1 (SD 7.0), a 27% decrease in mean score during treatment, suggesting sensitivity to change. A point estimate of the MID was approximately 3 points (range of 2-4). CONCLUSIONS: The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.

SARS-CoV-2 B.1.1.529 (Omicron) Variant Transmission Within Households - Four U.S. Jurisdictions, November 2021-February 2022.

The B.1.1.529 (Omicron) variant, first detected in November 2021, was responsible for a surge in U.S. infections with SARS-CoV-2, the virus that causes COVID-19, during December 2021-January 2022 (1). To investigate the effectiveness of prevention strategies in household settings, CDC partnered with four U.S. jurisdictions to describe Omicron household transmission during November 2021-February 2022. Persons with sequence-confirmed Omicron infection and their household contacts were interviewed. Omicron transmission occurred in 124 (67.8%) of 183 households. Among 431 household contacts, 227 were classified as having a case of COVID-19 (attack rate [AR] = 52.7%).† The ARs among household contacts of index patients who had received a COVID-19 booster dose, of fully vaccinated index patients who completed their COVID-19 primary series within the previous 5 months, and of unvaccinated index patients were 42.7% (47 of 110), 43.6% (17 of 39), and 63.9% (69 of 108), respectively. The AR was lower among household contacts of index patients who isolated (41.2%, 99 of 240) compared with those of index patients who did not isolate (67.5%, 112 of 166) (p-value <0.01). Similarly, the AR was lower among household contacts of index patients who ever wore a mask at home during their potentially infectious period (39.5%, 88 of 223) compared with those of index patients who never wore a mask at home (68.9%, 124 of 180) (p-value <0.01). Multicomponent COVID-19 prevention strategies, including up-to-date vaccination, isolation of infected persons, and mask use at home, are critical to reducing Omicron transmission in household settings.

The Effectiveness of Collaborative Care on Depression Outcomes for Racial/Ethnic Minority Populations in Primary Care: A Systematic Review.

BACKGROUND: Racial/ethnic minorities experience a greater burden of mental health problems than white adults in the United States. The collaborative care model is increasingly being adopted to improve access to services and to promote diagnosis and treatment of psychiatric diseases. OBJECTIVE: This systematic review seeks to summarize what is known about collaborative care on depression outcomes for racial/ethnic minorities in the United States. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Collaborative care studies were included if they comprised adults from at least one racial/ethnic minority group, were located in primary care clinics in the United States, and had depression outcome measures. Core principles described by the University of Washington Advancing Integrated Mental Health Solutions Center were used to define the components of collaborative care. RESULTS: Of 398 titles screened, 169 full-length articles were assessed for eligibility, and 19 studies were included in our review (10 randomized controlled trials, 9 observational). Results show there is potential that collaborative care, with or without cultural/linguistic tailoring, is effective in improving depression for racial/ethnic minorities, including those from low socioeconomic backgrounds. CONCLUSIONS: Collaborative care should be explored as an intervention for treating depression for racial/ethnic minority patients in primary care. Questions remain as to what elements of cultural adaptation are most helpful, factors behind the difficulty in recruiting minority patients for these studies, and how the inclusion of virtual components changes access to and delivery of care. Future research should also recruit individuals from less studied populations.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Applying the Principles for Digital Development: Case Study of a Smartphone App to Support Collaborative Care for Rural Patients With Posttraumatic Stress Disorder or Bipolar Disorder.

BACKGROUND: Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders. OBJECTIVE: The aim of this study was to seek to gain an understanding of how to incorporate a patient-provider mobile health (mHealth) platform to support the delivery of integrated primary care-based mental health services (Collaborative Care) to rural patients with posttraumatic stress disorder and/or bipolar disorder. METHODS: Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a mobile system to support Collaborative Care. The system consists of a patient-facing smartphone app that integrates with a Web-based clinical patient registry used by behavioral health care managers and consulting psychiatrists. Throughout development, we engaged representatives from the system's two user types: (1) providers, who use the Web-based registry and (2) patients, who directly use the mobile app. We extracted mobile metadata to describe the early adoption and use of the system by care managers and patients and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale (SUS). RESULTS: Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean SUS score at week 8 among four patients who completed this measure was 91.9 (range 72.5-100). We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions. CONCLUSIONS: Adhering to the Principles for Digital Development, we created and deployed an mHealth system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. On the basis of our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: design for public health impact, add value for all users, test the product and the process, acknowledge disruption, and anticipate variability.

Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study.

BACKGROUND: To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often on a weekly or monthly basis. Increasingly, patient-provider contacts occur remotely (eg, by telephone and Web-based portals), and mobile health tools can now monitor depressed mood daily or more frequently. However, the reliability and utility of daily ratings are unclear. OBJECTIVE: This study aimed to examine the association between a daily depressive symptom measure and the Patient Health Questionnaire-9 (PHQ-9), the most widely adopted depression self-report measure, and compare how well these 2 assessment methods predict patient outcomes. METHODS: A total of 547 individuals completed smartphone-based measures, including the Patient Health Questionnaire-2 (PHQ-2) modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent depression based on the PHQ-2 (for repeated measures) between weeks 2 and 4 and its correlation with the PHQ-9 at week 4. Regression models predicted week 8 depressive symptoms and disability ratings with daily PHQ-2 and PHQ-9. RESULTS: The daily PHQ-2 and PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r=.80). Findings were robust across demographic groups (age, gender, and ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting week 8 disability and were independent predictors of week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. CONCLUSIONS: Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care.

Digital technology and clinical decision making in depression treatment: Current findings and future opportunities.

Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains.

Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study.

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

BACKGROUND: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. OBJECTIVES: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. METHODS: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. RESULTS: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. CONCLUSIONS: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Estimated herd prevalence and sequence types of Coxiella burnetii in bulk tank milk samples from commercial dairies in Indiana.

BACKGROUND: Coxiella burnetii is the etiologic agent of Q fever, a zoonotic disease causing influenza-like illness, pregnancy loss, cardiovascular disease and chronic fatigue syndrome in people. C. burnetii is considered to be enzootic in ruminants, but clinical signs of infection do not always manifest. National studies have documented the presence of C. burnetii in dairy herds in Indiana. This represents an opportunity to better characterize the distribution and prevalence of C. burnetii infection at the state scale, allowing evaluation of the need for surveillance and response planning to occur at this level. A cross-sectional study was conducted to estimate the herd prevalence of C. burnetii in commercial cattle dairies in Indiana and characterize the strains of C. burnetii within these dairies. RESULTS: Bulk tank milk samples were collected between June and August of 2011 by the Indiana State Board of Animal Health (ISBOAH). A total of 316 of these samples were tested for the IS1111 transposon of C. burnetii using quantitative real time polymerase chain reaction (PCR). Single nucleotide polymorphism (SNP) genotyping was used to identify the multispacer sequence genotypes (ST) present in samples where the IS1111 transposon was identified. The geographic distribution of dairies testing positive for C. burnetii DNA and the identified STs were also evaluated. The estimated overall herd prevalence for C. burnetii DNA was 61.1 % (95 % CI 55.6-66.3 %). The highest estimated regional prevalence was 70.2 % in the Central region of Indiana. An ST was identifiable in 74 of the positive 178 samples (41.6 %) and none of the 10 negative samples tested. Of these samples, 71 (95.9 %) were identified as ST20, 2 (2.7 %) as ST8 and a combination of ST20 and ST8 was identified in a single sample. CONCLUSIONS: C. burnetii is present in dairy herds throughout Indiana. Indiana follows national trends with ST20 most commonly identified. The presence of multiple STs in a single bulk tank sample indicates that multiple strains of C. burnetii can circulate within a herd. This supports potential transmission of C. burnetii between goats and cattle, presenting the potential for a switch in the dominant genotype found in a given species.

Effectiveness of the Engagement and Counseling for Latinos (ECLA) intervention in low-income Latinos.

BACKGROUND: Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments. OBJECTIVE: Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6-8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression. DESIGN: Multisite randomized controlled trial. SETTING: Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico. PARTICIPANTS: 257 Latino patients recruited from primary care between May 2011 and September 2012. MAIN OUTCOME MEASURES: The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0). RESULTS: Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03). CONCLUSIONS AND RELEVANCE: The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.

Associations between antidepressant adherence and shared decision-making, patient-provider trust, and communication among adults with diabetes: diabetes study of Northern California (DISTANCE).

BACKGROUND: Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence. OBJECTIVE: To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence. DESIGN: Observational new prescription cohort study. SETTING: Kaiser Permanente Northern California. PATIENTS: One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010. MEASUREMENTS: Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription). RESULTS: After adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p < 0.05), early non-persistence (RR = 1.34, p < 0.01) and NPMG (estimated 5% greater gap in medication supply, p < 0.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22-1.25, ps < 0.05) and NPMG (estimated NPMG differences 5-8%, ps < 0.01). LIMITATIONS: All patients were insured and had consistent access to and quality of care. CONCLUSIONS: Patients' perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.

Binding of nucleoid-associated protein fis to DNA is regulated by DNA breathing dynamics.

Physicochemical properties of DNA, such as shape, affect protein-DNA recognition. However, the properties of DNA that are most relevant for predicting the binding sites of particular transcription factors (TFs) or classes of TFs have yet to be fully understood. Here, using a model that accurately captures the melting behavior and breathing dynamics (spontaneous local openings of the double helix) of double-stranded DNA, we simulated the dynamics of known binding sites of the TF and nucleoid-associated protein Fis in Escherichia coli. Our study involves simulations of breathing dynamics, analysis of large published in vitro and genomic datasets, and targeted experimental tests of our predictions. Our simulation results and available in vitro binding data indicate a strong correlation between DNA breathing dynamics and Fis binding. Indeed, we can define an average DNA breathing profile that is characteristic of Fis binding sites. This profile is significantly enriched among the identified in vivo E. coli Fis binding sites. To test our understanding of how Fis binding is influenced by DNA breathing dynamics, we designed base-pair substitutions, mismatch, and methylation modifications of DNA regions that are known to interact (or not interact) with Fis. The goal in each case was to make the local DNA breathing dynamics either closer to or farther from the breathing profile characteristic of a strong Fis binding site. For the modified DNA segments, we found that Fis-DNA binding, as assessed by gel-shift assay, changed in accordance with our expectations. We conclude that Fis binding is associated with DNA breathing dynamics, which in turn may be regulated by various nucleotide modifications.

Aligning health information technologies with effective service delivery models to improve chronic disease care.

OBJECTIVE: Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care, have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. METHOD: A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. RESULTS: Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. CONCLUSION: HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems.

Seventy-one important questions for the conservation of marine biodiversity.

The ocean provides food, economic activity, and cultural value for a large proportion of humanity. Our knowledge of marine ecosystems lags behind that of terrestrial ecosystems, limiting effective protection of marine resources. We describe the outcome of 2 workshops in 2011 and 2012 to establish a list of important questions, which, if answered, would substantially improve our ability to conserve and manage the world's marine resources. Participants included individuals from academia, government, and nongovernment organizations with broad experience across disciplines, marine ecosystems, and countries that vary in levels of development. Contributors from the fields of science, conservation, industry, and government submitted questions to our workshops, which we distilled into a list of priority research questions. Through this process, we identified 71 key questions. We grouped these into 8 subject categories, each pertaining to a broad component of marine conservation: fisheries, climate change, other anthropogenic threats, ecosystems, marine citizenship, policy, societal and cultural considerations, and scientific enterprise. Our questions address many issues that are specific to marine conservation, and will serve as a road map to funders and researchers to develop programs that can greatly benefit marine conservation.

A Technique for Arthroscopic Fixation of Tibial Eminence Avulsion Fractures: A Physeal-Sparing Construct With All-Suture Anchor Bridge Fixation.

Arthroscopic or open surgical treatment is indicated for displaced tibial spine fractures to obtain anatomic reduction and restore the functionality of the anterior cruciate ligament. Numerous open and arthroscopic techniques for the treatment of tibial spine fractures have been described. The purpose of this technical note is to describe a minimally invasive arthroscopic physeal- and ligament-sparing surgical technique using knotless all-suture anchors to provide stable bridge fixation over displaced tibial spine fractures.

Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9.

BACKGROUND: With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. OBJECTIVE: To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. DESIGN: Observational analysis of data collected from a patient registry. PARTICIPANTS: Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). INTERVENTIONS: MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. MAIN MEASURES: The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). KEY RESULTS: SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). CONCLUSIONS: Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE).

BACKGROUND: Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence. OBJECTIVE: To determine whether health literacy limitations are associated with poorer antidepressant medication adherence. DESIGN: Observational new prescription cohort follow-up study. PARTICIPANTS: Adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010 (N = 1,366) at Kaiser Permanente Northern California. MAIN MEASURES: Validated three-item self-report scale measured health literacy. Discrete indices of adherence based on pharmacy dispensing data according to validated methods: primary non-adherence (medication never dispensed); early non-persistence (dispensed once, never refilled); non-persistence at 180 and 365 days; and new prescription medication gap (NPMG; proportion of time that the person is without medication during 12 months after the prescription date). KEY RESULTS: Seventy-two percent of patients were classified as having health literacy limitations. After adjusting for sociodemographic and clinical covariates, patients with health literacy limitations had significantly poorer adherence compared to patients with no limitations, whether measured as early non-persistence (46 % versus 38 %, p < 0.05), non-persistence at 180 days (55 % versus 46 %, p < 0.05), or NPMG (41 % versus 36%, p < 0.01). There were no significant associations with primary adherence or non-persistence at 365 days. CONCLUSIONS: Poorer antidepressant adherence among adults with diabetes and health literacy limitations may jeopardize the continuation and maintenance phases of depression pharmacotherapy. Findings underscore the importance of national efforts to address health literacy, simplify health communications regarding treatment options, improve public understanding of depression treatment, and monitor antidepressant adherence.

Care managers' experiences in a collaborative care program for high risk mothers with depression.

OBJECTIVES: The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. METHODS: As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. RESULTS: Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient-provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient-provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. CONCLUSIONS: Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.