Treating major depression in primary care practice. Eight-month clinical outcomes.

BACKGROUND: We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care. METHODS: A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n = 91) or interpersonal psychotherapy (n = 93) provided within well-structured parameters, or a physician's usual care (n = 92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months. RESULTS: Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months. CONCLUSIONS: Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.

Recognition of alcoholism and substance abuse in primary care patients.

Alcohol and other substance abuse are frequently seen in primary medical practice but are underdiagnosed. Forty-two (14%) of 294 adult primary care patients suffered from alcohol or other substance abuse, as diagnosed by a structured psychiatric interview. Primary care physicians identified 17 (40%) of these patients, as well as another patient identified during a six-month follow-up period, as having a substance abuse problem at initial clinical evaluation. Clinically identified substance abusers were older, more likely to be married, and more often used multiple drugs. They more frequently had antisocial personality disorders, while patients not clinically recognized were often depressed. Logistic regression analysis indicated that the presence of antisocial personality, the absence of a coexisting depressive disorder, and better social functioning scores were the factors most strongly associated with clinical recognition. The study suggests clinical judgment issues, which may be useful to physicians in training to improve their recognition and treatment of substance abuse disorders.

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.

Medical comorbidity of major depressive disorder in a primary medical practice.

Despite much speculation about the relationship between depression and medical comorbidity in primary care settings, few investigators have examined this issue empirically. Using a two-stage screening procedure, we assessed 618 patients aged 18 to 64 years in an academic general medicine clinic. Forty-one patients (6.6%) suffered from a current episode of major depressive disorder (MDD). We compared this group with a 20% random sample of nondepressed patients. While patients with MDD were younger (mean age, 41.1 vs 47.2 years), they were assessed by the Duke University Severity of Illness Scale as having more severe medical illness. Patients with MDD were more likely to have malignant tumors and "ill-defined conditions" than nondepressed patients. The 18 patients with MDD (44%) who were correctly diagnosed by their physicians had less severe medical illness than those whose depression was clinically undetected. A logistic regression model predicting MDD group membership included female gender, younger age, higher Duke University Severity of Illness Scale score, and more frequent inactive ill-defined diagnoses. These findings are consistent with assertions: (1) patients with MDD have more physical illness than nondepressed patients and/or (2) somatic symptoms and disability caused by MDD add to the burden of physical illness.

Cardiovascular disease among American Indians and Alaska Natives.

OBJECTIVE: To compare the regional differences in cardiovascular disease in AI/AN with the U.S. general population and determine the parity gap and preventable proportion of cardiovascular mortality. RESEARCH DESIGN AND METHODS: Age-adjusted cardiovascular disease mortality rates for 1981-1983 and hospital discharge rates for 1982-1984 reported by the IHS were compared with U.S. data for 1982 and 1983, respectively. RESULTS: Rates of ischemic heart disease and atherosclerosis were found to be generally low among AI/AN although those in the 25- to 44-yr age-group have higher death rates from cardiovascular disease than in the U.S. population. Although the mortality rate from cardiovascular disease in AI/AN is 19% lower than the rate for the general U.S. population, the parity gap in individual regions of the U.S. ranges from favorable to extremely unfavorable. There were also wide variations in the preventable gap theoretically possible by reduction of the three major risk factors. CONCLUSIONS: Changing nutrition and exercise patterns and the increasing prevalence of diabetes in many Indian tribes may have adverse effects in the future, possibly increasing the prevalence of heart disease. Regional differences in the prevalence of some major cardiovascular risk factors (smoking, hypertension, hypercholesterolemia, and diabetes) are the probable explanation for these differences in cardiovascular morbidity and mortality rates. Prevention and treatment of these risk factors will have the greatest impact in attempts to reduce cardiovascular disease among AI/AN. In addition, moderation in the use of alcohol, or abstinence, may prevent sudden deaths resulting from acute intoxication.

Gasoline sniffing and lead toxicity in Navajo adolescents.

During a 6-year period, 23 Navajo adolescents were hospitalized 47 times for presumed lead intoxication secondary to gasoline sniffing. Most patients were male (87%) and sniffed gasoline as a social activity, more frequently in spring and summer. Sixty-five percent of the patients first presented with toxic encephalopathy. Of total episodes, 31% involved asymptomatic lead overload; 31% involved tremor, ataxia, and other neurologic signs; and 38% involved encephalopathy with disorientation and hallucinations. Free erythrocyte protoporphyrin levels were not consistently high, although blood lead levels were all elevated. One death occurred. Approximately 11% of 537 Navajo adolescents said they inhaled gasoline for enjoyment at least occasionally. Among 147 junior high school students, blood lead levels averaged 18 +/- 6 micrograms/dL with no values greater than 40 micrograms/dL. Three of these students had elevated zinc protoporphyrin levels and all three were anemic. No correlation was found between levels of blood lead or zinc protoporphyrin and whether or not the youth reported sniffing gasoline. However, sniffing gasoline was associated with poor school performance and delinquent behavior. Although apparently many Navajo adolescents experiment with gasoline inhalation, only a few engage in this activity frequently enough to develop either asymptomatic or symptomatic lead overload.

The study of literature in medical education.

The study of literature encourages the development of otherwise hard-to-teach clinical competencies. It provides access to the values and experiences of physicians, patients, and families; it calls for the exercise of skill in observation and interpretation, develops clinical imagination, and, especially through writing, preserves fluency in ordinary language and promotes clarity of observation, expression, and self-knowledge. Faculty in one-third of U.S. medical schools teach literature in courses that, although concentrated in the preclinical years, range from the first day of school, through residency programs. Once focused on the work of physician-authors and realist fiction about illness that encouraged moral reflection about the practice of medicine, literary study in medicine now encompasses a wide range of literature and narrative types, including the patient history and the clinical case. Literary study is intended not only to enrich students' moral education but also to increase their narrative competence, to foster a tolerance for the uncertainties of clinical practice, and to provide a grounding for empathic attention to patients. Literature may be included in medical humanities courses, and it may provide rich cases for ethics courses or introductions to the patient-physician relationship; it also may be the focus of small, elective, or selective courses, frequently on particular social issues or on the experience of illness. Reading, discussion, writing, and role-play rather than lectures are the methods employed; faculty include those with PhDs in literature and MDs who have strong interests in the contributions of literature to practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Using electronic mail for a small-group curriculum in ethical and social issues.

PURPOSE: To initiate an electronic mail (e-mail) program as a supplement to a medical humanities curriculum focusing on ethical and social issues. METHOD: In 1991-92 an e-mail track (called NET) was established for second-year students participating in Medicine in Contemporary Society, a four-year curriculum in medical humanities at the State University of New York at Stony Brook School of Medicine. In 1991-92 ten students volunteered to form a NET group; in 1992-93 22 students, forming two groups, were randomly selected from a volunteer pool of 76 students (from a class of 100). In both study years, the NET students analyzed and discussed electronically a series of cases posted sequentially through the academic year. Faculty tutors reviewed the students' responses, interacting with the groups and with individual students by e-mail. NET was evaluated in two ways: at the end of the course, the students completed e-mail questionnaires that included quantitative and qualitative assessments; and throughout the course, the tutors assessed the students' participation, quality of case analysis and discussion, and quality of writing. RESULTS: The students' assessments indicated that they considered NET to be more educational than the lectures, "live" group discussions, problem-based learning exercises, and formal papers in the medical humanities curriculum; that they made gains in computer literacy; and that NET enhanced their abilities to think about ethical and social issues. The tutors judged that the students had improved their written self-expression as the course progressed. CONCLUSION: NET adequately accomplished the goals set for it as an adjunct to the small-group sessions and other components of the medical humanities curriculum.

Treating depression in primary care practice. An application of decision analysis.

Decision analysis approaches complex treatment issues by considering alternative strategies in an explicit and logical manner, and examining their outcomes in the face of varied assumptions. Significant data gaps impede full application of this framework to the treatment of depressed primary care patients. Nevertheless, decision analysis already can be useful in emphasizing needed clinical information in treating these patients and highlighting future directions for research.

Psychiatric decision making in family practice. Future research directions.

Psychiatric illnesses in family practice are significantly underdiagnosed because of factors associated with both the physician and patient. Clinicians too often fail to utilize a biopsychosocial approach in the assessment process, tending to assess symptoms as organic regardless of their etiology. Patients similarly tend to emphasize the physical nature of their complaints when presenting in medical settings. Efforts have been made to improve the physician's diagnostic accuracy through the use of screening scores. The results, however, are inconclusive. It remains unclear whether the physician disregards this information or considers it irrelevant. We suggest that future research investigate not only the accuracy of the clinician's diagnostic formulation but also the processes whereby the family practitioner elicits, analyzes, and synthesizes or discards cues pertinent to mental illness. By combining statistical analyses with the analytic techniques developed in studies of medical decision making and general problem solving, detailed leads should emerge for the design of improved didactic and experiential training programs.

Strategies for evaluating treatments for major depression in primary care patients.

Primary care physicians are being urged to provide patients experiencing a major depression treatments validated with psychiatric patients. The propriety of transferring clinical technologies from one care-giving sector to another is questionable, however, as it has little scientific support. We suggest that clinical trials be initiated so as to expand the available knowledge base. This paper analyzes the methodologic issues involved in pursuing such experimental research and urges that it be conducted despite the possible need for initial design compromises.

Chiropractic and the clinical art.

Chiropractic is the largest 'unorthodox' health profession in the U.S.A. It is licensed in all 50 states and its services are covered by governmental and private health insurance. Yet chiropractic remains, in the opinion of medical commentators, an unscientific healing cult. Chiropractic holds that much illness is caused, directly or indirectly, by derangements in homeostasis that result from subtle vertebral malalignments called 'subluxations'. Only a minority of 'straight' chiropractors continue to provide spinal manipulation as their only modality, while the majority 'mixers' have embraced physical therapy, vitamin supplements and a wide variety of drugless treatments. Clinical trials suggest that spinal manipulation itself has short-term benefit in back pain, but the success of chiropractic is not fully explained by that effect. The clinical art, though, as manifested in the chiropractor-patient interaction contributes greatly to chiropractic healing. This process promotes patient acceptance and validation, fulfills expectations, provides explanations and engages the patient's commitment. The same process lies at the core of the 'art of medicine'. Seeing the clinical art as it functions in chiropractic can help us to understand its independent power in medicine.

Hypertension followup in an urban black population.

In a 5-year period, 215 black hypertensives were identified at a neighborhood primary care center that offered free services to residents of a low-income housing project. The mean length of followup for the group was about 34 months, and 183 persons were followed for more than 1 year. Their mean age was 56 years; there were 34 men and 181 women in the group. Fifty-six percent of the 215 persons had a history of hypertension when they came to the center. Three types of outcome measures were examined in this study: (a) compliance, in terms of continued activity in the clinic; (b) lower blood pressure, preferably in the normal range; and (c) development of complications of hypertension. Sixty-seven percent of those alive and still residing in the area were continuing in the program; 37% achieved normotension and an added 21% had improved blood pressure readings. There was no statistical difference in the occurrence of hypertensive complications by initial severity of the hypertension or by how well the blood pressure was controlled. The 75 obese women in the group had more severe hypertension, more new complications, and were less likely to achieve normotension than the 106 nonobese women. These relationships were statistically significant.

Cost-benefit of a streptococcal surveillance program among Navajo Indians.

A school-based streptococcal surveillance program has been in effect among Navajo Indians for more than 4 years. Throat cultures of symptomatic children are obtained when indicated, and routine throat cultures are performed monthly. Children whose cultures are positive for group A beta-hemolytic streptococci are treated. During 4 academic years, between 48 percent and 56 percent of elementary school children attended the schools that had 4 or more monthly surveys in each year, but only 24 percent (7 of 29) of the acute rheumatic fever (ARF) cases occurred in children at those schools. Six of seven children attending covered schools were not cultured before their ARF episodes. Five cases occurred in children attending previously covered schools, during years in which participation lapse. Three or four ARF cases per year appeared to have been prevented, but the program's costs were five times the estimated costs of the prevented cases, even excluding risks of allergic reactions to penicillin. There is little evidence that most asymptomatic carriers are at risk to develop ARF. The authors recommend that streptococcal surveillance efforts be confined largely to culturing throat swabs of children with pharyngitis.

Epidemiology of Haemophilus influenzae type B disease among Navajo Indians.

During a 7-year period ending June 30, 1980, the annual incidence of all Haemophilus influenzae type b disease among Navajo children less than 5 years old was 214 per 100,000, and that of H. influenzae meningitis was 152 per 100,000. Eighty-one percent of H. influenzae meningitis occurred in children 12 months of age or younger, and 64 percent clustered in children ages 4 through 8 months. Meningitis accounted for 70 percent of all invasive disease. No epiglottitis was observed. The epidemiology is similar to that in Yupik Eskimos, who have an even higher rate of H. influenzae type b disease than Navajos but are a much smaller population. Mortality from H. influenzae meningitis was low (4 percent) among Navajo children, but neurological sequelae were observed in at least 16 percent of the survivors. This high rate of sequelae may be due in part to clustering of cases in infancy. Among normal Navajo neonates, 79 percent had maternal capsular type b antibody titers greater than or equal to 0.15 micrograms per deciliter (microgram per dl), and the whole group had a geometric mean titer of 0.51 micrograms per dl. By age 4 months, when meningitis cases became frequent, only 14 percent of Navajo infants had antibody titers greater than or equal to 0.15 micrograms per dl. Twelve of 67 asymptomatic infants (18 percent), each monitored every 2 months, had H. influenzae type b or a cross-reacting organism isolated from the pharynx on at least one occasion before they were 9 months old. Active immunization would be theoretically indicated in this population with high H.influenzae type b exposure and disease, but a vaccine would have to confer substantial immunity in very young infants.

Bacterial meningitis in Navojo Indians.

An analysis of 219 confirmed cases of bacterial meningitis among Navajo Indians during a 5-year period, July 1, 1968, through June 30, 1973, revealed that 56 percent were caused by Haemophilus influenzae, 26 percent by Neisseria meningitidis, 6 percent by Mycobacterium tuberculosis, and 6 percent by other organisms. The annual incidence of H. influenzae meningitis (17.7 per 100,000 persons) and that of pneumococcal meningitis (8.0 per 100,000) were much higher than the rates for these diseases reported from other population groups. The annual incidence of meningococcal meningitis (2.0 per 100,000) was similar to that found elsewhere. There was an ususual concentration of cases during the first year of life; 78 percent of H. influenzae, 64 percent of pneumococcal, and 50 percent of meningococcal meningitis occurred during this time. However, bacterial meningitis during the first month of life was not frequent (0.29 per 1,000 live births). Case fatality rates were similar to those reported for other population groups.

A taxonomy of difficult physician-patient interactions.

A taxonomy of troublesome physician-patient interactions helps learners classify what goes wrong during an interview and then remedy the problem in order to obtain reliable symptom data. This framework permits an orderly approach to interactions that often become laden with emotion and also emphasizes the use of specific skills to acquire accurate and precise medical information. Like most systems of classification in medicine, this one is a mixed bag of nosology; although based on the needs of learners, it is arbitrary and imperfect and will change as new knowledge is integrated.

Psychiatric disorders in primary care: physician judgements of prevalence and management.

Primary care physicians underdiagnose depression, anxiety, and other psychiatric disorders. Decision analysis suggests that subjective estimates of the probability of a condition and the utility (severity and treatability) of identifying that condition play a role in diagnosis. We asked 108 internists (IM) and family practitioners (FP) to rank 25 conditions on ten-point scales for probability, severity, and treatability. FPs ranked depression significantly higher than IMs did on all three scales, anxiety reactions higher in probability and severity, and both alcoholism and drug dependency higher on the severity scale. Ranks for schizophrenia and personality disorder did not differ between specialties. Thirty-eight physicians completed the scales a second time after six to eight weeks. Test-retest agreement ranged from 47% to 100% for different conditions on different scales. Some common psychiatric disorders tended to have low test-retest agreement in probability and severity. With further refinement, this instrument may contribute to the investigation of psychiatric decision making in primary care.

Ascorbic acid and the common cold: reviewing the evidence.

Large-scale clinical trials of the effect of vitamin C on the common cold conducted since Pauling's pronouncement on its efficacy in 1970 have produced conflicting results. Benefits shown have been modest, and positive findings have not been reproducible. Reported benefits probably are due to statistical artifact, minor vitamin-induced physiologic changes, the placebo effect, or a combination of these.

Navajo Indian medicine: implications for healing.

Traditional medicine men coexist with physicians and hospitals on the 25,000 square mile Navajo Indian Reservation. Most seriously ill Navajos utilize both systems of health care. This natural experiment of coexistence emphasizes several general characteristics of all healing. Traditional ceremonies are successful because they are integrated into Navajo belief systems and meet needs of sick people not dealt with by the available Western medicine. Physicians and other healers simply remove obstacles to the body's restoration of homeostasis or, as the Navajo say, to harmony. Reductionism limits the spectrum of obstacles considered relevant (eg, causes of illness), but an alternate model might include emotional, social, or spiritual phenomena equally as significant to healing as are biochemical phenomena. In that context, nonmedical healers, as well as physicians, can potentially influence factors relevant to getting well.