Family-centered depression treatment for older men in primary care: a qualitative study of stakeholder perspectives.

BACKGROUND: Family members often play important roles in the lives of depressed older men and frequently attend primary care visits with their loved ones, yet surprisingly little is known about how to most effectively engage and include family members in depression treatment. However, including family in depression treatment may be difficult due to several factors, such as depression stigma and family conflicts. The objective of this study was to describe challenges in engaging family members in older men's depression treatment and potential strategies to overcome those challenges. METHODS: A cross-sectional, qualitative descriptive interview study was conducted in a safety-net, Federally Qualified Health Center in California's Central Valley. A total of 37 stakeholders were recruited, including 15 depressed older (i.e. age ≥ 60) men, 12 family members, and 10 clinic staff. Depressed men were identified through mail outreach, waiting room screening, and referral. Depressed men identified family members who were later approached to participate. We also recruited a purposeful sample of clinic staff. Interviews explored stakeholder perspectives on family involvement in men's depression treatment as part of a primary care intervention. Interviews were conducted using a semi-structured interview guide, tape-recorded, transcribed verbatim, and translated if the interview was conducted in Spanish. RESULTS: Four themes were identified representing core challenges: engaging men at the right time; preserving men's sense of autonomy; managing privacy concerns; and navigating family tensions. Stakeholders also provided practical suggestions and advice about how each of these challenges might be addressed. CONCLUSIONS: While engaging family is a promising approach to strengthen depression care for older men in primary care settings, several potential challenges exist. Family- centered depression intervention development and clinical practice need to anticipate these challenges and to develop approaches and guidelines to address them.

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations.

BACKGROUND: Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. OBJECTIVE: To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. DESIGN: This was an observational study using patient registry. SUBJECTS: The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. MAIN OUTCOMES: We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. KEY RESULTS: While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. CONCLUSIONS: Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

Prevalence of symptoms of depression and anxiety in adults with cystic fibrosis based on the PHQ-9 and GAD-7 screening questionnaires.

OBJECTIVE: To examine the prevalence of symptoms of depression and anxiety among patients with cystic fibrosis (CF) who were followed up at the University of Washington Adult CF clinic and to identify sociodemographic and clinical factors associated with symptoms. METHODS: A total of 178 adults with CF were asked to complete the Patient Health Questionnaire-9 for depression and General Anxiety Disorder-7 for anxiety when clinically stable. Clinically significant symptoms of depression and anxiety were defined in the following 2 ways: (1) symptom definition-presence of moderate-to-severe symptoms based on the questionnaires and (2) composite definition-symptom definition or the use of psychiatric medications to manage symptoms. Associations between Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores with sociodemographic (gender, age, age of CF diagnosis, vocation, and spousal status) and clinical factors (forced expiratory volume in 1 second, body mass index, and CF-related diabetes on insulin) were examined. RESULTS: Of 178 patients, 153 (85%) completed the screening questionnaires. Based on the symptom definition, 7% of patients had symptoms of depression and 5% had symptoms of anxiety. Using the composite definition, 22% of patients had symptoms of depression and 10% had symptoms of anxiety. Based on the Patient Health Questionnaire-9, 5% of patients reported suicidal thoughts. In multiple linear regression analysis, only forced expiratory volume in 1 second % predicted was independently associated with Patient Health Questionnaire-9 depression scores, and no sociodemographic or clinical factors were associated with General Anxiety Disorder-7 anxiety scores. CONCLUSIONS: We conclude that all adults with CF should be screened for symptoms of depression and anxiety given the difficulty in identifying strong clinical risk factors and the unexpected high rates of suicidal ideation.

The presentation, recognition and management of bipolar depression in primary care.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Substance screening and referral for substance abuse treatment in an integrated mental health care program.

OBJECTIVE: This study examined rates of substance screening and referral for substance abuse treatment as part of an integrated care program providing mental health services to low-income patients in primary care. METHODS: Adults (N=11,150) who were enrolled in the program between 2008 and 2010 were included. Primary outcomes included substance screening rates, treatment referral rates, and correlates of accessing recommended treatment. RESULTS: A total of 7,513 (67%) participants were screened for substance abuse. Among the 2,856 (38%) participants with a positive screen, 1,344 (47%) were referred for treatment. After adjustment for covariates, accessing recommended treatment was associated with past substance abuse treatment history, alcohol use, heavy drug use, posttraumatic stress disorder, and number of follow-up contacts with a care manager. CONCLUSION: This study of a vulnerable population highlights missed opportunities for identifying and referring patients in primary care to substance abuse treatment.

Strategies to improve the management of depression in primary care.

Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

Improving primary care for older adults with cancer and depression.

BACKGROUND: Depression is common among older cancer patients, but little is known about the optimal approach to caring for this population. This analysis evaluates the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, a stepped care management program for depression in primary care patients who had an ICD-9 cancer diagnosis. METHODS: Two hundred fifteen cancer patients were identified from the 1,801 participants in the parent study. Subjects were 60 years or older with major depression (18%), dysthymic disorder (33%), or both (49%), recruited from 18 primary care clinics belonging to 8 health-care organizations in 5 states. Patients were randomly assigned to the IMPACT intervention (n = 112) or usual care (n = 103). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care provider and who offered education, care management, support of antidepressant management, and brief, structured psychosocial interventions including behavioral activation and problem-solving treatment. RESULTS: At 6 and 12 months, 55% and 39% of intervention patients had a 50% or greater reduction in depressive symptoms (SCL-20) from baseline compared to 34% and 20% of usual care participants (P = 0.003 and P = 0.029). Intervention patients also experienced greater remission rates (P = 0.031), more depression-free days (P < 0.001), less functional impairment (P = 0.011), and greater quality of life (P = 0.039) at 12 months than usual care participants. CONCLUSIONS: The IMPACT collaborative care program appears to be feasible and effective for depression among older cancer patients in diverse primary care settings.

Strategies for identifying and channeling patients for depression care management.

OBJECTIVE: To determine optimal methods of identifying enrollees with possible depression for additional depression screening in the context of a care management program for chronically ill Medicare recipients. STUDY DESIGN: Observational analysis of telephone and mail survey and claims data collected for the Medicare Health Support (MHS) program. METHODS: This study examines data from 14,902 participants with diabetes mellitus and/or congestive heart failure in the MHS program administered by Green Ribbon Health, LLC. Depression screening was performed by administering a 2-item screen (the Patient Health Questionnaire 2 [PHQ-2]) by telephone or by mail. Additional information about possible depression was drawn from International Classification of Diseases, Ninth Revision (ICD-9) depression diagnoses on claims and from self-reported use of antidepressant medications. We evaluated positive depression screens using the PHQ-2 administered via telephone versus mail, examined variations in screener-positive findings by care manager, and compared rates of positive screens with antidepressant use and with claims diagnoses of depression. RESULTS: Almost 14% of participants received an ICD-9 diagnosis of depression during the year before program enrollment; 7.1% reported taking antidepressants, and 5.1% screened positive for depression on the PHQ-2. We found substantial variation in positive depression screens by care manager that could not be explained by case mix, prior depression diagnoses, or current depression treatment. After adjusting for demographic and clinical differences, the PHQ-2-positive screen rates were 6.5% by telephone and 14.1% by mail (P <.001). CONCLUSION: A multipronged effort composed of mail screening (using the PHQ-2), self-reported antidepressant use, and claims diagnoses of depression may capture the greatest number of enrollees with possible depression.

Depression and diabetes: a potentially lethal combination.

OBJECTIVE: To assess whether Medicare fee-for-service beneficiaries with depression and diabetes had a higher mortality rate over a 2-year period compared with beneficiaries with diabetes alone. DESIGN: Evidence of depression was based on a physician diagnosis or self-reported prescription of an antidepressant in the year prior to screening, or a score of > or = 3 on the Patient Health Questionnaire two-item questionnaire. Mortality was assessed bi-monthly by checking Medicare claims and eligibility files or from information from telephone contact with the participant's family. Cox proportional hazard regression models were used to calculate adjusted hazard ratios of death in depressed versus nondepressed beneficiaries with diabetes. PARTICIPANTS: A total of 10,704 beneficiaries with diabetes enrolled in a disease management program were surveyed with a health assessment questionnaire and followed over a two-year period. MAIN RESULTS: Comorbid depression in Medicare beneficiaries with diabetes participating in a disease management program was associated with an increased risk for all-cause mortality over a two-year period of approximately 36% to 38%, depending on the definition of depression that was used. No significant increase in rates of cause-specific mortality from macrovascular disease were found in depressed versus nondepressed beneficiaries. CONCLUSION: Among a large Medicare cohort of fee-for-service beneficiaries with diabetes, comorbid depression was associated with an increase in all-cause mortality over a two-year period. Future research will be required to determine whether the increase in mortality associated with depression is due to potential behavioral mediators (i.e., smoking, poor adherence to diet) or physiologic abnormalities (i.e., hypothalamic-pituitary axis dysregulation) associated with depression.

Screening for generalized anxiety disorder in geriatric primary care patients.

OBJECTIVE: To compare two brief screening measures as tools for detecting generalized anxiety disorder (GAD) among older primary care patients. METHODS: Receiver operating characteristic curve analysis was used to compare the Hospital Anxiety and Depression Scale (HADS) and the Brief Symptom Inventory-18 (BSI-18) against GAD diagnoses obtained from a structured diagnostic interview. RESULTS: The HADS Anxiety subscale was the only measure that distinguished individuals with and without GAD. A cutpoint greater than or equal to 8 on the HADS Anxiety subscale resulted in a sensitivity of 0.967 and a specificity of 0.667 for detecting GAD. CONCLUSIONS: The HADS Anxiety subscale appears to show some advantages over the BSI-18 Anxiety subscale as a brief, self-report measure of anxiety symptoms among older medical patients.

Regular use of prescribed opioids: association with common psychiatric disorders.

Use of opioids for chronic non-cancer pain is increasing, but the clinical epidemiology and standards of care for this practice are poorly defined. Psychiatric disorders are associated with increased physical symptoms and may be associated with opioid use. We performed a secondary analysis of cross-sectional data from the Health Care for Communities (HCC) survey conducted in 1997-1998 (N=9279) to determine the association of psychiatric disorders and self-reported regular use of prescribed opioids within the past year. Regular prescription opioid use was reported by 282 (3%) respondents. In unadjusted logistic regression models, respondents with common mental disorders in the past year (major depression, dysthymia, generalized anxiety disorder, or panic disorder) were more likely to report regular prescription opioid use than those without any of these disorders (OR=6.15, 95% CI=4.13, 9.14, P< 0.001). Respondents reporting problem drug use (OR=4.75, 95% CI=2.52, 8.94, P<0.001), or problem alcohol use (OR=1.89, 95% CI=1.03, 3.40, P=.041) reported higher rates of prescribed opioid use than those without problem use. In multivariate logistic regression models controlling for demographic and clinical variables, the presence of a common mental disorder remained a significant predictor of prescription opioid use (OR=3.15, 95% CI=1.69, 5.88, P<0.001), among individuals reporting low pain interference (N=8307); but not (OR=1.27, n.s.) among those reporting high pain interference (N=972). Depressive, anxiety and drug abuse disorders are associated with increased use of regular opioids in the general population. Depressive and anxiety disorders are more common and more strongly associated with prescribed opioid use than drug abuse disorders.

Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities.

OBJECTIVE: We sought to estimate national rates of screening and treatment of alcohol, drug, and mental (ADM) problems in primary care. DESIGN: This was a cross-sectional survey administered from 1997 to 1998. PARTICIPANTS: Our study included a nationally representative household probability sample of 7301 primary care patients. MEASUREMENT: We used patient self-reports from a telephone survey to estimate rates of screening and treatment of common ADM problems, to examine the types of screening and treatment received, and to investigate adherence with treatment recommendations. Covariates included measures of ADM conditions, physical health, and sociodemographic indicators. RESULTS: Among adult primary care patients, 38.6% (95% confidence intervals [CI] 37.2-40.0) reported clinician screening for an ADM problem. Alcohol or drug screening occurred more frequently (28.3%; 95% CI 27.0-29.6) than screening for depression and anxiety (21.2%; 95% CI 20.1-22.2). Among those screened, 30.1% (95% CI; 27.8-32.4) reported ADM treatment in primary care. Medications (16.4%; 95% CI 14.3-18.5) and counseling (18.2%; 95% CI 16.1-20.3) were the most common treatments. Rates of screening were higher among individuals with ADM disorders, the young and middle aged, and the college educated. Treatment rates were higher among individuals with ADM disorders. CONCLUSIONS: Substantial effort is expended screening and treating common ADM problems in primary care, and these efforts are targeted towards those with ADM disorders. However, only about half of individuals with an ADM disorder report being screened, and among this group, about 60% report receiving any treatment.

Common comorbidity scales were similar in their ability to predict health care costs and mortality.

OBJECTIVE: To compare the ability of commonly used measures of medical comorbidity (ambulatory care groups [ACGs], Charlson comorbidity index, chronic disease score, number of prescribed medications, and number of chronic diseases) to predict mortality and health care costs over 1 year. STUDY DESIGN AND SETTING: A prospective cohort study of community-dwelling older adults (n=3,496) attending a large primary care practice. RESULTS: For predicting health care charges, the number of medications had the highest predictive validity (R(2)=13.6%) after adjusting for demographics. ACGs (R(2)=16.4%) and the number of medications (15.0%) had the highest predictive validity for predicting ambulatory visits. ACGs and the Charlson comorbidity index (area under the receiver operator characteristic [ROC] curve=0.695-0.767) performed better than medication-based measures (area under the ROC curve=0.662-0.679) for predicting mortality. There is relatively little difference, however, in the predictive validity across these scales. CONCLUSION: In an outpatient setting, a simple count of medications may be the most efficient comorbidity measure for predicting utilization and health-care charges over the ensuing year. In contrast, diagnosis-based measures have greater predictive validity for 1-year mortality. Current comorbidity measures, however, have only poor to moderate predictive validity for costs or mortality over 1 year.

National Institutes of Health State-of-the-Science Conference Statement: Symptom management in cancer: pain, depression, and fatigue, July 15-17, 2002.

BACKGROUND: Despite advances in early detection and effective treatment, cancer remains one of the most feared diseases. Among the most common side effects of cancer and treatments for cancer are pain, depression, and fatigue. Although research is producing increasingly hopeful insights into the causes and cures for cancer, efforts to manage the side effects of the disease and its treatments have not kept pace. The challenge that faces us is how to increase awareness of the importance of recognizing and actively addressing cancer-related distress. The National Institutes of Health (NIH) convened a State-of-the-Science Conference on Symptom Management in Cancer: Pain, Depression, and Fatigue to examine the current state of knowledge regarding the management of pain, depression, and fatigue in individuals with cancer and to identify directions for future research. Specifically, the conference examined how to identify individuals who are at risk for cancer-related pain, depression, and/or fatigue; what treatments work best to address these symptoms when they occur; and what is the best way to deliver interventions across the continuum of care. STATE-OF-THE-SCIENCE PROCESS: A non-advocate, non-Federal, 14-member panel of experts representing the fields of oncology, radiology, psychology, nursing, public health, social work, and epidemiology prepared the statement. In addition, 24 experts in medical oncology, geriatrics, pharmacology, psychology, and neurology presented data to the panel and to the conference audience during the first 1.5 days of the conference. The panel then prepared its statement, addressing the five predetermined questions and drawing on submitted literature, the speakers' presentations, and discussions held at the conference. The statement was presented to the conference audience, followed by a press conference to allow the panel to respond to questions from the media. After its release at the conference, the draft statement was made available on the Internet. The panel's final statement is available at http://consensus.nih.gov. CONCLUSIONS: The panel concluded that the available evidence supports a variety of interventions for treating cancer patients' pain, depression, and fatigue. Clinicians should routinely use brief assessment tools to ask patients about pain, depression, and fatigue and to initiate evidence-based treatments. Assessment should include discussion about common symptoms experienced by cancer patients, and these discussions should continue over the duration of the illness. Impediments to effective symptom management in cancer patients can arise from different sources and interactions among providers, patients and their families, and the health care system. Numerous factors could interfere with adequate symptom management. Among these factors are incomplete effectiveness of some treatments, a lack of sufficient knowledge regarding effective treatment strategies, patient reluctance to report symptoms to caregivers, a belief that such symptoms are simply a part of the cancer experience that must be tolerated, and inadequate coverage and reimbursement for some treatments. Additional research is needed on the definition, occurrence, the treatment of pain, depression, and fatigue, alone and in combination, in adequately funded prospective studies. The panel also concluded that the state of the science in cancer symptom management should be reassessed periodically.

Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.

BACKGROUND: Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE: To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN: A group-level randomized controlled trial. SETTING: Forty-six primary care practices in 6 managed care organizations. PATIENTS: Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS: Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES: Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS: Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS: Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.

Cognitive impairment, chronic medical illness, and risk of mortality in an elderly cohort.

OBJECTIVE: The mortality risk for older persons with chronic medical illness and cognitive impairment is relatively unknown. The authors assessed 6-year mortality risks for cognitive impairment and six chronic diseases in 7,482 subjects from the East Boston, Massachusetts, and rural Iowa cohorts of the Established Populations for Epidemiologic Studies in the Elderly (EPESE). METHODS: Cognitive impairment was identified with a modified form of Pfeiffer's Short Portable Mental Status Questionnaire. Chronic medical illnesses included diabetes, stroke, myocardial infarction, hypertension, hip fracture, and cancer. The authors examined the association of cognitive impairment and each of the six chronic illnesses with mortality by means of Cox proportional-hazards regression models, and determined the interaction of cognitive impairment and chronic medical illness on mortality. RESULTS: Participants who were cognitively impaired at baseline were found to have a 68% increased relative risk of mortality. The relative risks of mortality from diabetes, heart attack, stroke, and hip fracture were similar to the risk from cognitive impairment. Interactions between cognitive impairment and each chronic medical illness on mortality were not statistically significant. CONCLUSION: Survival curves demonstrate that the effects of cognitive impairment and chronic medical illness on mortality are mostly additive, resulting in very poor survival for those with both medical illness and cognitive impairment. Further research should examine the healthcare behaviors and needs of older adults with cognitive impairment.

National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002.

BACKGROUND: Despite advances in early detection and effective treatment, cancer remains one of the most feared diseases. Among the most common side effects of cancer and treatments for cancer are pain, depression, and fatigue. Although research is producing increasingly hopeful insights into the causes and cures for cancer, efforts to manage the side effects of the disease and its treatments have not kept pace. The challenge that faces us is how to increase awareness of the importance of recognizing and actively addressing cancer-related distress. The National Institutes of Health (NIH) convened a State-of-the-Science Conference on Symptom Management in Cancer: Pain, Depression, and Fatigue to examine the current state of knowledge regarding the management of pain, depression, and fatigue in individuals with cancer and to identify directions for future research. Specifically, the conference examined how to identify individuals who are at risk for cancer-related pain, depression, and/or fatigue; what treatments work best to address these symptoms when they occur; and what is the best way to deliver interventions across the continuum of care. State-of-the-Science Process: A non-advocate, non-Federal, 14-member panel of experts representing the fields of oncology, radiology, psychology, nursing, public health, social work, and epidemiology prepared the statement. In addition, 24 experts in medical oncology, geriatrics, pharmacology, psychology, and neurology presented data to the panel and to the conference audience during the first 1.5 days of the conference. The panel then prepared its statement, addressing the five predetermined questions and drawing on submitted literature, the speakers' presentations, and discussions held at the conference. The statement was presented to the conference audience, followed by a press conference to allow the panel to respond to questions from the media. After its release at the conference, the draft statement was made available on the Internet. The panel's final statement is available at http://consensus.nih.gov. CONCLUSIONS: The panel concluded that the available evidence supports a variety of interventions for treating cancer patients' pain, depression, and fatigue. Clinicians should routinely use brief assessment tools to ask patients about pain, depression, and fatigue and to initiate evidence-based treatments. Assessment should include discussion about common symptoms experienced by cancer patients, and these discussions should continue over the duration of the illness. Impediments to effective symptom management in cancer patients can arise from different sources and interactions among providers, patients and their families, and the health care system. Numerous factors could interfere with adequate symptom management. Among these factors are incomplete effectiveness of some treatments, a lack of sufficient knowledge regarding effective treatment strategies, patient reluctance to report symptoms to caregivers, a belief that such symptoms are simply a part of the cancer experience that must be tolerated, and inadequate coverage and reimbursement for some treatments. Additional research is needed on the definition, occurrence, the treatment of pain, depression, and fatigue, alone and in combination, in adequately funded prospective studies. The panel also concluded that the state of the science in cancer symptom management should be reassessed periodically.

A comparison of gynecological variables and service use among older women with and without schizophrenia.

Gynecological variables and service use were examined in a sample of 65 older women outpatients who had schizophrenia and in a control group of 51 women who were not known to have a psychiatric diagnosis. The groups were similar in their age at menarche and at menopause, use of oral contraceptives, and number of pregnancies and births. The groups differed in their receipt of several gynecological services; women with schizophrenia were less likely to have received mammograms or pelvic examinations and Pap tests or to have ever been prescribed hormone replacement therapy. These results suggest that women with schizophrenia receive fewer gynecological services than other women. Interventions at the patient, provider, and system levels may be needed to address this disparity in service use.

A review of the case for neonatal thyrotropin screening in developing countries: the example of India.

BACKGROUND: Infantile hypothyroidism, either caused by iodine-deficiency disorder (IDD) or congenital hypothyroidism (CH), is the world's leading cause of preventable mental retardation. Such hypothyroidism has virtually been eliminated in the developed world by salt iodization and neonatal thyroid screening. However, most developing countries do not have neonatal thyroid screening programs. Using India as an example, we review the case for newborn screening in the developing world. METHODS: A literature review on infantile hypothyroidism in India was conducted and three Indian thyroid experts were queried about their views on neonatal screening in India. RESULTS: Iodine nutrition improved markedly in India during the 1990s; 49% of the households are now using adequately iodized salt. The control of IDD is still insufficient in India. Nationally representative data on neonatal screening in India are not available, but two regional studies have been published. One study (n = 12,407) measured cord blood thyrotropin and the other (n = 25,244) measured filter paper thyroxine. These studies reported difficult socioeconomic and organizational barriers to the implementation of neonatal screening in India. DISCUSSION: It is time for India to make neonatal thyroid screening and mandatory iodization of salt a priority and develop a comprehensive infantile hypothyroidism policy. Prioritization of infantile hypothyroidism prevention is justified by its high frequency, sensitivity of screening in detecting both IDD and CH, adverse consequences of missing diagnosis at birth, high effectiveness of prevention, severity of disability from hypothyroidism, cost effectiveness of prevention, and lack of a clinical method of diagnosis near birth.