Changes in Physical Activity Barriers among American Indian Elders: A Pilot Study​.

The objective of the present study was to assess whether selfreported physical activity barriers could be reduced among American Indian elders who participated in a 6-week randomized physical activity trial that compared the use of a pedometer only to that of pedometers with step-count goal setting. Elders (N = 32) were compared on the Barriers to Being Physically Active Quiz after participating in a pilot physical activity trial. Elders were classified into high- and low-barrier groups at baseline and compared on self-reported physical activity, health-related quality of life, pedometer step counts, and 6-minute walk performance. At the conclusion of the 6-week trial, only the lack of willpower subscale significantly decreased. The low-barrier group reported significantly higher physical activity engagement and improved mental health quality of life than the high-barrier group. The groups did not differ on daily step counts or 6-minute walk performance. Additional research is needed with a larger sample to understand relevant activity barriers in this population and assess whether they can be modified through participation in structured physical activity and exercise programs.

A Randomized Trial of Collaborative Care for Perinatal Depression in Socioeconomically Disadvantaged Women: The Impact of Comorbid Posttraumatic Stress Disorder.

OBJECTIVE: The comorbidity of posttraumatic stress disorder (PTSD) with antenatal depression poses increased risks for postpartum depression and may delay or diminish response to evidence-based depression care. In a secondary analysis of an 18-month study of collaborative care for perinatal depression, the authors hypothesized that pregnant, depressed, socioeconomically disadvantaged women with comorbid PTSD would show more improvement in the MOMCare intervention providing Brief Interpersonal Psychotherapy and/or antidepressants, compared to intensive public health Maternity Support Services (MSS-Plus). METHODS: A multisite randomized controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System, July 2009-January 2014. Pregnant women were recruited who met criteria for a probable diagnosis of major depressive disorder (MDD) on the Patient Health Questionnaire-9 and/or dysthymia on the MINI-International Neuropsychiatric Interview (5.0.0). The primary outcome was depression severity at 3-, 6-, 12-and 18-month follow-ups; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care. RESULTS: Sixty-five percent of the sample of 164 met criteria for probable comorbid PTSD. The treatment effect was significantly associated with PTSD status in a group-by-PTSD severity interaction, controlling for baseline depression severity (Wald χ²1 = 4.52, P = .03). Over the 18-month follow-up, those with comorbid PTSD in MOMCare (n = 48), versus MSS-Plus (n = 58), showed greater improvement in depression severity (Wald χ²1 = 8.51, P < .004), PTSD severity (Wald χ²1 = 5.55, P < .02), and functioning (Wald χ²1 = 4.40, P < .04); higher rates of depression response (Wald χ²1 = 4.13, P < .04) and remission (Wald χ²1 = 5.17, P < .02); and increased use of mental health services (Wald χ²1 = 39.87, P < .0001) and antidepressant medication (Wald χ²1 = 8.07, P < .005). Participants without comorbid PTSD in MOMCare (n = 33) and MSS-Plus (n = 25) showed equivalent improvement on these outcomes. CONCLUSIONS: Collaborative depression care had a greater impact on perinatal depressive outcomes for socioeconomically disadvantaged women with comorbid PTSD than for those without PTSD. Findings suggest that a stepped care treatment model for high-risk pregnant women with both MDD and PTSD could be integrated into public health systems in the United States. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01045655.

COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL.

BACKGROUND: Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression care. The authors evaluated whether "MOMCare,"a culturally relevant, collaborative care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus). METHODS: A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care. RESULTS: All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ(2) = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ(2) = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ(2) = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ(2) = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ(2) = 10.00, df = 1, P < .01). CONCLUSION: Compared to MSS-Plus, MOMCare showed significant improvement in quality of care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression care can be integrated into the services of a county public health system in the United States. CLINICAL TRIAL REGISTRATION: ClinicalTrials.govNCT01045655.

Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: the design of the MOMCare study.

BACKGROUND: Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS). METHODS: Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum). BASELINE RESULTS: 168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy. CONCLUSIONS: A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

Influence of framing and graphic format on comprehension of risk information among American Indian tribal college students.

We evaluated methods for presenting risk information by administering six versions of an anonymous survey to 489 American Indian tribal college students. All surveys presented identical numeric information, but framing varied. Half expressed prevention benefits as relative risk reduction, half as absolute risk reduction. One third of surveys used text to describe prevention benefits; one third used text plus bar graph; one third used text plus modified bar graph incorporating a culturally tailored image. The odds ratio (OR) for correct risk interpretation for absolute risk framing vs. relative risk framing was 1.40 (95 % CI = 1.01, 1.93). The OR for correct interpretation of text plus bar graph vs. text only was 2.16 (95 % CI = 1.46, 3.19); OR for text plus culturally tailored bar graph vs. text only was 1.72 (95 % CI = 1.14, 2.60). Risk information including a bar graph was better understood than text-only information; a culturally tailored graph was no more effective than a standard graph.

Does pedometer goal setting improve physical activity among Native elders? Results from a randomized pilot study.

We examined if step-count goal setting resulted in increases in physical activity and walking compared to only monitoring step counts with pedometers among American Indian/Alaska Native elders. Outcomes included step counts, self-reported physical activity and well-being, and performance on the 6-minute walk test. Although no significant between-group differences were found, within-group analyses indicated that elders significantly improved on the majority of step count, physical activity, health-related quality of life, and 6-minute walk outcomes.

Barriers and facilitators to walking and physical activity among American Indian elders.

INTRODUCTION: Physical inactivity is common among older American Indians. Several barriers impede the establishment and maintenance of routine exercise. We examined personal and built-environment barriers and facilitators to walking and physical activity and their relationship with health-related quality of life in American Indian elders. METHODS: We used descriptive statistics to report barriers and facilitators to walking and physical activity among a sample of 75 American Indians aged 50 to 74 years. Pearson correlation coefficients were used to examine the relationship between health-related quality of life and barriers to walking and physical activity after adjusting for caloric expenditure and total frequency of all exercise activities. RESULTS: Lack of willpower was the most commonly reported barrier. Elders were more likely to report personal as opposed to built-environment reasons for physical inactivity. Better health and being closer to interesting places were common walking facilitators. Health-related quality of life was inversely related to physical activity barriers, and poor mental health quality of life was more strongly associated with total barriers than poor physical health. CONCLUSION: We identified a variety of barriers and facilitators that may influence walking and physical activity among American Indian elders. More research is needed to determine if interventions to reduce barriers and promote facilitators can lead to objective, functional health outcomes.

Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents.

OBJECTIVE: To examine the validity of the Patient Health Questionnaire 2 (PHQ-2), a 2-item depression-screening scale, among adolescents. METHODS: After completing a brief depression screen, 499 youth (aged 13-17 years) who were enrolled in an integrated health care system were invited to participate in a full assessment, including a longer depression-screening scale (Patient Health Questionnaire 9-item depression screen) and a structured mental health interview (Diagnostic Interview Schedule for Children). Eighty-nine percent (n = 444) completed the assessment. Criterion validity and construct validity were tested by examining associations between the PHQ-2 and other measures of depression and functional impairment. RESULTS: A PHQ-2 score of > or =3 had a sensitivity of 74% and specificity of 75% for detecting youth who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression on the Diagnostic Interview Schedule for Children and a sensitivity of 96% and specificity of 82% for detecting youth who met criteria for probable major depression on the Patient Health Questionnaire 9-item depression screen. On receiver operating characteristic analysis, the PHQ-2 had an area under the curve of 0.84 (95% confidence interval: 0.75-0.92), and a cut point of 3 was optimal for maximizing sensitivity without loss of specificity for detecting major depression. Youth with a PHQ-2 score of > or =3 had significantly higher functional-impairment scores and significantly higher scores for parent-reported internalizing problems than youth with scores of <3. CONCLUSIONS: The PHQ-2 has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma.

OBJECTIVE: To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone. METHODS: A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs. RESULTS: Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures. CONCLUSIONS: Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

Long-term effects on medical costs of improving depression outcomes in patients with depression and diabetes.

OBJECTIVE: The purpose of this study was to examine the 5-year effects on total health care costs of the Pathways depression intervention program for patients with diabetes and comorbid depression compared with usual primary care. RESEARCH DESIGN AND METHODS: The Pathways Study was conducted in nine primary care practices of a large HMO and enrolled 329 patients with diabetes and comorbid major depression. The current study analyzed the differences in long-term medical costs between intervention and usual care patients. Participants were randomly assigned to a nurse depression intervention (n = 164) or to usual primary care (n = 165). The intervention included education about depression, behavioral activation, and a choice of either starting with support of antidepressant medication treatment by the primary care doctor or problem-solving therapy in primary care. Interventions were provided for up to 12 months, and the main outcome measures are health costs over a 5-year period. RESULTS: Patients in the intervention arm of the study had improved depression outcomes and trends for reduced 5-year mean total medical costs of -$3,907 (95% CI -$15,454 less to $7,640 more) compared with usual care patients. A sensitivity analysis found that these cost differences were largely explained by the patients with depression and the most severe medical comorbidity. CONCLUSIONS: The Pathways depression collaborative care program improved depression outcomes compared with usual care with no evidence of greater long-term costs and with trends for reduced costs among the more severely medically ill patients with diabetes.

Summary health status measures in advanced heart failure: relationship to clinical variables and outcome.

BACKGROUND: Patient-centered health status measures are important because they capture the patient's perspective on their heart failure, but it is unclear which of these have independent prognostic significance. METHODS AND RESULTS: A total of 142 consecutive subjects from a specialty heart failure clinic were assessed at baseline with a broad array of clinical, laboratory, and self-report measures including four summary measures of health status. The relationships between these measures and their association with the combined end point of transplantation or death over a mean follow-up of 3 years were examined. In unadjusted analyses, the Kansas City Cardiomyopathy Questionnaire (KCCQ) summary score had the strongest association with the combined end point (HR [for each unit score difference] = 0.98 [0.96-0.99], P = .002). In the adjusted Cox proportional hazards model including all 4 summary measures, the Seattle Heart Failure Score, V0(2,) systolic blood pressure, and medical comorbidity, only the Standard Gamble utility remained significantly associated with time to the combined end point (HR [for each 0.01 utility score difference] = 0.98 [0.97-0.99], P = .007). CONCLUSIONS: Our study suggests that summary health status measures are simple and significant indicators of prognosis in advanced heart failure patients. The KCCQ summary score summarizes a wide range of clinical variables from the patient's point of view, whereas the standard gamble utility contains important prognostic information not captured in usual clinical variables.

Clinical factors associated with relapse in primary care patients with chronic or recurrent depression.

BACKGROUND: Because in most patients depression is a relapsing/remitting disorder, finding clinical factors associated with risk of relapse is important. The majority of patients with depression are treated in primary care settings, but few previous studies have examined predictors of relapse in primary care patients with recurrent or chronic depression. METHODS: Data from a cohort of 386 primary care patients in a clinical trial were analyzed for clinical and demographic predictors of relapse over a one-year post-study observational period. Patients were selected for a high risk of relapse, based on a history of either 3 previous depressive episodes or dysthymia, and enrolled in a randomized trial of relapse prevention. RESULTS: Factors found to be associated with significantly higher risk of relapse included poorer medication adherence in the 30 days prior to the trial, lower self-efficacy to manage depression, and higher scores on the Child Trauma Questionnaire. LIMITATIONS: Use of a sample of limited diversity taken from a clinical trial, and use of retrospective information from patients with potential for recall bias. CONCLUSIONS: The findings of this report suggest specific risk factors to be targeted in depression relapse prevention interventions. It is encouraging that two of the factors associated with increased risk of relapse, self-efficacy and medication adherence have been seen to improve with the intervention utilized in the primary care trial from which the studied cohort was drawn.

The association of patient relationship style and outcomes in collaborative care treatment for depression in patients with diabetes.

PURPOSE: We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes. METHODS: From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes. RESULTS: Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style. CONCLUSION: Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style.

Assessment of beliefs about psychotropic medication and psychotherapy: development of a measure for patients with anxiety disorders.

OBJECTIVE: This study presents the psychometric properties of a brief measure to assess beliefs about psychotropic medications and psychotherapy among patients with anxiety disorders. METHOD: Data were collected on a large sample of primary care patients with a range of anxiety disorders, as part of the Collaborative Care for Anxiety and Panic study. Factor analyses using principal axis factoring with Varimax rotations were used to determine the factor structure of the beliefs scale. Internal consistency, concurrent validity and predictive validity of the resulting subscales were examined. RESULTS: Two subscales emerged, one reflecting beliefs about psychotropic medications and the other assessing beliefs about psychotherapy. Both showed strong internal consistency and concurrent validity. The beliefs about psychotropic medication demonstrated strong predictive validity. CONCLUSIONS: This measure may be a useful tool for assessing treatment beliefs among patients with anxiety disorders toward the provision of more quality treatment for this population. Its brevity may make it particularly useful in primary health care settings.

Beliefs about psychotropic medication and psychotherapy among primary care patients with anxiety disorders.

Primary health care clinics are increasingly providing psychiatric/psychological treatment of anxiety disorders, particularly for patients who do not have adequate access to specialty mental health services. Adequate treatment requires knowledge of and attention to patients' beliefs about available treatment options. The current investigation examined beliefs about psychotropic medications and psychotherapy among a sample of primary care patients with anxiety disorders. The influence of key demographic variables on strength of these beliefs was also explored. The presence of specific anxiety disorders was not found to impact strength of beliefs about either type of treatment. In contrast, there was a trend for the presence of depression to relate to more favorable attitudes toward psychotropic medication. Consistent with previous studies, ethnic minority patients reported less favorable attitudes toward both psychotropic medications and psychotherapy. These findings underscore the importance of assessing patient beliefs prior to the initiation of either psychotropic medications or psychotherapy across diagnostic and demographic groups. Practitioners should be particularly alert to the possibility that patients with anxiety disorders and members of ethnic minority groups may have less favorable attitudes toward treatment options. Treatment adherence may therefore be increased by addressing these beliefs directly.

Depression and health status in patients with advanced heart failure: a prospective study in tertiary care.

BACKGROUND: Depression impairs health status among patients with coronary disease. The effect of depression on patients with heart failure has been studied to date only in hospitalized patients. METHODS AND RESULTS: Prospective cohort study of 113 outpatients with advanced heart failure. At baseline, 19% (n = 21) had major depression or dysthymia, 9% (n = 10) had minor depression, and 72% (n = 82) had no current depression diagnosis. Repeated measures analyses of covariance adjusting for demographic and clinical differences demonstrated that the depression groups differed on observed function (6-minute walk distance [F = 4.8, P = .01]), and self-reported generic (SF-36) and disease-specific (Kansas City Cardiomyopathy Questionnaire) health status. Depression groups also differed in severity of self-reported breathlessness, chest pain, and fatigue. Subject- and spouse-reported role function also differed between the groups. Partial correlation (controlling for the same covariates) between baseline Hamilton Depression Scale scores and these outcomes was highly significant at baseline and follow-up. CONCLUSIONS: Depression is prospectively associated with poorer health status in patients with advanced heart failure. Physical and role function, symptom severity, and quality of life are all significantly affected.

Adult health status of women HMO members with posttraumatic stress disorder symptoms.

Posttraumatic stress disorder (PTSD) is associated with high numbers of self-reported physical symptoms and functional disability in clinical samples, but little is known about the magnitude of these associations in population samples and using actual physician-coded diagnoses. We administered a 22-page survey to 1225 female HMO enrollees randomly selected from the current membership of a large, staff model HMO in Seattle, Washington. Using the PTSD Checklist (internally validated against a subset of clinical interviews) we compared women with low, moderate, and high scores with respect to differences in self-reported physical health status, functional disability (36-item short form health survey), numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. Compared to women with low PTSD symptom severity, those with moderate or high severity reported significantly higher functional disability (P<.001), rates of abuse and neglect (P<.01 to P<.001), health risk behavior scores (P<0.05), as well as higher mean numbers of common physical symptoms (P<.05). Compared to women with low PTSD symptom severity those with moderate or high severity had significantly higher adjusted odds ratios for aversive physical symptoms (range, 1.7-10.1). The mean number of physician-coded ICD-9 diagnoses was also significantly higher in the both the moderate and high severity groups. Among female HMO members, PTSD symptoms are associated with a wide range of both self-reported and physician-coded adverse physical health outcomes.

Attachment theory in health care: the influence of relationship style on medical students' specialty choice.

INTRODUCTION: Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. METHODS: We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. RESULTS: Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. CONCLUSIONS: Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.

Predicting rehospitalization and outpatient services from administration and clinical databases.

The study tests whether psychiatric services utilization may be predicted from administrative databases without clinical variables equally as well as from databases with clinical variables. Persons with a psychiatric hospitalization at an urban medical center were followed for 1 year postdischarge (N = 1384.) Dependent variables included statewide rehospitalization and the number of hours of outpatient services received. Three linear and logistic regression models were developed and cross-validated: a basic model with limited administrative independent variables, an intermediate model with diagnostic and limited clinical indicators, and a full model containing additional clinical predictors. For rehospitalization, the clinical cross-validated model accounted for twice the variance accounted by the basic model (adjusted R2 = .13 and .06, respectively). For outpatient hours, the basic cross-validated model performed as well as the clinical model (adjusted R2 = .36 and .34, respectively). Clinical indicators such as assessment of functioning and co-occurring substance use disorder should be considered for inclusion in predicting rehospitalization.

Attachment theory: a model for health care utilization and somatization.

OBJECTIVE: Attachment theory proposes that cognitive schemas based on earlier repeated experiences with caregivers influence how individuals perceive and act within interpersonal relationships. We hypothesized that medical patients with two types of insecure attachment-preoccupied and fearful attachment-would have higher physical symptom reporting compared with those with other attachment styles, but that preoccupied attachment would be associated with higher and fearful attachment with lower primary care utilization and costs. METHODS: In a large sample of adult female primary care health maintenance organization patients (N = 701), we used analysis of covariance and Poisson regressions to determine whether attachment style was significantly associated with 1) symptom reporting based on questions from the somatization section of the Diagnostic Interview Schedule and 2) contemporaneous automated utilization and cost data. RESULTS: Attachment style was significantly associated with symptom reporting (p =.02), with patients with preoccupied (p =.03) and fearful (p =.003) attachment having a significantly greater number of physical symptoms compared with secure patients. There were no significant differences in medical comorbidity between attachment groups. Attachment was also significantly associated with primary care visits and costs. Patients with preoccupied attachment had the highest primary care costs and utilization, whereas patients with fearful attachment had the lowest. CONCLUSIONS: These results suggest that attachment style is an important factor in assessing symptom perception and health care utilization. Despite being on opposite ends of the utilization spectrum, patients with preoccupied and fearful attachment have the highest symptom reporting. These data challenge the observation that increased symptom reporting is uniformly associated with increased utilization in medical patients.