The utility of the CES-D as a depression screening measure among low-income women attending primary care clinics. The Center for Epidemiologic Studies-Depression.

OBJECTIVE: Depressive disorders are among the most common medical disorders seen in primary care practice. The Center for Epidemiologic Studies-Depression (CES-D) scale is one of the measures commonly suggested for detecting depression in these clinics. However, to our knowledge, there have been no previous studies examining the validity of the CES-D among low-income women attending primary care clinics. METHOD: Low-income women attending public primary care clinics (n = 179, ages 20-77) completed the CES-D and the Diagnostic Interview Schedule for the DSM-IV (DIS-IV). RESULTS: The results supported the validity of the CES-D. The standard cut-score of 16 and above yielded a sensitivity of .95 and specificity of .70 in predicting Major Depressive Disorder (MDD). However, over two-thirds of those who screened positive did not meet criteria for MDD (positive predictive value = .28). The standard cut-score appears valid, but inefficient for depression screening in this population. An elevated cut-score of 34 yielded a higher specificity (.95) and over 50 percent of the patients who screened positive had a MDD (positive predictive value = .53), but at great cost to sensitivity (.45). CONCLUSION: Results indicated that the CES-D appears to be as valid for low-income, minority women as for any other demographic group examined in the literature. Despite similar validity, the CES-D appears to be inadequate for routine screening in this population. The positive predictive value remains very low no matter which cut-scores are used. The costs of the false positive rates could be prohibitive, especially in similar public primary care settings.

Access to prenatal, delivery, and newborn care among undocumented Hispanics in the Memphis area.

The purpose of this study was to examine the prenatal, delivery, and newborn care received by undocumented Hispanics in the Memphis area. The focus was to sketch a demographic profile of this population, identify barriers encountered in obtaining prenatal, delivery and newborn care, and present a five-year projection of the demand for prenatal care for this population. Participants included 97 undocumented Hispanic women, who either were pregnant or had a baby within the past 12 months, and health care providers. Most women came from Mexico (90.7%). They tended to be young, to have low educational attainment, to be homemakers, to have a high number of members in their households, to be financially supported by their spouses, and to live at or below the poverty line. The average length of time that they had been in the United States and Memphis were 42 and 21 months respectively. With regard to access to health care, undocumented Hispanics who migrated to the Memphis area lacked adequate prenatal and delivery care, and we estimated that the demand for prenatal care in this population will increase over 60% in the next five years.

Socioeconomic status, ethnicity, and health care access among young and healthy women.

This study examined: (a) the relationship between socioeconomic status (SES) and health care access among healthy women; (b) which SES variable(s) were most strongly associated with HCA; and (c) whether the SES/HCA relationship was the same for Black and White women. A total of 383 women (57.4% Whites and 42.6% Blacks) participated in the study. Independent variables included family income, education levels, occupation, median income within zip code of participants' residence, and ethnicity. Dependent variables were the total and subscale scores (accessibility, accommodation, and affordability) on a measure of health care access. Family income was the SES variable that showed the strongest positive association with total health care access, and there was a significant interaction between occupation and ethnicity for total health care access. Unique relationships were observed between each SES variable and each subscale on the health care access measure. The overall patterns between SES and health care access were similar for Blacks and Whites. Results suggest that the relationship between health care access and SES should be investigated through a multi-dimensional approach, and that an array of SES variables must be considered when designing interventions to improve health care access among healthy women.

Utilization of medical services and quality of life among low-income patients with generalized anxiety disorder attending primary care clinics.

OBJECTIVE: Anxiety disorders appear to influence morbidity and medical utilization. However, little is known about the relationship between Generalized Anxiety Disorder, quality of life, and medical utilization, especially among low-income patients. The goals of this investigation were to 1) determine if low-income patients with GAD utilize medical services more than patients with other Axis I diagnoses, or no psychopathology, and 2) compare the health-related quality of life of these three groups. METHOD: Participants were randomly recruited from public primary care clinics and administered intake assessments of demographics, stress, and health-related self-report questionnaires. At the end of the first year a structured psychiatric interview was administered (N = 431). Over the second year, patients (n = 360) were administered a health-related quality of life measure every three months for four assessments. Medical charts were abstracted to collect information about chronic illnesses and visits to outpatient clinics and the emergency department during the two years. RESULTS: Patients were predominantly middle-aged, low-income, uninsured African-American females. In this low-income sample, patients with GAD utilized the emergency department more and reported poorer quality of life than patients with other Axis I disorders and patients without any psychopathology. CONCLUSION: Low-income patients with GAD utilize the emergency department more and report poorer quality of life than patients with other Axis I disorders and patients without any psychopathology. Programs to identify and treat patients with GAD may yield improvements in quality of life, as well as reduce emergency department utilization.

Socioeconomic status, ethnicity, and environmental tobacco exposure among non-smoking females.

This study examined the relationship between socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure among non-smoking females, determined which SES variable(s) were most strongly associated with ETS exposure, and examined whether the relationship between SES and ETS exposure was the same for Blacks and Whites. Participants were 404 never-smoker females recruited in the community. Independent variables included income, education, occupation, median income within zip code of participants' residence, and ethnicity. Number of days per week exposed to ETS in the past year was the dependent variable. There was a significant correlation between CO levels (parts per million, ppm) and self-reported ETS exposure (r = 0.22, p < 0.001). The mean CO level exposure was 1.81 +/- 1.19 ppm, and the mean number of days per week of ETS exposure was 4.72 +/- 4.71. The most frequent source of ETS exposure was at public places (64.4%). Although Blacks tended to report higher ETS exposure than Whites (p = 0.08), this tendency disappeared when SES indicators were entered in the model. Correlations among SES indicators were either non-significant or very modest suggesting that different SES indicators may not measure the same construct. Education was the only SES variable that was significantly associated with ETS exposure in this population. The relationship between SES and ETS exposure was similar for both Blacks and Whites. These findings suggest that education may be the most important factor to be considered when designing interventions to decrease ETS exposure among young non-smoking females (e.g., public education of the hazards of ETS exposure and awareness of existing tobacco-control laws and regulations).

Chronic minor stressors and major life events experienced by low-income patients attending primary care clinics: a longitudinal examination.

Chronic minor stressors and major life events were assessed from 129 randomly selected low-income patients attending primary care medical clinics. Participants reported experiencing an average of 15 chronic minor stressors in a 12-month period. The most common chronic minor stressors were reported in the areas of finances and domestic activities. Participants also reported these stressors as the most intense. The t tests revealed that female participants reported significantly (p = .05) more chronic events than males. The most common major life events were reported in the areas of vegetative symptoms (i.e., major change in sleeping and eating habits), financial status, illness, and interpersonal relationships. The most stressful life events were changes in vegetative symptoms, family illness, and interpersonal relationships. The t tests revealed that employed participants reported significantly (p < .05) more positive life events than did unemployed participants. Implications of the findings are discussed.

Prevalence of high-risk behaviors and obesity among low-income patients attending primary care clinics in Louisiana.

This study examined the prevalence of the most prominent high-risk behaviors that contribute to mortality in the United States (i.e., sedentary lifestyle, cigarette smoking, and high dietary fat intake) and obesity among low-income patients attending primary care clinics in Louisiana. The sample consisted of 1,132 patients attending primary care clinics that were randomly selected and administered a demographic questionnaire, the 1994 Behavioral Risk Factor Surveillance System, and the Eating Patterns Questionnaire. Participants consisted predominantly of African-American (67.7%), uninsured (73.3%), low-income, middle-aged females. Prevalence of high-risk behaviors included sedentary lifestyle (47.1%), cigarette smoking (26.2%), and high dietary fat intake (61.3%). Prevalence of obesity was 63.5%. In conclusion, low-income patients attending primary care clinics in Louisiana display a high frequency of important high-risk behaviors that contribute to mortality in this country. Obesity is also extremely prevalent in this population. Clinical implications and directions for future studies are discussed.

Alcoholism among indigent inpatients: identification and intervention by internal medicine residents.

BACKGROUND: This study examined alcoholism identification and interventions by internal medicine residents, determined the prevalence of alcoholism among indigent inpatients, and examined some variables related to alcoholism in this population. METHODS: The alcohol abuse and dependence section of the Diagnostic Interview Schedule was administered to 197 inpatients, and chart audits were done. RESULTS: The obtained prevalence of alcoholism was 17%. Residents identified current alcohol abuse among 71% of current alcoholics, 17% of past alcoholics, and 3% of nonalcoholics. Sixty-two percent of alcoholics identified by the residents did not receive advice or referral, 13% received advice, 17% were referred to Alcoholics Anonymous, and 8% were referred to an inpatient facility. CONCLUSIONS: Our results suggest that although residents' identification of alcoholism is satisfactory, it is necessary to improve their rates of intervention. The profile of the alcoholic inpatients in this study includes demographics, presence of chronic illnesses, and utilization of medical services as compared with nonalcoholics.

Modifiable high-risk behaviors for cardiovascular disease among family physicians in the United States. A national Survey.

OBJECTIVES: To study the prevalence of modifiable high-risk behaviors that contribute to mortality and morbidity from cardiovascular disease among family physicians in the United States, to examine whether these prevalence rates would differ across geographic regions of the United States, and to determine whether a family history of coronary artery disease differentiated physicians who engage in these high-risk behaviors from those who do not. DESIGN: A mailed self-report survey. SETTING: Family physician members of the American Board of Family Practice. PARTICIPANTS: The survey was mailed to 1500 randomly selected members of the American Board of Family Practice. RESULTS: The response was 62%. The results showed that 97% of the physicians were nonsmokers, 54% engaged in exercise regularly, 36% considered themselves overweight, and 91% knew their lipid profile. Of the respondents, 63% reported having a family physician, 78% reported visiting their physician as needed, and 41% reported having had a physician visit in the past year. Forty-one percent of the physicians reported having a family history of coronary artery disease. There were no notable differences regarding the prevalence of these behaviors across the 5 geographic areas or between respondents with a family history of coronary artery disease and those without such a history. CONCLUSION: Our results suggest that the respondents as a group engage in health practices that help to prevent cardiovascular disease. However, the frequency of exercise among these physicians is below the recommended level, and efforts should be made in promoting exercise among this population.

Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model.

OBJECTIVES: To evaluate the relationships between sexual/physical abuse, pain perception, environmental events, coping strategies, and psychiatric morbidity in a sample of female patients with painful gastrointestinal disorders. PATIENTS: Fifty paid volunteers from a tertiary care center including 13 patients with gastroesophageal reflux disease (GERD), 26 with noncardiac chest pain (NCCP), and 11 with irritable bowel syndrome (IBS). MEASUREMENTS: (1) Sexual and physical abuse interview questions; (2) Structured psychiatric interview; (3) Self-report questionnaires: demographics, clinical pain measurement, Millon Behavioral Health Inventory, Hassles and Uplifts Scales, Sickness Impact Profile, Life Experiences Survey, Pain Beliefs and Perceptions Inventory, and Coping Strategies Questionnaire; (4) Pain Perception and Sensory Decision Theory tasks. RESULTS: Fifty-six percent of the sample reported a history of sexual/physical abuse. Abuse was significantly more prevalent among patients with GERD (92%) and IBS (82%) compared with those with NCCP (27%). Abused patients, relative to nonabused patients, had significantly lower pain threshold levels in response to finger pressure stimuli and significantly lower cognitive standards for judging stimuli as noxious. Abused patients reported significantly higher levels of functional disability and a significantly greater number of psychiatric disorders, minor daily hassles, and pain syndromes unrelated to gastrointestinal disorders. In addition, abused patients more frequently blamed themselves for their pain and reported significantly greater use of maladaptive pain coping strategies than nonabused patients. CONCLUSION: These data suggest that the relationships between abuse, disability, multiple pain syndromes, and health care seeking behavior are mediated by abnormal pain perception, psychiatric disorders, disruption of physical function, and environmental stressors.

The relationship between stress and symptoms of gastroesophageal reflux: the influence of psychological factors.

This paper describes the first controlled study of the relationships among stress, psychological traits associated with chronic anxiety, acid reflux parameters, and perceptions of reflux symptoms. Seventeen subjects with symptomatic reflux disease were studied using a 2 (high vs. low gastrointestinal susceptibility score) x 2 (stress vs. neutral tasks) x 3 (periods 1, 2, or 3) experimental design. It was found that the stress tasks produced significant increases in systolic and diastolic blood pressure, pulse rates, and subjective ratings of anxiety and reflux symptoms. The stress tasks, however, did not influence objective parameters of acid reflux (total acid exposure, number of reflux episodes, duration of longest reflux episode). Moreover, the effect of stress on reflux ratings was due primarily to the responses of the subjects with high gastrointestinal susceptibility scale scores. These subjects' reflux ratings remained at high levels during all stress periods, whereas subjects in all other experimental conditions reported decreased reflux symptoms across periods. These results suggest that reflux patients who are chronically anxious and exposed to prolonged stress may perceive low intensity esophageal stimuli as painful reflux symptoms. Future effort should be devoted to examining the efficacy of anxiolytic and behavioral therapies with these reflux patients.

Psychosocial and psychophysical assessments of patients with unexplained chest pain.

It is imperative to assess the psychosocial factors that may influence the subjective experiences and pain behavior of persons with chronic unexplained chest pain. Both psychologists and physicians tend to rely on self-report measures of psychological distress, which provide little unique information about patients with chronic chest pain to differentiate them from patients with other painful disorders such as irritable bowel syndrome, gastroesophageal reflux disease, or coronary artery disease. However, assessment of pain-coping strategies, spouse responses to the patient's pain behaviors, and pain thresholds for esophageal balloon distention do differentiate patients with chronic chest pain from healthy controls and patients with various other chronic pain disorders. Specifically, chronic chest pain patients tend to use relatively passive pain-coping strategies such as praying and hoping, and to report relatively high levels of spouse reinforcement of pain behaviors. Finally, in response to esophageal balloon distention, chronic chest pain patients display low pain thresholds that do not generalize to stimulation by mechanical finger pressure. Preliminary evidence suggests these low thresholds are due primarily to a tendency to set low standards for making pain judgments regarding esophageal stimuli of moderate-to-high intensity levels.

Pain threshold levels and coping strategies among patients who have chest pain and normal coronary arteries.

Patients with noncardiac chest pain (NCCP) tend to show lower pain threshold levels for esophageal balloon distention than do patients with other painful gastrointestinal disorders and healthy controls. The NCCP patients also report greater usage of negative pain-coping strategies, less ability to perform specific behaviors to decrease pain, and higher levels of clinical pain than do other patient and healthy control groups. Behavioral treatments produce significant decreases in pain and disruption of daily activities. Further effort is needed, however, to develop treatments for NCCP that are based on knowledge of the behavioral manifestations of this disorder and the afferent mechanisms involved in perception of visceral pain.

[Psychological support: a necessity for nursing students]. / Apoio psicológico: uma necessidade dos alunos de enfermagem.

Taking into account the psychological difficulties of students in the beginning of their clinical practice, the authors design a course called "Psychology Applied to Nursing" aiming at providing psychological support to students in the fourth term of their Nursing and Obstetrics Course at the Universidade de Londrina. The results, according to the students and teachers evaluation, were satisfactory, leading to an integration between the formative and psychological aspects of nursing.