Psoriasis is independently associated with psychiatric morbidity and adverse cardiovascular risk factors, but not with cardiovascular events in a population-based sample.

BACKGROUND: Psoriasis may significantly reduce quality of life. Previous studies reported an association of psoriasis and cardiovascular risk factors and cardiovascular events. The extent to which psoriasis is associated with psychiatric morbidity and the role of psychiatric comorbidity as a potential confounder of the association between psoriasis and cardiovascular morbidity require further investigation. OBJECTIVES: To study the association between psoriasis, psychiatric morbidity and cardiovascular morbidity. METHODS: Case-control study utilizing an interdisciplinary administrative outpatient database from Germany. Patients with confirmed diagnosis of prevalent psoriasis within the study period (2003-2004) (n = 3147, mean age 57 years) were individually matched for age and gender with 3147 controls without psoriasis. The relationship of psoriasis with psychiatric morbidities (depression, stress-related disorders, behaviour disorders and schizophrenic disorders), cardiovascular risk factors (diabetes, hypertension, obesity and dyslipidaemia) and cardiovascular events [myocardial infarction (MI), stroke] was investigated using logistic and linear regression models. RESULTS: Crude analyses suggested an association of psoriasis with depression, stress-related disorders, behaviour disorders and cardiovascular risk factors, but not with MI [odds ratio (OR) 1.14; 95% confidence interval (95% CI) 0.81-1.62] or stroke (OR 0.97; 95% CI 0.61-1.54). Multivariate models controlling for age, gender and consulting behaviour indicated that psoriasis is independently associated with depression (OR 1.49; 95% CI 1.20-1.86), stress-related disorders (OR 1.41; 95% CI 1.22-1.62), behaviour disorders (OR 1.58; 95% CI 1.05-2.39), diabetes (OR 1.21 95% CI 1.04-1.40), hypertension (OR 1.34; 95% CI 1.18-1.51), dyslipidaemia (OR 1.29; 95% CI 1.07-1.55), and obesity (OR 1.63; 95% CI 1.39-1.90). For each psychiatric condition, the likelihood of being affected significantly increased with each physician visit due to psoriasis, suggesting that the risk of psychiatric comorbidity increases with the severity of psoriasis. CONCLUSION: Psoriasis appears to be independently associated with major psychiatric disorders and with cardiovascular risk factors, but not with cardiovascular events.

Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up.

OBJECTIVE: To study the relationship of minor depression to first onset of major depressive disorder (MDD) among 1634 individuals over a 15-year follow-up using the Baltimore Epidemiologic Catchment Area cohort. METHOD: Logistic regression analyses were conducted with minor depression alone and also adjusting for anxiety, sociodemographic, and medical variables, with MDD as the outcome variable. Also, among those with minor depression, depressive symptom categories were studied with both logistic regression and population attributable risk (PAR) to determine if they predicted MDD. RESULTS: Individuals with a history of minor depression had an odds ratio of more than 5 of having a first lifetime episode of MDD (adjusted OR: 5.37, 95% CI: 2.87, 10.06). Suicidal ideation, appetite/weight issues, and sleep difficulty had the highest PARs. CONCLUSION: Minor depression strongly predicts MDD. Clinical and public health interventions for individuals with minor depression can potentially impact the pathway leading to MDD.

The Quality Improvement for Depression collaboration: general analytic strategies for a coordinated study of quality improvement in depression care.

It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.

Patient perspectives on spirituality and the patient-physician relationship.

OBJECTIVE: To identify the preferences and concerns of seriously ill patients about discussing religious and spiritual beliefs with physicians. DESIGN: Three focus group discussions with patients who had experienced a recent life-threatening illness. Discussions were audiotaped, transcribed verbatim, and reviewed independently by two investigators to identify discrete comments for grouping into domains. A third investigator adjudicated differences in opinion. Comments were then independently reviewed for relevance and consistency by a health services researcher and a pastoral counselor. SETTING: Academic medical center. PARTICIPANTS: Referred sample of 22 patients hospitalized with a recent life-threatening illness. MEASUREMENTS AND MAIN RESULTS: Almost all of the 562 comments could be grouped into one of five broad domains: 1) religiosity/spirituality, 2) prayer, 3) patient-physician relationship, 4) religious/spiritual conversations, and 5) recommendations to physicians. God, prayer, and spiritual beliefs were often mentioned as sources of comfort, support, and healing. All participants stressed the importance of physician empathy. Willingness to participate in spiritual discussions with doctors was closely tied to the patient-physician relationship. Although divided on the proper context, patients agreed that physicians must have strong interpersonal skills for discussions to be fruitful. Physician-initiated conversation without a strong patient-physician relationship was viewed as inappropriate and as implying a poor prognosis. CONCLUSION: Religion and spirituality are a source of comfort for many patients. Although not necessarily expecting physicians to discuss spirituality, patients want physicians to ask about coping and support mechanisms. This exploratory study suggests that if patients then disclose the importance of spiritual beliefs in their lives, they would like physicians to respect these values.

Sleep disturbances and mood disorders: an epidemiologic perspective.

Epidemiologic studies of sleep disturbances and mood disorders that may provide more valid estimates of associations between these two conditions than clinical samples due to differential use of health care services. Increasing uniformity of questionnaires to assess sleep disturbances has decreased the variance in estimates of insomnia and hypersomnia within community samples. Women are more likely to report insomnia than men in every age group. There appear to be no clear racial or ethnic differences in rates of insomnia or hypersomnia. Several community-based studies have found that sleep disturbances are powerful risk factors for the development of new episodes of major depression in the following year. Individuals who report insomnia or poor quality sleep may be at higher risk for depression throughout their lifetime. Epidemiologic studies will be useful for developing the long-term perspective on the natural history of sleep disturbances and mood disorders and the consequences of treatment.

How important is intrinsic spirituality in depression care? A comparison of white and African-American primary care patients.

We used a cross-sectional survey to compare the views of African-American and white adult primary care patients (N = 76) regarding the importance of various aspects of depression care. Patients were asked to rate the importance of 126 aspects of depression care (derived from attitudinal domains identified in focus groups) on a 5-point Likert scale. The 30 most important items came from 9 domains: 1) health professionals' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, 7) financial access, 8) life experiences, and 9) social support. African-American and white patients rated most aspects of depression care as similarly important, except that the odds of rating spirituality as extremely important for depression care were 3 times higher for African Americans than the odds for whites.

Epidemiology of unexplained fatigue and major depression in the community: the Baltimore ECA follow-up, 1981-1994.

BACKGROUND: Fatigue is a common, non-specific, subjective symptom associated with several medical and psychiatric illnesses. The purpose of this investigation was to explore further the epidemiology of unexplained fatigue in the general population and the relationship between fatigue and depression. METHODS: The design was a prospective population-based study. Subjects included community-dwelling adults who were participants of the Baltimore sample of the Epidemiologic Catchment Area Program in 1981 and who were reinterviewed 13 years later. Lay interviewers using the Diagnostic Interview Schedule interviewed subjects. RESULTS: Number of somatization symptoms and history of a dysphoric episode at baseline were the two strongest predictors of both new onset of fatigue as well as recurrent/chronic fatigue over the 13-year follow-up interval. In addition, individuals who reported a history of unexplained fatigue at baseline as well as during the follow-up, were at markedly increased risk for new onset major depression as compared to those who never reported such fatigue, (RR = 28.4, 95% CI) (11.7, 68.0). Similarly, respondents who developed new fatigue or had remitted fatigue after 1981 were also at increased risk for developing major depression. CONCLUSIONS: Somatization was the strongest predictor of both new and chronic fatigue with unknown cause. In addition, fatigue was both predictive and a consequence of the depression syndrome.

Screening the public for depression through the Internet.

OBJECTIVE: Despite increased public screening, many individuals with depression remain undetected or untreated. This study explored the performance of an Internet-based program in screening for depression. METHODS: The Centers for Epidemiological Studies Depression (CES-D) scale was adapted as an online screening test. The program advised persons whose score indicated a high probability of depression to seek treatment and asked them to complete a survey of attitudes and preferences that could be printed and taken to a health professional. Responses were collected anonymously for epidemiologic research. Demographic characteristics of participants were compared with those of the U.S. population and participants in previous community screenings. The costs of the program were calculated. RESULTS: The CES-D scale was completed 24,479 times during the eight-month study period. The respondents' median age category was 30 to 45 years, and almost 30 percent were male; 58 percent (N=14,185) screened positive for depression, and fewer than half of those had never been treated for depression. The proportion of younger individuals was larger than in previous public screenings, but was still lower than that in the U.S. population. Our sample contained a lower proportion of minorities than the U.S. population (16.6 percent versus 28.3 percent). Sunk costs totaled $9,000, and additional marginal costs to maintain the system totaled $3,750. CONCLUSIONS: The Internet provides a continuously available, inexpensive, easily maintained platform to anonymously screen a large number of individuals from a broad geographic area. However, older adults and minorities may visit screening sites less frequently than other populations.

Major depression and cancer: the 13-year follow-up of the Baltimore epidemiologic catchment area sample (United States).

OBJECTIVE: The relationship between depression and development of cancer is not well understood, with some studies finding a significant but small increase in risk for cancer among persons with depression. No studies have employed standardized interviews keyed to the diagnostic criteria for Major Depression. Our objective was to evaluate the relationship between Major Depression at baseline and new onset of cancer at follow-up. METHOD: The study was based on a population-based 13-year follow-up survey of community-dwelling adults living in East Baltimore in 1981. After excluding 372 persons with a history of cancer or those whom reported their health as poor at the baseline interview, 3109 adults remained. Information on baseline depression status and cancer at follow-up was available for 2017 persons. A diagnosis of cancer was ascertained at follow-up through interview of survivors and from death certificates. RESULTS: There were 203 new cases of cancer among 2017 persons at risk. Neither Major Depression (relative risk (RR) = 1.0, 95% confidence interval (CI) 0.5-2.1) nor dysphoric episode (RR = 1.3, 95% CI 0.9-1.9) were significantly associated with increased risk of cancer at follow-up. However, among women with Major Depression, the risk of breast cancer was increased (adjusted RR = 3.8, 95% CI 1.0-14.2). CONCLUSIONS: We found no overall association of depression with cancer. However, among women, Major Depression (but not dysphoric episode alone) was associated with the onset of breast cancer.

Physician, heal Thyself? Regular source of care and use of preventive health services among physicians.

BACKGROUND: Little is known about the regular source of care (RSOC) among physicians, a group whose self-care may reflect the attitudes and recommendations they convey to their patients. METHODS: We performed a cohort study of physicians who graduated from the Johns Hopkins School of Medicine from 1948 through 1964 to identify predictors of not having an RSOC, and to determine whether not having an RSOC was associated with subsequent receipt of preventive services. The RSOC was assessed in a 1991 survey; use of cancer screening tests and the influenza vaccine was assessed in 1997. RESULTS: The response rate in 1991 was 77% (915 respondents); 35% (312) had no RSOC. Internists (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.58-6.74), surgeons (OR, 2.42; 95% CI, 1.17-5.02), and pathologists (OR, 5.46; 95% CI, 2.09-14.29) were significantly more likely to not have an RSOC than pediatricians. Not having an RSOC was inversely related to the belief that health is determined by health professionals (OR, 0.45; 95% CI, 0.29-0.68) and directly related to the belief that chance (OR, 1.90; 95% CI, 1.28-2.82) determines health. Not having an RSOC in 1991 predicted not being screened for breast, colon, and prostate cancer, as well as not receiving an influenza vaccine at 6 years of follow-up. CONCLUSIONS: A large percentage of physicians in our sample had no RSOC, and this was associated with both medical specialty and beliefs about control of health outcomes. Not having an RSOC was significantly associated with failure to use preventive services several years later. Arch Intern Med. 2000;160:3209-3214.

Opportunities for improving inpatient smoking cessation programs: a community hospital experience.

BACKGROUND: This cohort study examined the role of smoking during hospitalization, duration of cessation counseling, patient awareness of the hospital's smoke-free policy, belief that smoking is associated with a current symptom or disease, and the presence of withdrawal symptoms with 12-month smoking cessation among inpatients enrolled in a smoking cessation program. METHODS: Inpatients in four community hospitals (N = 1,317) participated in a smoking cessation intervention consisting of face-to-face counseling at baseline and four follow-up counseling phone calls. Patients were classified as nonsmokers only if they reported not smoking at both the 6- and the 12-month interviews. All patients lost to follow-up were considered smokers. RESULTS: At 1 year the smoking cessation rate was 22.5%. Cessation was independently associated with reporting no smoking during hospitalization, noting no withdrawal symptoms at baseline, and believing that a current illness or symptom is related to smoking. Length of counseling interview and awareness of the hospital's smoke-free policy were not independently associated with cessation. CONCLUSIONS. Smoking cessation programs and hospital policies that decrease smoking during hospitalization, address withdrawal symptoms during hospitalization, and make clear the connection between a patient's health and cigarette smoking may increase the effectiveness of their smoking cessation efforts.

Primary care patients' opinions regarding the importance of various aspects of care for depression.

The objectives of this study were to 1) ascertain the importance of various aspects of depression care from the patient's perspective and 2) select items and scales for inclusion in a new instrument to measure primary care patients' attitudes toward and ratings of depression care. We used a cross-sectional survey at a university-based urban primary care clinic; the subjects were adult patients being recruited for a study of minor depression. To help prioritize attitudinal domains, including 126 items identified previously in focus groups, we asked patients to rate the importance of each aspect of depression care on a five-point scale. Items were ranked according to mean scores and the percentage of patients ranking the items as extremely important. The items were selected for inclusion in an instrument to measure patients' attitudes toward depression care based on their importance ratings. We performed reliability and validity testing of scales comprising the 30 most important items and a shortened version that includes 16 items. The sample included 76 patients (mean age 34.8 years; mean CES-D score, 22.2; 72% women; 36% African-American; 32% college graduates). Forty-six percent had visited a mental health professional in the past. The top 30 items for the overall sample came from the following domains: 1) health care providers' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, and 7) financial access to services. Scales comprising items from these domains show adequate internal consistency (Cronbach's alpha >0.70) as well as convergent and discriminant validity. We have designed a brief patient-centered instrument for measuring attitudes toward depression care that has evidence for internal item consistency reliability and discriminant validity.

Feasibility of using recipients of health promotional newsletters for post-marketing surveillance.

Achieving an adequate sample size is one of the major difficulties in performing post-marketing observational studies of health outcomes in persons taking specific drug preparations. We assessed the feasibility of recruiting participants for such a study of Cardizem CD from approximately 400,000 U.S. recipients of a health promotion newsletter. A three-page questionnaire was sent to a 2.5% random sample (n = 10,000) of recipients, stratified by geographic region. After two mailings, 2779 (28%) returned the questionnaire. Of the 2779 respondents, 2132 (77%) reported having high blood pressure. Eighty-seven percent indicated a willingness to participate in a long-term prospective study. In a multivariate model, calcium channel blocker (CCB) use was associated with a history of coronary heart disease, duration of hypertension medication use greater than 1 year, a rating of good or excellent hypertension care, higher systolic blood pressure, higher education level, family history of cardiovascular disease, and history of smoking. These results indicate that self-reported CCB users may be at greater risk of cardiovascular heart disease and that it is feasible to use health promotion newsletters as a source of participants in prospective studies of cardiovascular disease.

Comparison of five measures of motivation to quit smoking among a sample of hospitalized smokers.

OBJECTIVE: To compare the predictive validity of several measures of motivation to quit smoking among inpatients enrolled in a smoking cessation program. METHODS: Data collected during face-to-face counseling sessions included a standard measure of motivation to quit (stage of readiness [Stage]: precontemplation, contemplation, or preparation) and four items with responses grouped in three categories: "How much do you want to quit smoking" (Want), "How likely is it that you will stay off cigarettes after you leave the hospital" (Likely), "Rate your confidence on a scale from 0 to 100 about successfully quitting in the next month" (Confidence), and a counselor assessment in response to the question, "How motivated is this patient to quit?" (Motivation). Patients were classified as nonsmokers if they reported not smoking at both the 6-month and 12-month interviews. All patients lost to follow-up were considered smokers. MAIN RESULTS: At 1 year, the smoking cessation rate was 22. 5%. Each measure of motivation to quit was independently associated with cessation ( p <.001) when added individually to an adjusted model. Likely was most closely associated with cessation and Stage was least. Likely had a sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of 70.2%, 68.1%, 39.3%, 88.6%, and 2.2, respectively. CONCLUSIONS: The motivation of inpatient smokers to quit may be as easily and as accurately predicted with a single question as with the series of questions that are typically used.

The psychiatric profile of patients with chronic diseases who do not receive regular medical care.

OBJECTIVE: To assess the relationship between psychiatric disorders and lack of regular medical care in individuals with chronic medical diseases. METHODS: Nine hundred sixty-three respondents to the household-based Baltimore Epidemiologic Catchment Area (ECA) Follow-Up Study were interviewed in 1981, 1982, and 1993-1996. The main outcome measures were: 1) not receiving regular care from a health professional for an active chronic medical condition in 1981, 2) persistent lack of regular medical care, and 3) leaving regular medical care. RESULTS: In cross-sectional analyses, having a psychiatric disorder (OR 1.70, 95% CI 1.17-2.48) was associated with not receiving regular medical care. This was mostly due to individuals with phobic disorder (OR 1.57, 95% CI 1.02-2.43). In prospective analyses, depression (RR 2.4, p < 0.04) and alcohol abuse (RR 2.9, p < 0.001) predicted leaving regular medical care one year later. Phobic disorder (RR 2.8, p < 0.001) predicted leaving care thirteen years later. CONCLUSIONS: Psychiatric disorders appear to place an individual at risk for irregular medical care. Studies of the quality and continuity of care for patients with chronic medical conditions should include measures of common psychiatric conditions.

An evidence-based interactive computer program to assist physicians in counseling smokers to quit.

Computerized expert systems offer the promise of increasing the frequency and efficiency of physician counseling of smokers to quit by collecting pertinent data and presenting it to physicians in a useful manner to guide and inform the counseling session. This article explores one such program that collects patient information, before the physician visit, that is pertinent to counseling smokers as described in the Agency for Health Care Policy and Research's Smoking Cessation Guidelines and supported in the medical literature. The program uses the information collected to produce two reports: one for the physician to use during the visit and the other for the patient as a means of supplementing and reinforcing the counseling message. Pilot data are presented from volunteers and primary care patients.

Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up.

OBJECTIVE: To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s. DESIGN: Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996. SETTING: The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up. SUBJECTS: Subjects included 1,662 adults (590 African Americans and 1,072 whites). MAIN OUTCOME VARIABLE: Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview. RESULTS: In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites. CONCLUSIONS: Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.

Race, gender, and partnership in the patient-physician relationship.

CONTEXT: Many studies have documented race and gender differences in health care received by patients. However, few studies have related differences in the quality of interpersonal care to patient and physician race and gender. OBJECTIVE: To describe how the race/ethnicity and gender of patients and physicians are associated with physicians' participatory decision-making (PDM) styles. DESIGN, SETTING, AND PARTICIPANTS: Telephone survey conducted between November 1996 and June 1998 of 1816 adults aged 18 to 65 years (mean age, 41 years) who had recently attended 1 of 32 primary care practices associated with a large mixed-model managed care organization in an urban setting. Sixty-six percent of patients surveyed were female, 43% were white, and 45% were African American. The physician sample (n = 64) was 63% male, with 56% white, and 25% African American. MAIN OUTCOME MEASURE: Patients' ratings of their physicians' PDM style on a 100-point scale. RESULTS: African American patients rated their visits as significantly less participatory than whites in models adjusting for patient age, gender, education, marital status, health status, and length of the patient-physician relationship (mean [SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P = .03). Ratings of minority and white physicians did not differ with respect to PDM style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites, 61.7 [3.1]; P = .13). Patients in race-concordant relationships with their physicians rated their visits as significantly more participatory than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P = .02). Patients of female physicians had more participatory visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5 [3.1]; P = .03), but gender concordance between physicians and patients was not significantly related to PDM score (unadjusted mean [SE] PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P = .12). Patient satisfaction was highly associated with PDM score within all race/ethnicity groups. CONCLUSIONS: Our data suggest that African American patients rate their visits with physicians as less participatory than whites. However, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.