Effects of continuity of care and patient dispositional factors on the physician-patient relationship.

BACKGROUND: We developed a questionnaire to examine the influence of physician and patient variables on the quality of the physician-patient relationship. METHODS: More than 300 family medicine patients completed self-report measures of the physician-patient relationship and variables likely to influence it. RESULTS: The quality of relationship was related to continuity of physician care (having a primary physician, duration of that relationship, and frequency of visits) and to patient dispositional variables (neuroticism, positive and negative affectivity) but not to demographic variables. The regression model included having a primary physician, duration of relationship with that physician, and positive affectivity. Relationship quality was, in turn, associated with outcomes (adherence to care, treatment response, satisfaction with care, and commitment to physician). CONCLUSIONS: The quality of physician-patient relationship is influenced by physician continuity and patient dispositional variables. Better understanding of these may contribute to the therapeutic potential of this important relationship.

Hypochondriacal symptoms associated with a less therapeutic physician-patient relationship.

The purpose of this study was to examine the association between hypochondriacal symptoms and the physician-patient relationship. Family medicine patients (n = 310) completed self-report measures of hypochondriacal symptoms, quality of physician-patient relationship, and variables likely to influence that relationship. These variables included physician relationship factors, such as duration of relationship and frequency of visits, as well as patient characteristics, such as neuroticism and positive and negative affectivity. Hypochondriacal symptoms were negatively correlated (r = -.24) with the quality of physician-patient relationship. In addition to hypochondriacal symptoms, the regression model included having a primary physician, length of relationship with that physician, frequency of physician visits, and the level of positive affectivity in the patient. Hypochondriacal symptoms appear to be associated with a less therapeutic physician-patient relationship. Physicians must recognize symptoms of this kind in order to properly address the relationship needs of their patients.

Risk factors for insomnia in a rural population.

PURPOSE: This study compared in one data set the relative importance of most previously examined risk factors for different symptoms of insomnia. METHODS: Data were obtained from personal interviews of 1,588 adults in a rural area. Statistical methods evaluated the association of 42 risk factors with any insomnia and each of four insomnia subtypes: difficulty with initiating sleep (DIS), difficulty maintaining sleep (DMS), early morning awakening (EMA), and restless sleep (RS). RESULTS: Insomnia rates were greater in this rural population than most U.S. studies and greater in the United States than other countries. The correlations between insomnia subtype and energy level was highest for RS, -0.29, and lowest for EMA, -0.11. All sleep disturbances increased monotonically with depressive symptoms, but the increase was greatest for RS (r = 0.57) and weakest for EMA (r = 0.24). Anxiety and pain also were independently associated with each insomnia subtype. Insomnia problems of spouses were uncorrelated. Other risk factors were independently associated with some insomnia subtypes but not others. For example, the association of age with difficulty maintaining sleep was independent of health measures. CONCLUSION: The results suggest that different insomnias have different rates and risk factors and therefore possibly different etiologies and management strategies.

Telehealth screen for depression in a chronic illness care management program.

Chronic illness accounts for the majority of healthcare expenditures in the United States. Innovative telemedicine programs have been developed to help lessen the chronic illness burden, yet few have been developed to address comorbidity. Programs accommodating comorbidity are needed because most older adults suffer from two or more chronic illnesses. One of the most common and serious comorbidities in chronic illness is major depression, which has been shown to exacerbate morbidity, mortality, and cost. This study presents data on a telephone-based interactive voice recording (IVR) home monitoring program that was expanded to include quarterly screens for depression using the Patient Health Questionnaire (PHQ). Patients in an ongoing telehealth heart failure program were administered the PHQ-2 and PHQ-9 in November 2005 (Round 1) and February 2006 (Round 2). Patients were informed about the screen beforehand and an emergency protocol was established. At both screens, more than 90% of the patients completed the screen. Approximately 30% of the patients endorsed one of the PHQ-2 items in both rounds. Patients endorsing either of the PHQ-2 items then completed the full PHQ-9. Nurse care-managers contacted those scoring above the threshold of 10 on the PHQ-9 indicating possible depression. One patient expressed suicidality and was appropriately assessed for safety. There was no indication that patients were less likely to complete the screen in Round 2, although their average depression scores were slightly lower when compared with Round 1. A regular telephonic IVR screen for depression can be integrated into a standard illness management protocol. Following a preestablished emergency plan for the assessment of suicidality was successful. This serves as a model for using technology to manage comorbid depression and chronic illness.

Exacerbation of panic disorder with rifampin therapy in a patient receiving citalopram.

Citalopram, a selective serotonin reuptake inhibitor, is used in the management of anxiety disorders. A 55-year-old man receiving citalopram for panic disorder reported a decrease in the agent's therapeutic efficacy when rifampin was started for osteomyelitis. His condition improved when the rifampin was stopped. Rifampin is known to induce the metabolism of cytochrome P450 3A4 substrates and thus plays a role in several drug-drug interactions. We suspect that the efficacy of citalopram was blunted with the concurrent use of rifampin. To our knowledge, only one other case of an interaction of rifampin with a selective serotonin reuptake inhibitor is described in the literature. Clinicians should monitor all drugs and dietary supplements that patients with psychiatric conditions take, regardless of the indication, intended purpose, or prescriber. This is especially important, however, for a drug that is pivotal to a patient's well-being; its therapeutic effect should be carefully monitored when any new drug is added or a change in the dosage of a concurrent drug is made.