A qualitative comparison of DSM depression criteria to language used by older church-going African-Americans.

OBJECTIVE: Depression in late life is associated with substantial suffering, disability, suicide risk, and decreased health-related quality of life. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a depression diagnosis is derived from a constellation of symptoms that may be described differently by different people. For example, the DSM language may be inadequate in capturing these symptoms in certain populations such as African-Americans, whose rates of depression misdiagnosis is high. METHODS: This study reports the findings from a church-based, qualitative study with older African-Americans (n = 50) regarding the language they use when discussing depression and depression treatment, and how this compares to the DSM-IV depression criteria. Content analyses of the in-depth discussions with African-American male and female focus group participants resulted in a deeper understanding of the language they used to describe depression. This language was then mapped onto the DSM-IV depression criteria. RESULTS: While some words used by the focus group participants mapped well onto the DSM-IV criteria, some of the language did not map well, such as language describing irritability, negative thought processes, hopelessness, loneliness, loss of control, helplessness, and social isolation. CONCLUSIONS: The focus group setting provided insight to the language used by older, church-going African-Americans to describe depression. Implications include the advantages of using qualitative data to help inform clinical encounters with older African-Americans.

Racial differences in adherence to antidepressant treatment in later life.

OBJECTIVE: Although antidepressants are an effective treatment for later-life depression, older patients often choose not to initiate or to discontinue medication treatment prematurely. Although racial differences in depression treatment preferences have been reported, little is known about racial differences in antidepressant medication adherence among older patients. DESIGN: Prospective, observational study comparing antidepressant adherence for older African American and white primary care patients. PARTICIPANTS: A total of 188 subjects age 60 and older, diagnosed with clinically significant depression with a new recommendation for antidepressant treatment by their primary care physician. MEASUREMENT: Study participants were assessed at study entry and at the 4-month follow-up (encompassing the acute treatment phase). Depression medication adherence was based on a well-validated self-report measure. RESULTS: At the 4-month follow-up, 61.2% of subjects reported that they were adherent to their antidepressant medication. In unadjusted and two of the three adjusted analyses, African American subjects (n = 82) had significantly lower rates of 4-month antidepressant adherence than white subjects (n = 106). African American women had the lowest adherence rates (44.4%) followed by African American men (56.8%), white men (65.3%), and white women (73.7%). In logistic regression models controlling for demographic, illness, and functional status variables, significant differences persisted between African American women and white women in reported 4-month antidepressant adherence (OR: 3.58, 95% CI: 1.27-10.07, Wald χ(2) = 2.42, df = 1, p <0.02). CONCLUSIONS: The results demonstrate racial and gender differences in antidepressant adherence in older adults. Depression treatment interventions for older adults should take into account the potential impact of race and gender on adherence to prescribed medications.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists.

BACKGROUND: Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria. METHODS: This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases. RESULTS: We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria. CONCLUSION: Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.

Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort.

OBJECTIVES AND HYPOTHESIS: Our objectives were to characterize the quality of acute sinusitis care and to identify nonclinical factors associated with antibiotic use for acute sinusitis. We hypothesized that we would identify provider-level factors associated with antibiotic use. STUDY DESIGN: Retrospective cohort at a single academic institution. METHODS: We developed and clinically annotated an administrative dataset of adult patients diagnosed with acute sinusitis between January 1, 2005, and December 31, 2006. We used identify factors associated with receipt of antibiotics. RESULTS: We find that 66.0% of patients with mild symptoms of short duration are given antibiotics, and that nonclinical factors, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence antibiotic use. Relative to internal medicine providers, family medicine providers use fewer antibiotics, and emergency medicine providers use more antibiotics for acute sinusitis. CONCLUSIONS: Antibiotics continue to be overused for patients with mild acute sinusitis of short duration. Nonclinical characteristics, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence use of antibiotics for acute sinusitis. LEVEL OF EVIDENCE: 4.