Long-term effectiveness of disseminating quality improvement for depression in primary care.

BACKGROUND: This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC). METHODS: The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years. RESULTS: For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively). CONCLUSIONS: While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

Influence of emotional engagement and habituation on exposure therapy for PTSD.

This study examined 2 process variables, emotional engagement and habituation, and outcome of exposure therapy for posttraumatic stress disorder. Thirty-seven female assault victims received treatment that involved repeated imaginal reliving of their trauma, and rated their distress at 10-min intervals. The average distress levels during each of 6 exposure sessions were submitted to a cluster analysis. Three distinct groups of clients with different patterns of distress were found: high initial engagement and gradual habituation between sessions, high initial engagement without habituation, and moderate initial engagement without habituation. Clients with the 1st distress pattern improved more in treatment than the other clients. The results are discussed within the framework of emotional processing theory, emphasizing the crucial role of emotional engagement and habituation in exposure therapy.

A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims.

Ninety-six female assault victims with chronic posttraumatic stress disorder (PTSD) were randomly assigned to 4 treatment conditions: prolonged exposure (PE), stress inoculation training (SIT), combined treatment (PE-SIT), or wait-list control (WL). Treatment consisted of 9 twice-weekly, individual sessions. Independent evaluations were conducted at pretreatment; posttreatment; and 3-, 6-, and 12-month follow-ups. All 3 active treatments reduced severity of PTSD and depression compared with WL but did not differ significantly from each other, and these gains were maintained throughout the follow-up period. However, in the intent-to-treat sample, PE was superior to SIT and PE-SIT on posttreatment anxiety and global social adjustment at follow-up and had larger effect sizes on PTSD severity, depression, and anxiety. SIT and PE-SIT did not differ significantly from each other on any outcome measure.

Prevention of depressive symptoms in school children.

This paper describes the development and preliminary efficacy of a program designed to prevent depressive symptoms in at-risk 10-13 year-olds, and relates the findings to the current understanding of childhood depression. The treatment targets depressive symptoms and related difficulties such as conduct problems, low academic achievement, low social competence, and poor peer relations, by proactively teaching cognitive techniques. Children were identified as 'at-risk' based on depressive symptoms and their reports of parental conflict. Sixty-nine children participated in treatment groups and were compared to 73 children in control groups. Depressive symptoms were significantly reduced and classroom behavior was significantly improved in the treatment group as compared to controls at post-test. Six-month follow-up showed continued reduction in depressive symptoms, as well as significantly fewer externalizing conduct problems, as compared to controls. The reduction in symptoms was most pronounced in the children who were most at risk.

Determination of total sulfur compounds and benzothiazole in asphalt fume samples by gas chromatography with sulfur chemiluminescence detection.

As part of a collaborative project between the National Institute for Occupational Safety and Health and the Federal Highway Administration to evaluate asphalt pavers' exposures to asphalt fume and their potential health effects, a method was developed for the determination of total sulfur compounds and benzothiazole in asphalt fume samples. Asphalt fume samples were collected from asphalt mixtures with and without the addition of ground-up rubber tires. The asphalt fume samples were collected with sampling trains that consisted of a Teflon membrane filter and an XAD-2 adsorbent tube. Filter and sampling tube media were extracted with hexane and subsequently analyzed by gas chromatography with a sulfur chemiluminescence detector. Separation was achieved with a 100 percent dimethyl polysiloxane fused silica column. Typical calibration curves had linear correlation coefficients of 0.99 or better with a relative standard deviation (RSD) of 5 percent. Benzothiazole desorption efficiency (DE) determined using spiked sampling tubes ranged from 96.5 percent at 5.0 micrograms to 89.4 percent at 40 micrograms with RSD values from 0.9 to 4.0 percent. Benzothiazole storage recovery determined using sampling tubes spiked at 20 micrograms and refrigerated for 30 days at 4 degrees C was 89.8 percent when corrected for the DE with an RSD of 1.1 percent. The limit of detection for the method determined using spiked sampling tubes was 0.30 microgram. Quantitation for total sulfur compounds and benzothiazole was against benzothiazole standards in hexane. Because of detector selectivity, sample preparation consisted of a simple hexane extraction even when samples had a high background due to hydrocarbon overload. Detector sensitivity provided quantitation in the sub-microgram region. Because of the sample preparation step and because benzothiazole was determined during the same analysis run, this method is straightforward and analytically efficient. The method has been used to analyze asphalt fume samples collected at several asphalt paving and roof operations.

Depression in youth: psychosocial interventions.

Witnessed over the past 20 years are major advances in knowledge regarding depression in children and adolescents. Although additional research is needed, clinicians can now turn to treatment strategies with demonstrated efficacy. In this article we review the literature on psychosocial interventions for depression in youth and offer a working model to guide the treatment of depressed youth. We begin with a brief overview of the model, followed by a review of the treatment efficacy and prevention literatures. We offer some caveats that impact the ability to move from this treatment literature to the real world of clinical practice. We conclude by considering how extant research can inform treatment decisions and highlight critical questions that need to be addressed through future research.

Development of a versatile method for the detection of nicotine in air.

Nicotine, a rapid-acting poison, is present in environmental tobacco smoke and has been used as a greenhouse insecticide. Due to its toxicity, several health hazard evaluations (HHE) have resulted from potential nicotine exposures to casino workers, airline flight attendants, and greenhouse employees. Exposure to nicotine can occur by inhalation, skin adsorption, and ingestion, resulting in such adverse health effects as nausea, vomiting, headache, dizziness, tachycardia, hypertension, convulsions, and cardiac arrhythmia. The development of an improved sampling and analytical methodology for nicotine was required to accommodate the broad concentration of nicotine levels and varying sampling scenarios presented by the differing HHE requests. A XAD-4 sorbent tube was selected for the collection of airborne nicotine. Analytical methodology for the separation, identification, and quantitation of nicotine by both gas chromatography-flame ionization detection and gas chromatography-nitrogen/ phosphorous detection is described. The limit of detection for nicotine was 0.013 microg/sample. The desorption efficiency for nicotine was determined over the range of study and ranged from 90.9% (0.096 microg) to 93.7% (24.0 microg). Nicotine exhibited storage stability for 30 days at 5 degrees C and for 14 days at ambient temperature. Based on the results of this research study, the new method for nicotine was published in the NIOSH Manual of Analytical Methods (NMAM 2551).

Predicting response to exposure treatment in PTSD: the role of mental defeat and alienation.

Not all patients with posttraumatic stress disorder benefit from exposure treatment. The present paper describes two cognitive dimensions that are related to inferior response to exposure in rape victims. First, individuals whose memories during relieving of the trauma reflected mental defeat or the absence of mental planning showed little improvement. Second, inferior outcome was correlated with an overall feeling of alienation or permanent change following the trauma. These results are based on blind ratings of transcripts of exposure treatment sessions from 10 women with good outcome and 10 women with inferior outcome. Patients in the two groups were matched for initial symptom severity and were comparable in many aspects of the assault. Patients who experienced mental defeat, alienation, or permanent change may require cognitive restructuring in addition to exposure.

A national survey of stress reactions after the September 11, 2001, terrorist attacks.

BACKGROUND: People who are not present at a traumatic event may also experience stress reactions. We assessed the immediate mental health effects of the terrorist attacks on September 11, 2001. METHODS: Using random-digit dialing three to five days after September 11, we interviewed a nationally representative sample of 569 U.S. adults about their reactions to the terrorist attacks and their perceptions of their children's reactions. RESULTS: Forty-four percent of the adults reported one or more substantial stress symptoms; 91 percent had one or more symptoms to at least some degree. Respondents throughout the country reported stress syndromes. They coped by talking with others (98 percent), turning to religion (90 percent), participating in group activities (60 percent), and making donations (36 percent). Eighty-five percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 34 percent restricted their children's television viewing. Thirty-five percent of children had one or more stress symptoms, and 47 percent were worried about their own safety or the safety of loved ones. CONCLUSIONS: After the September 11 terrorist attacks, Americans across the country, including children, had substantial symptoms of stress. Even clinicians who practice in regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.