Epilepsy in mainstream and special educational primary school settings.

This population based study compared the prevalence, nature and management of epilepsy between primary school children in mainstream education and those attending a special educational placement (children with special needs). The overall prevalence of epilepsy was 4.3/1000, but was 30 times higher in children with special needs, many of whom also had severe physical disabilities. Seizure types and the proportion of subjects with multiple seizures were similar in mainstream children and those with special needs. Epilepsy syndromes were identified in 74% of children. Although seizures were better controlled in children at mainstream school, 44% of these children did not have well controlled seizures. Children with epilepsy are an educationally vulnerable group and both education and health staff need to be aware of the additional support that many of these children require in all types of primary educational settings.     

Study of the Prevalence of Epilepsy Among Schoolchildren in Valladolid, Spain

A population study was performed to estimate the prevalence of epilepsy in the juvenile population of Valladolid, Spain. Using a mixed questionnaire (postal-domiciliary), we studied a sample of 5,100 primary school pupils (aged between 6 and 14 years) and 48 pupils receiving state-run special education. We also identified all the students receiving private special education and from specific special education centers belonging to the same age group (90 and 145, respectively). The prevalence of epilepsy in the school age population on December 1, 1987 was estimated at 5.72/1,000 inhabitants. Our results are comparable to those of other studies in Western countries.     

Two-year effects of quality improvement programs on medication management for depression

BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.     

An epidemiological survey of age-related dementia in an urban area of Beijing

An epidemiological survey of age-related dementia among community residents of an urban of Beijing was conducted in 1986. Initial screening of 1331 subjects aged 60 and above was made using the Mini-Mental State Examination (MMSE) with a cutoff point of 17. All suspected cases of dementia and 5.5% of all others were then given a full clinical examination, with subjects being diagnosed and classified according to DSM-III criteria. The MMSE was found to have satisfactory sensitivity, although scores were significantly correlated with education. Prevalence rates of moderate and severe dementia were 1.28% for those aged 60 and above and 1.82% for those aged 65 and above. Rates for multi-infarct dementia were higher than those for primary degenerative dementia; females had higher rates than males and rates increased sharply with age. All the dementia cases were cared for in their own homes, by relatives. There is a need for increased knowledge and services for elderly people in the community.     

A randomised controlled trial of an educational intervention for depression among Asian women in primary care in the United Kingdom

OBJECTIVE: To determine the effect of patient education on patient perspectives and outcome of depression in a sample of Asian women in primary care. DESIGN: A randomised, clinical trial of "patient education" versus "usual care". SETTING: A general practice in London, which has a high proportion of Asians. SUBJECTS: Seventy patients with psychiatric morbidity (a score of 3 or more on the General Health Questionnaire 12) were recruited for the trial. OUTCOME MEASURES: Patient's explanatory models of illness (the patient's perspective on depression; recognition of depression as illness and recommend a medical intervention for this condition) and psychiatric morbidity at follow-up after two months were the primary outcome measures. RESULTS: One hundred and fifty-five women of Asian decent were contacted. One hundred and forty-eight (95.5%) agreed to take part in the study. Seventy (47.3%) were classed as cases of common mental disorder using the General Health Questionnaire 12. Thirty-five were randomly allocated to receive education about the nature, causes, prevalence and treatment of depression, 35 did not receive such information. There were no statistical differences between the two groups on baseline characteristics. Sixty-six (94.3%) subjects were followed up at two months. An intention to treat analysis showed that there was no difference in explanatory model measures between the two groups at the end of the study. However, more patients who received education were no longer cases (a score of 2 or less on the GHQ) (15/35; 42.9%) compared to controls (7/35; 20%) (p < 0.05) as did those with lower GHQ scores at entry (p < 0.03). Receipt of educational intervention (OR 3.4; 95% CI 1.01, 11.5) and lower GHQ scores at entry (OR 7.1; 95% CI 1.05, 30.2) remained significantly associated with recovery after adjusting for baseline variables using logistic regression. CONCLUSIONS: Patients with common mental disorders, especially those with milder forms of the condition, who received the educational material had a higher recovery rate than patients who do not receive such education. The mechanism for this improvement was unclear, not being reflected in patient's apparent understanding of depression nor explained by change in general practitioner's response. The results of this study need to be replicated.     

Patient characteristics associated with participation in a practice-based study of depression in late life: the Spectrum study

OBJECTIVE: An important component of generalizing study results to patients is the extent to which study participants adequately represent individuals targeted for the study. The Spectrum study of depression in older primary care patients was utilized to consider patient characteristics associated with nonparticipation. METHOD: Interviewers utilized a validated questionnaire to screen adults aged 65 years and older for depression who presented to one of the participating primary care practices in the Baltimore, Maryland area. Screening interviews included information about sociodemographic factors, functioning, health, and attitudes about depression and its treatment in order to compare participants with persons who declined. RESULTS: In all, 2,560 adults aged 65 years and older were screened. Comparison of the characteristics of the patients who were eligible for the study (n = 773) with patients who participated fully in the in-home evaluation (n = 355) found that the study sample included proportionately more persons who: 1) were less than 80 years old; 2) completed high school; and 3) reported two or more visits to the practice site within six months of the interview. Among patients who were depressed, no significant differences were found in the characteristics of those who met study eligibility criteria and those who agreed to participate. CONCLUSIONS: Persons over the age of 80 years of age or those with less than a high school education may require tailored strategies for recruitment even when approached by a trained interviewer in a primary care doctor's office.     

General practitioners' educational needs in intellectual disability health

Background The community general practitioner (GP) has a central role in the provision of primary health care to people with intellectual disability (ID) as an indirect result of deinstitutionalization in Australia. This population, however, continues to experience poor health care compared to the general population. The current paper describes results from a questionnaire that aimed to identify the perceptions of practising GPs on the standards of health care for people with ID, the adequacy of prior training, and their interest in further education in relation to nine health care areas. Method A questionnaire was posted to a selective sample of 1272 practising GPs in Victoria selected from a database from the Centre for Developmental Disability Health Victoria and the Victorian Medical Directory of GPs registered with the Australian Medical Association. Data were available for 252 respondents with a response rate of 28.5%. Results The health areas in which many GPs reported to be inadequately trained were the same as those areas that were perceived as being of a poor standard. These areas were behavioural or psychiatric conditions, human relations and sexuality issues, complex medical problems, and preventative and primary health care. Ninety four per cent of respondents were interested in further education in at least one of the nine health care areas, with the most frequently nominated areas being behavioural or psychiatric conditions, syndrome‐specific medical problems, human relations and sexuality issues and collaboration with government services. General practitioners did not nominate complex medical problems or preventative and primary health care for further education as frequently as they identified care in these areas to be substandard and their prior training inadequate. Conclusions The findings from the current research are discussed in relation to the implications for development of educational programmes based on learning needs identified by the GP. The most frequently nominated health care areas in all three questions were behavioural or psychiatric conditions and human relations and sexuality issues. Reasons for incongruence between the frequency of responses for complex medical problems and preventative and primary health care are explored.     

Randomized control trial of a behavioral intervention for overweight women: impact on depressive symptoms

Phone and Internet-based interventions can improve the management of depression in primary care, and interventions using these communication channels are increasingly used to improve behaviors such as diet and physical activity. Increased physical activity has been shown to improve depressive symptoms, but to date there are no reports of the effects of a phone and Internet diet and exercise intervention on symptoms of depression in patients seen in primary care. This study assessed depressive symptoms in 401 participants in a randomized control trial of a 12-month primary care, phone and Internet-based behavioral intervention for overweight women. A one-way analysis of variance examining the mean change in Center for Epidemiological Studies Depression (CESD) score from baseline to 12 months, controlling for age, education, marital status, and employment showed that those receiving the intervention significantly decreased their CESD scores (P=.03) more than those receiving standard care. Although the intervention did not target depressed individuals or present material relating to mood management, those with probable depression (27% of the whole sample) showed clinically important improvements-a mean five-point change on the CESD short form. Participants who engaged more readily with the intervention were more likely to reduce their depression scores. A 1-year primary care based phone and Internet diet and exercise intervention can improve depressive symptoms in overweight women. Given the promise of phone and Internet-based interventions to improve both depression and lifestyle-related behaviors, and given that such interventions could extend the reach of primary care to many individuals at relatively low cost, these results suggest the need for further research, including the effects of additional mood management components.     

Relationships between years of education,regional grey matter volumes,and working memory-related brain activity in healthy older adults

The aim of this study was to examine the relationships between educational attainment, regional grey matter volume, and functional working memory-related brain activation in older adults. The final sample included 32 healthy older adults with 8 to 22 years of education. Structural magnetic resonance imaging (MRI) was used to measure regional volume and functional MRI was used to measure activation associated with performing an n-back task. A positive correlation was found between years of education and cortical grey matter volume in the right medial and middle frontal gyri, in the middle and posterior cingulate gyri, and in the right inferior parietal lobule. The education by age interaction was significant for cortical grey matter volume in the left middle frontal gyrus and in the right medial cingulate gyrus. In this region, the volume loss related to age was larger in the low than high-education group. The education by age interaction was also significant for task-related activity in the left superior, middle and medial frontal gyri due to the fact that activation increased with age in those with higher education. No correlation was found between regions that are structurally related with education and those that are functionally related with education and age. The data suggest a protective effect of education on cortical volume. Furthermore, the brain regions involved in the working memory network are getting more activated with age in those with higher educational attainment.     

Job satisfaction and career commitment among nursing assistants providing Alzheimer's care

As part of a statewide dementia-specific training collaborative, data were collected from nursing assistants and aides who provide paid Alzheimer's care. This study explored the relevance of previous education and practical experiences to specific constructs associated with worker recruitment and retention. Direct-care providers with prior training in gerontology and geriatrics had lower levels of extrinsic job satisfaction and career resilience than those without this kind of continuing education. Program participants who were currently or previously the primary caregiver for a friend or relative with Alzheimer's disease had higher levels of intrinsic job satisfaction but lower levels of career resilience than those with no informal caregiving experience. Current or previous informal caregiving experience may enhance intrinsic job satisfaction by increasing personal commitment to pursue formal care work and providing a kind of inoculation against the demoralization that is too often suffered in these very challenging jobs.     

Differences between detected and undetected patients in primary care and depressed psychiatric patients

The aim of this study was to explore differences between primary care and tertiary psychiatry patients meeting DSM-III-R criteria for depressive disorders in terms of a wide range of demographic and clinical variables including psychiatric comorbidity. A weighted sample of 153 depressed primary care patients was obtained from the waiting rooms of family physicians using a two-stage selection and assessment procedure including the Structured Clinical Interview for the DSM-III-R (SCID). A measure of physician detection was also obtained. The 123 depressed psychiatric patients were seeking evaluation and treatment at a university-based depression program, and DSM-III-R diagnoses were also obtained using the SCID. Overall, fewer depressed primary care patients met criteria for major depressive disorder, and more of those who did were only mildly depressed. Depressed primary care patients were more likely to be women, older, and had less education, less past treatment, and greater lifetime comorbidity. Clinical differences were greatest for the depressed patients who had gone undetected by their physicians: they were higher functioning, less distressed, and more mildly depressed. Findings are discussed in terms of the validity and acceptability of practice guidelines for depression in primary care.     

Personality disorders in dysthymia and major depression.

OBJECTIVE: The purpose of the present study was to investigate the comorbidity of personality disorders in patients with primary dysthymia compared to those with episodic major depression. METHOD: A total of 177 out-patients with primary dysthymia and 187 outpatients with episodic major depression were administered a structured diagnostic interview for DSM-III-R Axis II disorders. In addition, all of these patients completed the BDI, and those with the appropriate level of education also completed the Minnesota Multiphasic Personality Inventory (MMPI). RESULTS: A significantly higher proportion of dysthymic patients than patients with major depression met the criteria for a personality disorder, for borderline, histrionic, avoidant, dependent, self-defeating types and for personality disorders of clusters B and C. Further analysis revealed that the above differences were mainly due to the subgroup of patients with 'early-onset dysthymia'. Finally, patients with a personality disorder, both dysthymics and those with major depression, had significantly higher scores on the BDI and on the majority of the MMPI scales compared to those without a personality disorder. CONCLUSION: The data indicated that (i) dysthymia--mainly that of early onset--is associated with significantly higher personality disorder comorbidity than episodic major depression, and (ii) the presence of a personality disorder is related to more severe overall psychopathology.     

Predictors of nonresponse to treatment in primary care patients with dysthymia

Dysthymia is one of the most prevalent problems in primary care, especially in the elderly. In this study, we evaluated the demographic and clinical predictors of nonresponse to treatment in primary care patients with dysthymia. The study sample consisted of 338 primary care patients meeting DSMIII-R criteria for dysthymia from 4 diverse geographic sites in a randomized controlled 11-week trial of paroxetine, problem-solving therapy or placebo. Patients who attended at least 4 treatment sessions were used in the analysis. A score of less than 7 on the Hamilton was defined as a positive response to treatment. By Week 11, 52.2% of patients had a positive response to treatment. Patients with lower levels of education (odds ratio 0.44, 95% CI 0.23, 0.86), higher scores on the personality dimension of neuroticism (odds ratio 0.58, 95% CI 0.36, 0.92) and those with more severe medical illness (odds ratio 0.97, 95% CI 0.95, 0.99) were less likely to recover with either active or placebo treatments. Elderly women (>60 years of age; odds ratio 0.19, 95% CI 0.05, 0.66) were also less likely to respond to all treatments; however, females had a significantly higher response to placebo treatment compared to males. The factors associated with lack of response to treatment included lower-levels of education, high neuroticism, more severe medical illness and being an older female. This analysis is based on patients agreeing to participate in a randomized controlled trial, limiting representativeness of the sample, however, the demographic and clinical characteristics are common in elderly depressed primary care patients, and may signal the need for increased mental health specialty consultation.     

Patterns and Predictors of Mental Healthcare Utilization in Schools and Other Service Sectors Among Adolescents at Risk for Depression

This study examined racial/ethnic and socioeconomic differences in service utilization across sectors (specialty mental health, school, primary care) for youth at risk for depression. Our sample included 362 adolescents who were enrolled in a larger project examining the effects of an indicated school-based depression prevention program. Service use across sectors mirrored national trends and previous research findings in which the education sector was most frequently utilized for mental health services. Race/ethnicity was significantly associated with parent-reported specialty mental health service utilization, even when controlling for other predictors of use. The study also suggests that racial disparities in service access generally appear to be reduced through the availability of education sector mental health services. Socioeconomic status was not associated with service use in any sector when controlling for other predictors. Parent–child agreement was moderate for report of specialty mental health service use and low for report of use of services within the education and primary care sectors.     

Implications of mainstream classrooms for adolescents with spina bifida

This study examined the social and academic implications of mainstream, mainstream and special (combined) or special-class education for 31 adolescents with spina bifida, and for their primary caretakers. The Peabody Picture Vocabulary Test and the UCLA Loneliness Scale (adolescents) and the Personality Inventory for Children (caretakers) were administered. Adolescents in mainstream classes had the most normal scores for academic and social skills, those in combined classes had intermediate scores and those in special classes had the lowest scores. Paradoxically, adolescents in combined classes reported the least loneliness. This study suggests that even among students with relatively good social skills, mainstream placement is associated with greater subjective experience of loneliness than is combined placement.     

Teaching behavioral sciences to medical students. Education or training?

Accepted paradigms in medical behavioral science education are development, conflict and defense, and disease. Teaching under these paradigms blurs distinctions between preclinical and clinical education, and between education and training--most commonly by including an introduction to clinical psychiatry in preclinical courses. Such approaches may provide students with technical skills at the expense of their developing conceptual bases for continuing self-education. We developed a first-year behavioral sciences course using the paradigm of symbolic function and language. This paradigm can organize knowledge that underlies clinical skills involved in talking with patients and establishing an effective physician-patient relationship. Believing that fostering knowledge should be the primary goal of preclinical education, we emphasized primary sources and classics. Our goal was to encourage analysis and synthesis rather than memorization; evaluating such higher taxonomic levels of education is extraordinarily difficult.     

Influence of patient preference and primary care clinician proclivity for watchful waiting on receipt of depression treatment

OBJECTIVE: We examined whether patients' preference for watchful waiting and their primary care clinician's proclivity for watchful waiting were associated with decreased likelihood of receiving depression treatment. METHODS: In a quality improvement intervention for depression in primary care, patients with depressive symptoms were identified through screening in 46 clinics from June 1996 to March 1997. We analyzed baseline survey data completed by clinicians and patients using logistic regression models. RESULTS: Of 1140 patients, 179 (16%) preferred watchful waiting over active treatment. After controlling for covariates, patients with depressive disorders who preferred watchful waiting were less likely to report use of antidepressants (OR=0.86, 95% CI=0.77-0.95). Among patients with depressive symptoms only, those who preferred watchful waiting were less likely to report antidepressant use (OR=0.84, 95% CI=0.76-0.93) or counseling (OR=0.84, 95% CI=0.77-0.95). Patients with less knowledge about depression were less likely to receive depression treatment. Clinician proclivity for watchful waiting was not associated with the likelihood that patients received depression treatment. CONCLUSIONS: Patient preference for watchful waiting is associated with lower rates of some depression treatments, especially among patients with subsyndromal depression. Addressing patient preference for watchful waiting in primary care may include active symptom monitoring and patient education.     

Somatized depression in primary care attenders

OBJECTIVE: The aim of this study is to determine, within the context of primary care, the frequency of the various ways in which depression is presented with respect to somatic symptoms and to compare depressed patients who present their distress somatically with those with psychological complaints. METHOD: In the two-phase cross-sectional study, first, we screened 906 consecutive patients, and second, we interviewed in detail 306 selected patients. RESULTS: The prevalence of depression was 16.8% (CI 95%: 13.4-20.2). There were 59 cases with psychological presentation, 45 somatizers and 16 had organic disorders with depressive comorbidity. Somatizers had lower level of education, and somatized depression was less serious and caused less repercussion. Detection, antidepressive treatment and psychiatric care were lower for somatizers than for psychologizers. CONCLUSIONS: Somatization is a frequent way to present depression in primary care. For somatizers, depression is less severe and is associated with less repercussion. Somatization is associated with the under-detection of the underlying psychiatric process.     

Education effects on the international HIV dementia scale

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) within the Indian subcontinent continues to spread. Although the primary clade of HIV in India differs from that of most Western countries, recent evidence suggests that the Indian clade (Clade C) also impacts neurocognitive functioning. India also has extremely high illiteracy rates that may confound detection of neurocognitive impairment, since many assessments to detect such impairment are heavily influenced by formal schooling. Among those with HIV/AIDS who have had limited educational opportunities and who are in the early stage of infection, the confounding effects of education on tests for neurocognitive impairment may be particularly salient. We therefore tested influence of HIV serostatus and education on a commonly used tool to screen for cognitive impairment, the International HIV Dementia Scale (IHDS), among Indian men and women in the catchment area of the Post Graduate Institute of Medical Education and Research (PGIMER) located in Chandigarh, India. Adjusted analyses showed that from a sample of 295 HIV-positive and HIV-negative individuals, only education was significantly associated with performance on the IHDS. HIV-negative and HIV-positive individuals, who were in the early stages of infection, performed similarly. Further development of this test to account for the effects of education on cut-off scores used to indicate possible dementia are needed, particularly for use in resource-limited settings such as India where low levels of education are widespread.     

The impact of anxiety disorders on educational achievement

Anxiety disorders typically have an age of onset in childhood and adolescence, resulting in significant disability in social and occupational functioning. Epidemiological evidence suggests that persons with psychiatric disorders and perhaps especially social phobia are at increased risk for premature withdrawal from school [Am. J. Psychiatry 157 (2000) 1606]. In order to further determine the impact of anxiety disorders on school functioning and/or premature withdrawal from school, 201 patients meeting DSM-IV criteria for a primary anxiety disorder completed a school leaving questionnaire as well as self-report measures of anxiety, depression, and social adjustment. About 49% (n = 98) reported leaving school prematurely and 24% of those indicated that anxiety was the primary reason for this decision. Patients who had left school prematurely were significantly more likely to have a lifetime diagnosis of generalized social phobia, a past history of alcohol abuse/dependence and a greater number of lifetime diagnoses than those who completed their desired level of education. This study suggests that anxiety disorders, and perhaps especially generalized social phobia, are associated with premature withdrawal from school. Further studies are required to determine methods for early identification and treatment of anxiety disorders in school aged children to enable these students to reach their full potential.