Improving depression care for older, minority patients in primary care

OBJECTIVE: Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes. STUDY DESIGN: A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care. PRINCIPAL FINDINGS: Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10). CONCLUSIONS: Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.     

The evaluation and treatment of depression in primary care

The evaluation and treatment of depressive disorders are vital functions for practicing primary care physicians. Depression is a prevalent, recurrent, highly treatable disorder that is debilitating and leads to significant psychosocial impairment. In view of the broadly available armamentarium of safe, newer medications, primary care physicians should be proficient in the treatment of these disorders. The following review will provide a synopsis of the current state of diagnosis, evaluation, and treatment of depression in the primary care setting. Appropriate treatment of depression can result in improvement in emotional, cognitive, and behavioral symptoms of depression and reduce psychosocial impairment, disability, and associated medical morbidity.     

Race and preventive services delivery among black patients and white patients seen in primary care

BACKGROUND: Numerous studies have documented racial disparities in delivery of health care treatment services, but there is little information to determine whether similar disparities exist in the delivery of preventive services. OBJECTIVE: To determine if disparities exist in preventive service delivery to non-Hispanic white patients and black patients in primary care. RESEARCH DESIGN: Multimethod study using direct observation of patient encounters, medical record review, and patient exit questionnaire. SUBJECTS: Four thousand three hundred thirteen outpatients presenting to 138 family physicians. MEASURES: Delivery of 15 screening, 24 health-habit counseling and 11 immunization services recommended by the US Preventive Services Task Force. RESULTS: Using multilevel linear regression analysis, no significant racial differences were found in rates of delivery of screening services or immunizations. However, black patients were more likely to receive preventive health-habit counseling (mean percent of patients up-to-date on all recommended counseling services, adjusted for covariates: 11.6% for black patients, 9.5% for whites, P = 0.003). CONCLUSIONS: Black patients able to access primary care receive preventive services at rates equal to or greater than white patients. This suggests that efforts to increase delivery of preventive care in black patients need to focus on access to primary care.     

Process of care in Hispanic,black, and white VA beneficiaries

OBJECTIVE: To examine whether process of hospital care differs among Hispanic, black, and white VA beneficiaries. SUBJECTS: Two thousand eight-hundred fifty-two Hispanic, black, and white male VA beneficiaries from a case-control study discharged alive from one of twelve southern veterans hospitals with one of three diagnoses, diabetes mellitus (DM), congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). METHODS: We applied diagnosis-specific explicit criteria for the process of hospital care to each patient's hospital record and computed the adherence score; the percentage of applicable criteria performed during the hospital stay. We compared mean scores in Hispanic, black, and white patients and then compared adjusted scores using multiple linear regression. MAIN OUTCOME MEASURE: Process of inpatient care (adherence score) in Hispanic, black, and white patients at admission, treatment, and discharge. RESULTS: Mean admission adherence scores differed (P = 0.003) among Hispanic patients, black patients, and white patients for CHF and COPD, but not DM. Mean treatment and discharge scores were not different among Hispanic patients, black patients, and white patients. In bivariate comparisons, mean admission scores were higher in black patients compared with white patients for CHF (P= 0.003) and COPD (P= 0.01). In stratified analyses, admission and treatment scores were higher (P= 0.0001) in patients admitted to teaching compared with nonteaching hospitals. Process of inpatient care did not differ among Hispanic, black, and white patients after adjusting for admission to a teaching hospital and other covariates. CONCLUSION: In contrast to findings in other studies, process of inpatient care was generally similar in Hispanic patients, black patients, and white patients. Our findings may reflect several characteristics of veterans' hospitals that may lead to care that is more equitable.     

Sequential treatment of depression in primary care

BACKGROUND: In the past decade, in clinical psychiatry several investigations suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aim of this paper was to illustrate the practical implications of sequential treatment strategy for depression in primary care, with particular reference to the increasingly common problem of recurrent depression. METHODS: The Authors tried to integrate the evidence which derives from meta-analyses and comprehensive general reviews with the insights which derive from controlled studies concerned with specific populations. CONCLUSIONS: The sequential treatment of mood disorders is an intensive, two-stage approach, which derives from the awareness that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the affective disturbances of patients, both in research and in clinical practice settings. The aim of the sequential approach is to add therapeutic ingredients as long as they are needed. In this sense, it introduces a conceptual shift in clinical practice.     

Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design

Depression frequently negatively affects patient overall self-care and social stress management within United States safety net care systems. Rates of major depression are significantly high among low-income predominantly Hispanic/Latino with chronic illness, such as diabetes and heart disease. The study design of the A Helping Hand to Activate Patient-Centered Depression Care among Low-income Patients (AHH) randomized clinical trial aims to enhance patient depression care receipt and overall bio-psychosocial self-care management.The AHH trial is conducted in collaboration with three Los Angeles County Department of Health Services (DHS) safety net clinics that provide Patient-Centered Medical Home (PCMH) care. The study compares AHH intervention (AHH) in which community-based bilingual promotoras provide in-person or telephone patient engagement and intervention aimed to reduce the burden and strain on patients, families, and care providers by assessing, enhancing, and facilitating patient depression and co-morbid illness self-care management skill, and activating patient communication with clinic medical providers versus DHS PCMH team usual care (PCMHUC). AHH independent bilingual recruiters screened 1957 and enrolled 348 predominantly Hispanic/Latino patients, of whom 296 (85%) had diabetes, 14 (4%) with heart disease, and 38 (11%) with both diseases. Recruiters identified depressed patients by baseline Patient Health Questionnaire-9 scores of 10 or more, completed baseline assessments, and randomized patients to either AHH or PCMHUC study group. The comprehensive assessments will be repeated at 6 and 12 months by an independent bilingual follow-up interviewer. Baseline and outcome data include mental health assessment and treatment receipt, co-morbid illness self-care, social relationships, and environmental stressor assessments.     

Prevalence of diagnosed diabetes among African-American and non-Hispanic white youth, 1999

OBJECTIVE: To document diabetes prevalence among African-American and non-Hispanic white youth in a two-county region in South Carolina. RESEARCH DESIGN AND METHODS: We conducted a population-based surveillance effort to identify case subjects aged 0-18.9 years with a physician diagnosis of diabetes residing in a two-county region in 1999. Case subjects were ascertained from hospitals, the sole office of pediatric endocrinology, and several smaller sources. Case subjects were classified according to the diagnosis made by a pediatric endocrinologist. As a completeness check, eight randomly selected physicians were queried for eligible case subjects. Capture-recapture provided an additional measure of completeness. Prevalence estimates used U.S. 2000 Census data for the two-county denominator. RESULTS: Crude total diabetes prevalence was 1.7 cases per 1000 youth and similar between African-American and non-Hispanic white youth. Among younger youth (0-9.9 years), non-Hispanic white total prevalence was 1.1 per 1000 and African-American prevalence was 0.6 per 1000. Among older youth (10.0-18.9 years), non-Hispanic white total prevalence was 2.5 per 1000 and African-American prevalence was 3.1 per 1000. Type 2 diabetes was only confirmed among older prevalent cases. Ascertainment completeness was estimated to be 98%. CONCLUSIONS: Our estimates suggest that total diabetes prevalence among non-Hispanic white youth is similar to rates observed over 20 years ago. Among African-American youth, the difference in prevalence noted between younger and older age-groups was notably greater than that observed among the non-Hispanic white youth, potentially reflecting a more marked increase in diabetes incidence with age.     

老年抑郁症病人的防治与护理

经临床研究发现，老年抑郁症的发病率呈上升趋势，已发现的仅是少量的病例，大部分病人尚未引起医护人员的重视。老年抑郁症是老年人在思维、行为、情感等方面出现紊乱，是一种以精神障碍为特征的综合征。这种疾病影响一个人的情绪、行为、思维和身体状况，主要以抑郁心境、思维迟缓和意志活动减退为主，多数病例还存在各种躯体症状。     

老年抑郁症病人的防治与护理

经临床研究发现,老年抑郁症的发病率呈上升趋势,已发现的仅是少量的病例,大部分病人尚未引起医护人员的重视。老年抑郁症是老年人在思维、行为、情感等方面出现紊乱,是一种以精神障碍为特征的综合征。这种疾病影响一个人的情绪、行为、思维和身体状况,主要以抑郁心境、思维迟缓和意志活动减退为主,多数病例还存在各种躯体症状。老年抑郁症起病大多缓慢,少数病人在躯体、精神因素作用下起病较急。起病前可有失眠、无力、食欲不振、适应能力下降及各种自感不适等症状。他与正常的情绪起落、心境改变、短暂的伤心、疲劳感等有较为明确的界限。…     

Early detection and treatment of postnatal depression in primary care

BACKGROUND: Postnatal depression has a relatively high incidence and gives rise to considerable morbidity. There is sound evidence supporting the use of the Edinburgh Postnatal Depression Scale as a screening tool for possible postnatal depression. AIM: This paper reports on a project developed by two health visitors and a community mental health nurse working in the United Kingdom. The aim of the project was to improve the early detection and treatment of postnatal depression in the population of the general practice to which they were attached. METHOD: The health visitors screened for postnatal depression in the course of routine visits on four occasions during the first postpartum year. Women identified as likely to be suffering from postnatal depression were offered 'listening visits' as a first-line intervention, with referral on to the general practitioner and/or community mental health nurse if indicated. FINDINGS: Data collected over 3 years showed that the project succeeded in its aim of enhancing early detection and treatment of postnatal depression. These findings replicate those of other studies. The data also showed that a substantial number of women were identified for the first time as likely to be suffering from postnatal depression at 12 months postpartum. Women screened for the first time at 12 months were at greater risk than those who had been screened earlier than this. CONCLUSIONS: Health visitors should screen for postnatal depression throughout the period of their contact with mothers, not solely in the immediate postnatal period. It is particularly important to screen women who, for whatever reason, were not screened when their child was younger. The knowledge and skills needed to use the Edinburgh Postnatal Depression Scale and provide first-line intervention and onward referral can be developed at practitioner level through close collaborative working.     

Electronic health records: use, barriers and satisfaction among physicians who care for black and Hispanic patients

Objectives  Electronic health records (EHRs) are a promising tool to improve the quality of health care, although it remains unclear who will benefit from this new technology. Given that a small group of providers care for most racial/ethnic minorities, we sought to determine whether minority-serving providers adopt EHR systems at comparable rates to other providers.
Methods  We used survey data from stratified random sample of all medical practices in Massachusetts in 2005. We determined rates of EHR adoption, perceived barriers to adoption, and satisfaction with EHR systems.
Results  Physicians who reported patient panels of more than 40% black or Hispanic had comparable levels of EHR adoption than other physicians (27.9% and 21.8%, respectively, P  = 0.46). Physicians from minority-serving practices identified financial and other barriers to implementing EHR systems at similar rates, although these physicians were less likely to be concerned with privacy and security concerns of EHRs (47.1% vs. 64.4%, P  = 0.01). Finally, physicians from high-minority practices had similar perceptions about the positive impact of EHRs on quality (73.7% vs. 76.6%, P  = 0.43) and costs (46.9% vs. 51.5%, P  = 0.17) of care.
Conclusions  In a state with a diverse minority population, we found no evidence that minority-serving providers had lower EHR adoption rates, faced different barriers to adoption or were less satisfied with EHRs. Given the importance of ensuring that minority-serving providers have equal access to EHR systems, we failed to find evidence of a new digital divide.     

Dementia care: critical interactions among primary care physicians, patients and caregivers

Enormous progress has been made in understanding and treating Alzheimer's disease (AD) and other dementing illnesses, and developing home and community-based support services to assist patients and their families. This article reviews the range of interactions and barriers physicians, patients who have dementia, and their families face over the course of the disease. In addition, strategies are presented which enhance referral of patients and families to appropriate community support services.     

Risk and protection for HIV/AIDS in African-American, Hispanic, and White adolescents

African-Americans and Hispanics are disproportionately affected by HIV/AIDS in the United States. HIV infection is often acquired during adolescence, a time when risky sexual behaviors are at their peak. This study explored relationships among selected risk factors, protective factors, and risky sexual behaviors among African-American, Hispanic, and White adolescents, from a sample of adolescents from the National Longitudinal Study of Adolescent Health. African-Americans and Hispanics were more likely to have sexual intercourse without the use of birth control than were Whites. African-Americans were more likely to have sexual behavior with multiple sexual partners than either Hispanics or Whites were, and African-Americans had higher self-esteem than did Hispanics and Whites. In order to develop culturally sensitive, effective interventions to prevent HIV/AIDS in adolescents, racial differences in risk and protective factors must be examined.