Showing papers in "International Journal of Psychiatry in Medicine in 1998"
TL;DR: Strategies which enable and/or reinforce appear to “work” in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change.
Abstract: Objective: To answer the question, “does CME work?” by reviewing the effectiveness of continuing medical education (CME) and other related educational methods on objectively-determined physician performance and/or health care outcomes. These interventions include educational materials, formal, planned CME activities or programs, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit and feedback, reminders, or a combination of these strategies. Methods'. MEDLINE, ERIC, NTIS, the Research and Development Resource Base in CME and other relevant data sources including review articles were searched for relevant terms, from 1975 to 1994. O f those articles retrieved, randomized controlled trials of educational strategies or interventions which objectively assessed physician performance and/or health care outcomes were selected for review. Data were extracted from each article about the specialty of the physician targeted, the clinical subject of the intervention, the setting and the nature of the educational method, and the presence or degree of needs assessment or barriers to change. Results: More than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be most effective activities. Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without
256 citations
TL;DR: Religiously active older adults tend to have lower blood pressures than those who are less active, and those who frequently watched religious TV or listened to religious radio actually had higher blood pressures.
Abstract: Objective:To examine the relationship between religious activities and blood pressure in community-dwelling older adults.Method:Blood pressure and religious activities were assessed in a probability sample of 3,963 persons age sixty-five years or older participating in the Duke EPESE survey. Participants were asked if their doctor had ever informed them that they had high blood pressure and if they were currently taking medication for high blood pressure. After the interview, systolic and diastolic blood pressures were measured following a standardized protocol. Data were available for three waves of the survey (1986, 1989–90, and 1993–94). Analyses were stratified by age (65–74 vs. over 75) and by race (Whites vs. Blacks) and were controlled for age, race, gender, education, physical functioning, body mass index, and, in longitudinal analyses, blood pressure from the previous wave.Results:Cross-sectional analyses revealed small (1–4 mm Hg) but consistent differences in measured systolic and diastolic blo...
236 citations
TL;DR: Major depression is a prevalent disorder in older primary care patients which affects their ability to perform expected social and physical roles and Mechanisms for delivering efficacious treatments in routine medical practice are of a high priority.
Abstract: Objective: Identify the morbidity patterns displayed by older primary care patients experiencing depressive symptomatology who do and do not meet criteria for a major depression. Method: Patients ages sixty and older presenting at two ambulatory internal medicine centers were administered the CES-D. Among those scoring ≥ 11, 104 completed a comprehensive assessment of their psychiatric symptomatology, medical illness, and functional abilities. The assessment battery was again administered six months later. Results: The point prevalence of major depression in older primary care patients is estimated at 9 percent based on SCID interviews. Patients meeting criteria for this diagnosis compared to those who are symptomatic but not experiencing a major depression described ore extensive psychopathology but also significantly more limitations in performing social and functional roles. At six-month follow-up, only 11.5 percent of those initially diagnosed with a major depression were considered fully recovered. Conclusions: Major depression is a prevalent disorder in older primary care patients which affects their ability to perform expected social and physical roles. Mechanisms for delivering efficacious treatments in routine medical practice are of a high priority.
94 citations
TL;DR: Results suggest that men and women respond differently to the burden of heart failure, but interpretation of the results should be considered as tentative and additional research is required to examine mechanisms that explain gender differences in response to heart failure.
Abstract: Objective:The study was designed 1) to examine the prevalence of depression in patients with congestive heart failure (CHF); 2) to explore associations between the physician's rating of functional status (NYHA class) and patient's assessment of functional status (physical limitation, dyspnea) with symptoms of depression; and 3) to explore gender related differences in relation to physician's rating and patient's rating of function status, and symptoms of depression.Method:A sample of 119 clinically stable heart failure patients (85 males and 34 females) was recruited from an outpatient cardiology hospital practice. The patients underwent a physical examination and completed a set of questionnaires. Prevalence of depressive symptoms and the association of these symptoms with NYHA class and patient's perceived functional status was studied.Results:Findings indicate that depressive symptoms were not predominant among this sample of CHF patients. Path analyses showed non-significant direct associations betwee...
91 citations
TL;DR: In this article, the authors discuss the principles of academic detailing, or educational outreach, in primary care and review the evidence of its effectiveness in, and potential for improving, mental health care.
Abstract: Objective: The purpose of this article is to discuss the principles of academic detailing, or educational outreach, in primary care and review the evidence of its effectiveness in, and potential for improving, mental health care. Methods: The general educational researcl literature on improving physician performance was reviewed along with studies that were designed to test academic detailing. Four rigorous studies have tested this approach specifically on mental health care. These studies are reviewed in detail. Results: Measuring pre-intervention performance to target those with increased educational needs and identifying barriers to change are associated with substantially improved program effectiveness. To change strongly held beliefs or to overcome patient demands, person-to-person contact with credible experts who provide structured alternatives is necessary. Brief reinforcement visits increase success rates and targeting programs to physicians at greatest need improves the cost effectiveness of educational interventions. Conclusions: Academic detailing is one of the few educational interventions that has consistently demonstrated improved physician performance. Educational outreach methods to improve mental health practices in primary care are in need of much additional research. Improving the detection of mental disorders and underuse of mental health treatment may prove to be more difficult than reducing the overuse of unnecessary medications.
87 citations
TL;DR: The pattern of prescribing antidepressant pharmacotherapy is influenced by a patient's age, gender, self-report of depression, and type of insurance coverage, and further research is required to discern the reasons for these observed effects.
Abstract: Objective: This study was designed to identify: 1) predictors of antidepressant pharmacotherapy among patients diagnosed with depression; and 2) predictors of prescription for either a selective-serotonin reuptake inhibitor (SSRI), or a serotonin-norepinephrine reuptake inhibitor (SNRI). Method: Data from the 1995 National Ambulatory Medical Care urvey (NAMCS) were used to discern the number of office-based encounters documenting a diagnosis of depression (ICD-9-CM codes 296.2-296.36; 300.4; or 311) among patients eighteen years of age or older. Logistic regression-derived odds ratios (OR) and 95 percent confidence intervals (CI) were used to elucidate factors predictive of receipt of antidepressant pharmacotherapy, and, more specifically, factors predictive of receipt of an SSRI or an SNRI. Model variables included age (1849 years as compared to ≥ 50 years); race (white as compared to nonwhite, inclusive of Hispanics); gender; self-report of depression as a reason for the office-based encounter; and payer type (private insurance program as compared to public). Results: Among the estimated 18,046,293 office-based visits resulting in a diagnosis of depression, 56.2 percent of patients self-reported depression as a reason for the office-based encounter; 67.5 percent were prescribed or continued a regimen of antidepressant pharmacotherapy; and 48.3 percent were prescribed an SSRI or an SNRI. Factors predictive of receipt of antidepressant pharmacotherapy included age less than fifty years (OR = 1.30, CI = 1.01-1.67); female gender (OR = 1.45, CI = 1.13-1.85); and self-report of depression as a reason for the office-based encounter (OR = 1.98, CI = 1.57-2.51). Factors predictive of receipt of an SSRI or an SNRI included age less than fifty years (OR = 1.31, CI = 1.03-1.65); female gender (OR = 1.55, CI = 1.23-1.95); and self-report of depression as a reason for the office-based encounter (OR = 1.56, CI = 1.25-1.95). In addition, having private insurance increased the likelihood of having been prescribed an SSRI or SNRI by 46 percent (OR = 1.46, CI = 1.13-1.89). Conclusions: Among patients with a diagnosis of depression, the pattern of prescribing antidepressant pharmacotherapy is influenced by a patient's age, gender, self-report of depression, and type of insurance coverage. Further research is required to discern the reasons for these observed effects and to advance clinically rational and equitable access to pharmacotherapeutic innovation.
49 citations
TL;DR: The application of technology to promote more comprehensive clinical education in the biopsychosocial aspects of primary care is discussed and a new model for technology-based clinical training, the “Virtual Practicum,” is proposed, based on these models.
Abstract: This article discusses the application of technology to promote more comprehensive clinical education in the biopsychosocial aspects of primary care. Comprehensive refers to the inclusion, in addition to scientific and technical knowledge, of knowledge that is less easily characterized, quantified, and taught: empathy, intuition, the demonstration of artistry. Clinical education will be increasingly facilitated by the proliferation of computers capable of displaying combinations of text, graphics, video, and sound; broadband networks capable of delivering these multiple media to the home or office; and new methods for using these technologies for education and training. However, current models for technology-based learning are limiting, lagging behind the rapid technological evolution driving our entry into the Information Age. Some recent educational models (Schon's reflection-in-action and reflective practicums [1], Boisot's E-space [2], Kolb's learning cycle [3]) provide for a more comprehensive and complete view of health professional education. This article describes these models in depth and proposes a new model for technology-based clinical training, the Virtual Practicum, based on them. The Virtual Practicum is illustrated with a new interactive CD-ROM program, dealing with primary care of patients with HIV/AIDS. The concepts presented here are generally useful in thinking about clinical education, regardless of the means used.
49 citations
TL;DR: Videofeedback training appears to be most effective when it is provided with a clear model for the professional-patient interaction and can be further enhanced by delineating sets of component microskills that can be learned using a combination of videotape modeling, role-play, and feedback.
Abstract: Objective: Development and evaluation of a method of training primary care providers in psychiatric skills which utilizes videofeedback of real and role-played consultations in a group setting. Method: The development of the basic training approach and additional material for teaching specific skills is described. Evaluation has addressed the impact of training on 1) clinician behavior and 2) measures of outcome. Results: Research over a number of years has demonstrated an impact on clinician behavior with some evidence of impact on clinical and economic measures and patient satisfaction. Conclusions : Videofeedback training appears to be most effective when it is provided with a clear model for the professional-patient interaction. Its effectiveness can be further enhanced by delineating sets of component microskills that can be learned using a combination of videotape modeling, role-play, and feedback. Challenges for future research include investment in randomized controlled trials for outcome, developing the training approach for a range of primary care workers, training sufficient group facilitators, and achieving widespread dissemination without subsequent dilution of effectiveness.
40 citations
TL;DR: Clock tests may be useful for identifying depressed patients with underlying dementia with significantly lower scores on clock-drawing, copying, and reading than patients with depression or the controls.
Abstract: Objective: While clock-drawing tests are commonly used to screen for cognitive impairment in the elderly, little is known about the performance of elderly depressives. Methods: We compared thirty-three patients with major depression to forty-two Alzheimer's disease and thirty age-matched controls on clock-drawing, copying, and reading. Results: Patients with Alzheimer's disease had significantly lower scores on clock-drawing, copying, and reading than patients with depression or the controls (p < 0.05). Patients with depression did not differ significantly from controls on quantitative scores or qualitative errors. Conclusions: Clock tests may be useful for identifying depressed patients with underlying dementia.
36 citations
TL;DR: Using some or all of these techniques can help turn a “lecture format” into a much more fun, interactive, and valuable session that emphasizes “learning” rather than “teaching.”
Abstract: While teaching in a tutorial, seminar, or problem-based learning group format may be the most fun and most active/interactive for both learner and faculty mentor, there are situations in medical student education in which various constraints require the use of the "lecture" format. Similar constraints may occur in the field of continuing medical education, or graduate medical education, as well. When this occurs, the faculty mentor can increase the active participation of the learners in the audience by continuously stressing seven key pedagogical (androgogical) principles. These include: 1) begin the learning exercise with a clinical example or anecdote to show the relevance of the material to the student; 2) frequently ask the students whether they have ever seen examples of what you describe in their previous experience with patients, personal experience, experience with relatives, etc.; 3) ask students frequently whether they have heard similar material presented differently in other courses; 4) recruit students to help solve "mystery cases"; 5) show examples of similar material from real life (e.g., patient descriptions, or even excerpts from favorite TV shows); 6) ask students to help summarize key points at the end of the session; and 7) allow, or even encourage, whispering during the class. Using some or all of these techniques can help turn a "lecture format" into a much more fun, interactive, and valuable session that emphasizes "learning" rather than "teaching."
31 citations
TL;DR: The findings in this study demonstrate that the current categories in DSM-IV do not provide physicians with a diagnosis that describes this particular type of pathological denial of illness.
Abstract: Objective: Denial of physical illness and/or refusal of treatment are critical issues in the practice of medicine. A previous article proposed DSM-IV consider a new diagnosis for a subgroup of patients who refuse treatment, i.e., maladaptive denial of physical illness [1]. It is necessary to be able to use this form of denial as a diagnosis rather than invoke the term denial as merely a mental mechanism. This is a report of a prospective descriptive study of psychiatric consultations for medical inpatients who deny that they are ill or who refuse treatment. Method: In order to investigate the utility of this proposed diagnosis we conducted a one year study of all psychiatric consultations at a community hospital in Manhattan, New York. Results: The diagnosis of maladaptive denial of physical illness was made in 2.5 percent of 317 psychiatric consultations. The patients did not fit into other DSM-III-R or DSM-IV categories. Conclusions: We suggest a clarification of the concept of denial for use with medically ill patients. The findings in this study demonstrate that the current categories in DSM-IV do not provide physicians with a diagnosis that describes this particular type of pathological denial of illness.
TL;DR: This issue presents this special issue devoted to successful educational techniques for application to mental health in primary care, based on presentations at a conference that took place June 27 to 29, 1997, at Dartmouth College in Hanover, New Hampshire.
Abstract: It is with great pleasure that the Journal presents this special issue devoted to successful educational techniques for application to mental health in primary care. The articles in this issue are based on presentations at a conference that took place June 27 to 29, 1997, at Dartmouth College in Hanover, New Hampshire. The conference was in honor of the 200th anniversary of the founding of Dartmouth Medical School and was sponsored by an unrestricted educational grant from Solvay Pharmaceuticals. Dartmouth Medical School is the nation's fourth oldest medical school and the first in a rural setting. Seeking to improve medical care in northern New England, Dr. Nathan Smith, a young physician from Cornish, New Hampshire, persuaded the Dartmouth Trustees to let him develop a medical school. Dr. Smith persevered, gave his first lecture on November 22, 1797, and comprised the entire faculty for ten years. He was a gifted teacher, ahead of his time in medical theory and practice. He subsequently contributed to founding medical schools at Yale, Bowdoin, and the University of Vermont [l]. Today, Dartmouth Medical School continues to follow the path set by Nathan Smith, with a renewed attention to the importance of teaching primary care, excellent science, and compassionate concern for patients and the community. The conference was planned jointly by the Editor, James Barrett, and Barbara Wagner to bring together educational leaders in medical education, primary care, and psychiatry. In addition to the participants who prepared these articles, three
TL;DR: Examination of response by diagnostic category indicated that geriatric patients with late onset delusional disorder showed the best response while adults with either schizophrenia or affective syndromes also showed positive response.
Abstract: Objective:to Compare the Efficacy and Side Effects of Risperidone in Younger Adult and Geriatric Patients.Methods:Open Retrospective Study of 102 Consecutive Intakes, prescribed risperidone, by a m...
TL;DR: Recommendations are made to increase the role of physicians in the detection of factitious patients, as well as to move toward a more uniform reporting of cases offactitious disorders in the literature.
Abstract: Objective:The current article offers a new conceptualization of Factitious Disorders based on Cases Reported in the Literature.Method:The Current Analysis Examines Twenty-Nine Cases Of Factitious D...
TL;DR: Attributes of the workshops which might have facilitated their success were their duration, funding, frequency of offering, collegial learning environment, opportunities for active learning, emotionally moving exposure to recovering individuals, and readily usable instructional materials.
Abstract: Objective: Screening and brief intervention for substance abuse is effective yet underutilized by primary care physicians. This article reports on Project SAEFP (Substance Abuse Education for Family Physicians), which aimed to enhance the clinical and teaching skills and activities of U.S. family practice residency faculty. Method: Ten five-day workshops were designed and administered for 165 participants. Evaluation data included measures of participant satisfaction and pre-workshop and twelve-month post-workshop measures of the frequency of teaching, consulting, and clinical activities, and the attainment of self-identified teaching goals. Results: The participants were very satisfied with the workshops. They improved significantly in the key outcome measures. Conclusions: Several workshops may have contributed to the apparent success of Project SAEFP. Attributes of the workshops which might have facilitated their success were their duration, funding, frequency of offering, collegial learning environment, opportunities for active learning, emotionally moving exposure to recovering individuals, focus on how to modify curriculum at participant residency programs, availability of family physician role models as faculty, and readily usable instructional materials. Planners of interventions for physician educators might profit from similar attention to these attributes.
TL;DR: Though reporting modest improvement in pelvic pain since laparoscopy, both groups reported a high incidence of anxiety, depression, physical worries, and marital/sexual problems.
Abstract: Objective:Pelvic pain can account for up to 40 percent of laparoscopies performed by gynecologists. This report compares the psychological profiles and efficacy of laparoscopic surgery at long-term follow-up in a series of laparoscopy-positive and laparoscopy-negative patients with chronic pelvic pain.Method:A retrospective chart review was performed on patients diagnosed with chronic pelvic pain combined with postoperative written questionnaires and self-rating scales. These questionnaires were used to assess long-term post laparoscopy follow-up of the physical and psychological status of women with positive findings at laparoscopy compared to those women with negative findings.Results:There were no statistically significant demographic differences between respondents and nonrespondents. In the respondents, no statistically significant differences were noted even with long-term follow-up when comparing responses of the laparoscopy-positive and laparoscopy-negative groups on the above questionnaires.Concl...
TL;DR: It is suggested that propranolol may be useful for the treatment of polydipsia in patients with schizophrenia because its efficacy could be related to inhibition of the renin-angiotensin system.
Abstract: Objective:Psychiatric patients presenting with polydipsia are often difficult to treat with standard psychiatric interventions. Pharmacological intervention was attempted in these patients based on the hypothesis that angiotensin II, a potent dipsinogen, may be involved in the drinking behavior of patients with polydipsia. Beta-blockers inhibit renin release (and thus indirectly angiotensin II) by blocking beta receptors in the kidney.Methods:Three patients were identified as excessive water drinkers during their hospital admissions. All three patients were eunatremic but polydipsic at the time of study. Two of the three had histories of hyponatremia and required emergency medical treatment on more than one occasion. No patients had been controlled by strict fluid restriction. Trials of propranolol were initiated to control their water drinking.Results:After starting propranolol, two patients responded quickly. In one patient, fluid intake decreased from 2650 ± 647 to 1577 ± 361, p < .001. In the other, f...
TL;DR: A workshop for medical educators to examine their understanding of learning in order to change their behavior as teachers demonstrated the importance of adult learning theory in which it is more important for the learner than for the teacher to determine what, when, and how to learn.
Abstract: Objective: An experiential model of learning suggests that changing a learner's understanding will lead to the learner choosing to change behavior. A workshop was designed for medical educators to examine their understanding of learning in order to change their behavior as teachers. This article describes that workshop which was presented as part of a conference on successful techniques for education of primary care practitioners. Method: Eighteen medical educators participated in the workshop. The educators were instructed to reflect on a recent personal learning experience. Group discussion led to production of a list of components of effective learning. These learning components were then applied in small groups to three hypothetical tasks related to mental health education. Results: Essential characteristics of three generic features of learning were identified: characteristics of the teacher, learner, and learning experience. When these characteristics were then applied to the hypothetical tasks, a major theme that emerged was a focus on the importance of learner motivation. Conclusions: The essential components of learning and their application demonstrate the importance of adult learning theory in which it is more important for the learner than for the teacher to determine what, when, and how to learn. This is in contrast to traditional medical education in which the teacher decides what to learn and if it has been learned. To improve education for practicing primary care providers, a shift from a teaching paradigm to a learning paradigm is indicated.
TL;DR: Compatibility among systems can be optimized by strictly following a number of rules, and the conversion between ICPC and ICD-10 (and consequently DSM-IV) allows simultaneous use of IC PCs as a classification and the standard nomenclature.
Abstract: Background Primary care physicians traditionally have a strong interest in the mental health of their patients. Three classification systems are available for them to diagnose, label, and classify mental disorders: 1) The ICD-10 approach with three options, 2) The DSM-IV approach with two options, and 3) the ICPC approach with two options. This article lists important similarities and differences between the systems to help potential users choose the option that best meets their needs. Methods Definitions for depressive disorder, anxiety disorder, and somatization disorder are compared on five characteristics of classification: 1. the domain, 2. the scope, 3. the nature of the definitions, 4. focus on episodes of care, and 5. clinical guidelines. Results Primary care physicians and psychiatrists have different perspectives, reflected in different classifications. Each system has specific possibilities and limitations with regard to the diagnosis of mental disorders. For common mental disorders it is possible, however, to choose codes from one system while maintaining compatibility with the other two. Comparability as to the diagnostic content of the different classes, however, is more difficult to establish. The available classification systems give both primary care physicians and psychiatrists options to diagnose, label, and to classify mental disorders from their own perspective, but once a system has been chosen the clinical comparability of a patient with the same diagnosis in other systems is limited. Conclusion Compatibility among systems can be optimized by strictly following a number of rules. The conversion between ICPC and ICD-10 (and consequently DSM-IV) allows simultaneous use of ICPC and ICD-10 as a classification and DSM-IV as the standard nomenclature. This is of particular interest for computer based patient records in primary care. The clinical comparability of the same diagnosis in different systems however is limited by the characteristics of the different system.
TL;DR: The data suggest that high scores of neuroticism in anxiety disorders patients may be involved in elevated serum LDL cholesterol levels and, thereby, may lead to an increased risk of coronary heart disease.
Abstract: Objective: This study evaluates the association between certain personality variables, especially neuroticism, and serum lipid levels in patients suffering from anxiety disorders as opposed to normal control individuals. It addresses the question whether in anxiety disorder patients neuroticism is associated with elevated serum cholesterol and serum LDL cholesterol levels. Method: Thirty (15 male, 15 female) patients with anxiety disorders as defined by DSM-IV and thirty normal matched controls were enrolled in this study. The patients were either admitted for inpatient treatment or referred to the behavioral therapy outpatient clinic at the Department of Psychiatry of the University Hospital Eppendorf (Hamburg/Germany). Control individuals were selected on a voluntary basis and recruited from the authors' colleagues and peers. Matching included Body-Mass-Index, age, and gender. Results: This study showed a significant positive association of neuroticism and serum cholesterol (r =.29) and serum LDL cholesterol (r =.35) within the entire cohort of participants. An even higher significant positive relation (r =.43) could be detected between neuroticism and serum LDL cholesterol within the psychiatric patient group. As far as differences of personality variables between patients and normal controls are concerned, patients seemed to be significantly less satisfied with life, more generally inhibited, more irritable, more stressed, and more emotionally labile than controls. Anxiety disorder patients also tended to complain significantly more often about physical problems. Conclusions: Our data suggest that high scores of neuroticism in anxiety disorders patients may be involved in elevated serum LDL cholesterol levels and, thereby, may lead to an increased risk of coronary heart disease.
TL;DR: There is a moderately well developed literature describing self-perceived and observed gaps in the current care for depression in primary care, and recommendations for educational content are identified.
Abstract: Objective: The purpose of this article is to identify literature-based content for the design of educational programs on depression for practicing primary care physicians. Methods: A MEDLINE search was conducted of English-language medical literature published from 1982 through July 1997 for studies describing primary care physicians' knowledge, skills, practice patterns, and perceived barriers related to care of depressed patients. Studies focusing exclusively on residency training and those describing physician practices outside North America were excluded. Of 377 articles identified, forty met inclusion and exclusion criteria. Results: Recommendations for educational content were identified from the literature review. For recognition, educators should prioritize communication skills and strategies for the use of depression questionnaires. For diagnosis, practice interpreting symptoms in the medically ill, strategies for efficient diagnosis, and systematic approaches to assessing suicide risk should be emphasized. For treatment, greater attention to the therapeutic alliance, staged therapy, and strategies for improving medication adherence are indicated. Conclusions: There is a moderately well developed literature describing self-perceived and observed gaps in the current care for depression in primary care. Addressing the entire list of needs would take more time than practicing physicians are likely to have. An important challenge for educators is to design flexible programs based on individualized needs assessment or, when not possible, to prioritize the most generalizable needs.
TL;DR: The data suggest that most PCPs are able to recognize panic disorder, however, they may be excessively inclined to prescribe benzodiazepines rather than more appropriate medications.
Abstract: Objective:To study current patterns of panic disorder (PD) recognition and management by primary care physicians (PCPs).Method:We administered a vignette describing a female PD patient to 189 PCPs.Results:Three-quarters of respondents believed that PD was at least 50 percent probable, and the mean PD likelihood rating was 63 percent. Diagnostic suspicion was significantly higher for PD than for other anxiety disorders, major depressive disorder, and cardiac disorders. Medication was rated as significantly more necessary than medical testing and mental health referral. A benzodiazepine was suggested by 78 percent of respondents, while 35 percent suggested a serotonin reuptake inhibitor (SRI). Under half rated the patient as requiring medical testing, mostly for hyperthyroidism (70%) and/or cardiovascular disorder (62%), and half felt that the patient required mental health referral.Conclusions:The data suggest that most PCPs are able to recognize PD. However, they may be excessively inclined to prescribe b...
TL;DR: The NAPCRG Task Force on Mental Health Problems as discussed by the authors was created to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action.
Abstract: Purpose: The NAPCRG Task Force on Mental Health Problems was commissioned to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action by NAPCRG. This White Paper presents the key findings and recommendations of the Task Force. Methods: A comprehensive review of the primary care mental health literature, using MEDLINE searches with manual follow up, and personal communications with many active researchers in the field were performed by the authors; Task Force members participated in the editing and refinement of the White Paper in a series of email and face-to-face meetings. Summary and Conclusions: Although primary care researchers have made major contributions to our growing understanding of mental health problems as they exist in the real world of primary care, rapid changes in the U.S. health care environment threaten to undo the integration of mental and physical health that is at the heart of primary care. It will be necessary for the primary care leaders in this field to primary care to guide policy-makers, purchasers, and the public as primary care is reengineered for the next generation. Efforts to operationalize episode of care and comorbidity recording with EMR systems, particularly in cooperation with managed care corporations and/or primary care research networks, may represent the most effective strategy for promoting the integration of mental health services into primary care. The most promising area for research in the immediate future may be descriptive studies that capture and explore the clinical epidemiology of common mental health problems as they occur in routine practice.
TL;DR: Surprisingly, this screening was found to emphasize psychological rather than vegetative symptoms, which suggests that a means for efficiently identifying individuals who warrant screening for depression may be readily available to primary care physicians.
Abstract: Objective:It is estimated that 5 percent to 10 percent of primary care patients meet criteria for Major Depressive Disorder with an additional 10 percent to 30 percent experiencing significant subclinical depression. However, only 18 percent to 50 percent of depressed primary care patients are so diagnosed by their primary care physicians and even fewer receive professional mental health care. The current study proposes a quick and efficient means to assist physicians in determining for which patients the resource intensive process of thoroughly screening for depression should be engaged.Method:The present study examined responses of 358 consecutively reporting patients to a midwest university-based primary care clinic on the Beck Depression Inventory.Results:Among individuals reporting high levels of depressive symptomatology, five questions from the Beck Depression Inventory were endorsed by 90 percent or greater of the participants. Analyses by gender indicated that while the same five items were endor...
TL;DR: Conservatism is warranted when applying somatic indicators of distress to diabetes patients, whereas numbness was endorsed more often by diabetes patients than diabetes patients.
Abstract: Objective:Because psychiatric screening methods are usually developed using psychiatric samples but not medical samples, they often include distress indicators that overlap with medical illness. Th...
TL;DR: To reduce mortality, especially in male veterans, management of geropsychiatric patients should include early recognition of pneumonia symptoms, especially for patients with history of pulmonary disease.
Abstract: Objective:This study investigated the deaths of patients sixty-five and older on a psychiatric ward to determine the mortality rate, the characteristics of illness, and the cause of death.Methods:We analyzed the case record of patients sixty-five and older who had died during hospitalization on a psychiatric ward during a seventeen-year period. Case data was collected by review of chart records.Results:The mortality rate in the patients sixty-five and older was 18/1208 (1.5%). Eight of these eighteen patients died of pneumonia. Mortality in the acutely ill geropsychiatric inpatients was difficult to predict. Age, sex, and diagnosis did not predict mortality.Conclusions:To reduce mortality, especially in male veterans, management of geropsychiatric patients should include early recognition of pneumonia symptoms, especially for patients with history of pulmonary disease.
TL;DR: The Physician Prescribed Educational Program is described, an integrated series of programs that incorporate a formalized, structured evaluation strategy that can provide appropriate and successful experiences for participants.
Abstract: Objective: Individualized educational programs based upon structured comprehensive evaluations have the highest opportunity for success in addressing the needs of physicians with lapsed skills. The purpose of this article is to describe the Physician Prescribed Educational Program (PPEP), an integrated series of programs that incorporate a formalized, structured evaluation strategy. Methods: The PPEP is structured to determine: 1) The presence of deficits which are amenable to educational remediation, 2) The likelihood that an appropriate educational program can be developed, and 3) The structure of such a program. Results: Of 300 referrals, 100 have received evaluations thus far. A wide range of deficits were addressable, although there were specific exclusions to participation. Conclusions: Administrators and others who wish to undertake these efforts should avail themselves of educational and other resources but should not expect rapid results. With careful planning and execution, these programs can provide appropriate and successful experiences for participants.
TL;DR: The findings support the need for testing the hypothesis of a multidetermined origin of Tourette's Syndrome, a disorder in which hereditary, neuropsychological, and environmental factors play a role.
Abstract: Objective:As many as 35 percent of Tourette's Syndrome patients do not acquire this disorder genetically. Since there has been little research conducted in this area, the purpose of this study was to compare the clinical differences between two groups of patients with Tourette's Syndrome (TS), one with family history of TS and one without.Method:Using data of eight previously diagnosed TS patients, the authors made comparisons of clinical and sociodemographic variables between a group of three patients with family history of TS and five with no family history.Results:There were no differences in clinical presentation, current age, age at diagnosis, gender, and socioeconomic status. There were differences in birth history, developmental milestones, I.Q., and neurological findings between patients with family history and no family history of TS.Conclusions:Our findings support the need for testing the hypothesis of a multidetermined origin of TS, a disorder in which hereditary, neuropsychological, and envir...
TL;DR: In a pilot study involving consecutive patients referred for a psychiatric evaluation in an urban ED, symptom severity was quantified using the Brief Psychiatric Rating Scale (BPRS) to determine the sensitivity, specificity, and optimal cutoff score of the BPRS in predicting admission for non-suicidal patients.
Abstract: Objective We hypothesized that a systematic determination of symptom severity would predict psychiatric admission for non-suicidal patients referred for a psychiatric evaluation in an urban emergency department (ED) setting. Method In a pilot study involving consecutive patients referred for a psychiatric evaluation in an urban ED, symptom severity was quantified using the Brief Psychiatric Rating Scale (BPRS). The BPRS scores of all non-suicidal patients were subjected to receiver operator characteristic (ROC) curve analysis to determine the sensitivity, specificity, and optimal cutoff score of the BPRS in predicting admission for non-suicidal patients. Results A BPRS cutoff score of 39 had a sensitivity of 85.71 percent and a specificity of 86.11 percent. The area under the ROC curve was .8671 (Somer's D = .7342) and the standard error of the curve was .1124. The cutoff score of 39 correctly identified six of seven non-suicidal patients who were hospitalized. Conclusions It is anticipated that use of the BPRS in the ED will be further refined when a larger patient sample is studied. Potentially, a subset of BPRS items could be identified which would be more sensitive in predicting admission than the full BPRS and increase the overall efficiency of administering the BPRS in the ED.
TL;DR: The fact that psychiatric illness is a significant predictor of psychotropic drug use suggests that these drugs were prescribed aptly, and the longer duration of use among psychiatric cases supports the idea of appropriate prescriptions.
Abstract: Objective: The purpose of the present study was to investigate the prevalence of psychotropic drug use and the predictors of use during hospitalization. Method: We investigated 728 patients admitted to medical, gynecological, and surgical wards of two non-university general hospitals in Austria for psychotropic drug use, psychiatric morbidity, and sociodemographic characteristics. Results: The use of psychotropics was highest in medical wards (67.6%), followed by surgical (59.3%), and gynecological wards (37.8%). Older age, psychiatric caseness, consultation by psychiatrists and use of psychotropics before admission were predictors for psychotropic drug use. Psychotropics were given for a longer duration to psychiatric cases than to non-cases. Anxiolytics were prescribed most often (39.6%), followed by hypnotics (16.9%), neuroleptics (10.7%), and antidepressants (7.0%). Conclusions: The fact that psychiatric illness is a significant predictor of psychotropic drug use suggests that these drugs were prescribed aptly. The longer duration of use among psychiatric cases supports the idea of appropriate prescriptions.