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Objective Telephone psychotherapy is an emerging model of care that appears feasible for extending the reach of evidence-based psychotherapy treatment without accruing the full costs of traditional office-based, mental health care. This manuscript describes the development, implementation and acceptance of a 12-month telephone psychotherapy program (TPP) for depressed adults not fully responding to standard antidepressant treatment in primary care. Method The TPP combined a population-based medication monitoring and information system with a structured cognitive-behavioral treatment (CBT) program. The TPP included 8–12 telephone sessions (eight core CBT sessions and three to four clinical booster sessions) delivered by a master-level therapist working in tandem with each patient's primary care physician (PCP). Results The TPP was well accepted (i.e., 80% completed the core program) by a population-based sample of adult primary care patients initiating antidepressant treatment. The mean duration of core telephone psychotherapy sessions was approximately 31 min during acute-phase treatment (0–6 months). Eighty-two percent of TPP patients maintained contact with their therapist during maintenance-phase treatment (6–12 months). Conclusions The practical and efficient nature of this TPP appears to sidestep many of the treatment barriers encountered in traditional office-based care. Implementation of this TPP program in other primary care settings may be valuable for enhancing standard pharmacotherapy treatment of adult depression, especially among populations facing greater barriers of care.

Objective:This article uses data from two studies that have demonstrated the overall effectiveness of Collaborative Care interventions to evaluate factors associated with poor outcomes overall (general prognostic factors) and factors associated with greater or lesser effects of treatment (differential treatment effects).Methods:Adult primary care patients initiating antidepressant treatment for major depression were randomized to usual care or to Collaborative Care, a structured depression treatment program that included planned, proactive and coordinated care with a health care team and informed, activated patients ( n = 156, mean age = 43, 85% white). Response to treatment was defined as a 50% or greater reduction in depression at four months.Results:High neuroticism and a history of recurrent major depression (3+ episodes) or dysthymia predicted poor outcomes in general. While the magnitude of the intervention effects differed, frequently cited predictors of persistence of depression (age, gender, depression severity, medical and psychiatric comorbidity) were not significantly associated with greater or lesser benefit from Collaborative Care (no differential treatment effects). Results demonstrate the robustness of intervention effects across numerous groups at risk for persistence of depression.Conclusions:These findings suggest that at the time of diagnosis it is not possible to predict who is most likely to benefit from Collaborative Care. Instead, outcomes of treatment should be routinely monitored among depressed patients to ensure optimal response.

The prevalence of major depression is approximately 2-fold higher in patients with diabetes mellitus compared to medical controls. We explored the association of major depression with 8 cardiac risk factors in diabetic patients with and without evidence of cardiovascular disease (CVD).A mail survey questionnaire was administered to a population-based sample of 4,225 patients with diabetes to obtain data on depression status, diabetes self-care (diet, exercise, and smoking), diabetes history, and demographics. On the basis of automated data we measured diabetes complications, glycosylated hemoglobin, medical comorbidity, low-density lipid levels, triglyceride levels, diagnosis of hypertension, and evidence of microalbuminuria. Separate analyses were conducted for subgroups according to the presence or absence of CVD.Nine primary care clinics of a nonprofit health maintenance organization.Patients with major depression and diabetes were 1.5- to 2-fold more likely to have 3 or more cardiovascular risk factors as patients with diabetes without depression (62.5% vs 38.4% in those without CVD, and 61.3% vs 45% in those with CVD). Patients with diabetes without CVD who met criteria for major depression were significantly more likely to be smokers, to have a body mass index (BMI)or = 30 kg/m2, to lead a more sedentary lifestyle, and to have HbA1c levels of8.0% compared to nondepressed patients with diabetes without heart disease. Patients with major depression, diabetes, and evidence of heart disease were significantly more likely to have a BMIor = 30 kg/m2, a more sedentary lifestyle, and triglyceride levels400 mg/dl than nondepressed diabetic patients with evidence of heart disease.Patients with major depression and diabetes with or without evidence of heart disease have a higher number of CVD risk factors. Interventions aimed at decreasing these risk factors may need to address treatment for major depression in order to be effective.

The objective of this study was to determine whether racial or ethnic differences in prevalence of diabetic microalbuminuria were observed in a large primary care population in which comparable access to health care exists. A cross-sectional analysis of survey and automated laboratory data 2969 primary care diabetic patients of a large regional health maintenance organization was conducted. Study data were analyzed for racial/ethnic differences in microalbuminuria (30 to 300 mg albumin/g creatinine) and macroalbuminuria (>300 mg albumin/g creatinine) prevalence among diabetes registry–identified patients who completed a survey that assessed demographics, diabetes care, and depression. Computerized pharmacy, hospital, and laboratory data were linked to survey data for analysis. Racial/ethnic differences in the odds of microalbuminuria and macroalbuminuria were assessed by unconditional logistic regression, stratified by the presence of hypertension. Among those tested, the unadjusted prevalence of micro- or macroalbuminuria was 30.9%, which was similar among the various racial/ethnic groups. Among those without hypertension, microalbuminuria was twofold greater (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.14 to 3.53) and macroalbuminuria was threefold greater (OR 3.17; 95% CI 1.09 to 9.26) for Asians as compared with whites. Among those with hypertension, adjusted odds of microalbuminuria were greater for Hispanics (OR 3.82; 95% CI 1.16 to 12.57) than whites, whereas adjusted odds of macroalbuminuria were threefold greater for blacks (OR 3.32; 95% CI 1.26 to 8.76) than for whites. For most racial/ethnic minorities, hypertriglyceridemia was significantly associated with greater odds of micro- and macroalbuminuria. Among a large primary care population, racial/ethnic differences exist in the adjusted prevalence of microalbuminuria and macroalbuminuria depending on hypertension status. In this setting, racial/ ethnic differences in early diabetic nephropathy were observed despite comparable access to diabetes care.

Objectives: Major depression occurs in approximately 11% to 15% of patients with diabetes and is associated with poor glycemic control and adverse medical outcomes. This study examined the rates and predictors of recognition of depression among primary care patients with diabetes and comorbid major depression and the quality of depression care provided during a 12-month period. Methods: This study used automated utilization, pharmacy, and laboratory data from a health maintenance organization to describe the rate of recognition of depression and quality of care provided for patients with major depression and diabetes in the 12-month period before diagnosis. Major depression was diagnosed based on the Patient Health Questionnaire (PHQ-9) that was included in a mail survey sent to 9063 patients on the Group Health diabetes registry from 9 primary care clinics. Results: Approximately 51% of patients with major depression and diabetes were recognized as depressed by the health care system. Women were more likely to be recognized (odds ratio [OR] 1.58, 95% confidence interval [CI 1.26–1.97]), as were those with dysthymia (OR 3.44, 95% CI 2.08–5.72), panic attacks (OR 1.55, 95% CI 1.19–2.19), patients with more than 7 primary care visits (OR 1.42, 95% CI 1.06–1.91) and patients reporting poor health (OR 1.62, 95% CI 1.04–2.53). Of the 51% of patients with major depression who were recognized, 43% received 1 or more antidepressant prescriptions but only 6.7% received 4 or more psychotherapy sessions during a 12-month period. Discussion: There were large gaps in both recognition and quality of depression care provided to patients with major depression and diabetes within a health maintenance organization system.

Background There is a high prevalence of depression in patients with diabetes mellitus. Depression has been shown to be associated with poor self-management (adherence to diet, exercise, checking blood glucose levels) and high hemoglobin A1c(HbA1c) levels in patients with diabetes. Objective To determine whether enhancing quality of care for depression improves both depression and diabetes outcomes in patients with depression and diabetes. Design Randomized controlled trial with recruitment from March 1, 2001, to May 31, 2002. Setting Nine primary care clinics from a large health maintenance organization. Participants A total of 329 patients with diabetes mellitus and comorbid major depression and/or dysthymia. Intervention Patients were randomly assigned to the Pathways case management intervention (n = 164) or usual care (n = 165). The intervention provided enhanced education and support of antidepressant medication treatment prescribed by the primary care physician or problem-solving therapy delivered in primary care. Main Outcome Measures Independent blinded assessments at baseline and 3, 6, and 12 months of depression (Hopkins Symptom Checklist 90), global improvement, and satisfaction with care. Automated clinical data were used to evaluate adherence to antidepressant regimens, percentage receiving specialty mental health visits, and HbA1clevels. Results When compared with usual care patients, intervention patients showed greater improvement in adequacy of dosage of antidepressant medication treatment in the first 6-month period (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.28-7.55) and the second 6-month period (OR, 2.90; 95% CI, 1.69-4.98), less depression severity over time (z = 2.84,P = .004), a higher rating of patient-rated global improvement at 6 months (intervention 69.4% vs usual care 39.3%; OR, 3.50; 95% CI, 2.16-5.68) and 12 months (intervention 71.9% vs usual care 42.3%; OR, 3.50; 95% CI, 2.14-5.72), and higher satisfaction with care at 6 months (OR, 2.01; 95% CI, 1.18-3.43) and 12 months (OR, 2.88; 95% CI, 1.67-4.97). Although depressive outcomes were improved, no differences in HbA1coutcomes were observed. Conclusion The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.

OBJECTIVE—We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS—In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. RESULTS—This predominantly type 2 diabetic population had a mean HbA1c level of 7.8 ± 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA1c tests was 2.2 ± 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m2, and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 ± 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. CONCLUSIONS—In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.

OBJECTIVE—The goal of this study was to determine the behavioral and clinical characteristics of diabetes that are associated with depression after controlling for potentially confounding variables. RESEARCH DESIGN AND METHODS—A population-based mail survey was sent to patients with diabetes from nine primary care clinics of a health maintenance organization. The Patient Health Questionnaire was used to diagnose depression, and automated diagnostic, pharmacy, and laboratory data were used to measure diabetes treatment intensity, HbA1c levels, and diabetes complications. RESULTS—Independent factors that were associated with a significantly higher likelihood of meeting criteria for major depression included younger age, female sex, less education, being unmarried, BMI ≥30 kg/m2, smoking, higher nondiabetic medical comorbidity, higher numbers of diabetes complications in men, treatment with insulin, and higher HbA1c levels in patients CONCLUSIONS—Smoking and obesity were associated with a higher likelihood of meeting criteria for major and minor depression. Diabetes complications and elevated HbA1c were associated with major depression among demographic subgroups: complications among men and HbA1c among individuals

This paper describes the methodology of a population based study of primary care patients with diabetes mellitus enrolled in a health maintenance organization. The first goal was to determine the prevalence and impact of depression in patients with diabetes. The second goal was to randomize approximately 300 patients with diabetes and major depression and/or dysthymia in a trial to test the effectiveness of a collaborative care intervention in improving quality of care and health outcomes among patients with diabetes and depression.

This randomized trial evaluated an intervention for reducing at-risk drinking practices in a sample of 307 patients. Eligible drinking patterns included chronic drinking (or = 2 drinks per day in the past month), binge drinking (or = 5 drinks per occasion at least twice in the past month), and drinking and driving (driving after2 drinks in the past month). Members of the intervention group received a message from their physician during their regularly scheduled visit, a self-help manual, written personalized feedback, and up to 3 telephone counseling calls. Dropout was significantly higher in the intervention than control group.

Background Continued high rates of smoking among socioeconomically disadvantaged women lead to increases in children's health problems associated with exposure to tobacco smoke. The pediatric clinic is a "teachable setting" in which to provide advice and assistance to parents who smoke. Objective To evaluate a smoking cessation intervention for women. Design Two-arm (usual care vs intervention) randomized trial. Setting Pediatric clinics serving an ethnically diverse population of low-income families in the greater Seattle, Wash, area. Intervention During the clinic visit, women received a motivational message from the child's clinician, a guide to quitting smoking, and a 10-minute motivational interview with a nurse or study interventionist. Women received as many as 3 outreach telephone counseling calls from the clinic nurse or interventionist in the 3 months following the visit. Participants Self-identified women smokers (n = 303) whose children received care at participating clinics. Main Outcome Measure Self-reported abstinence from smoking 12 months after enrollment in the study, defined as not smoking, even a puff, during the 7 days prior to assessment. Results Response rates at 3 and 12 months were 80% and 81%. At both follow-ups, abstinence rates were twice as great in the intervention group as in the control group (7.7% vs 3.4% and 13.5% vs 6.9%, respectively). The 12-month difference was statistically significant. Conclusions A pediatric clinic smoking cessation intervention has long-term effects in a socioeconomically disadvantaged sample of women smokers. The results encourage implementation of evidence-based clinical guidelines for smoking cessation in pediatric practice.

The authors analyzed data from 615 depressed primary care patients to determine their willingness to pay for depression treatment.A sample of 615 adult patients from four primary care clinics participated in a randomized controlled trial of a disease management program for depression in primary care. Participants were asked at baseline interviews and six-month follow-up interviews how much they would be willing to pay per month for a six-month treatment that would eliminate their symptoms of depression. Multiple regression analyses were used to estimate the association between demographic and clinical factors and willingness to pay for depression treatment and to examine changes.The mean amount that participants were willing to pay for depression treatment at baseline was $270+/-187 per month, or about 9 percent of the participants' household income. Willingness to pay was significantly associated with household income and with the severity of depressive symptoms. Over six months, the amount that participants were willing to pay decreased along with their severity of depressive symptoms.The amount that participants were willing to pay was comparable to that reported for the treatment of other chronic medical disorders and higher than the actual cost of depression treatment. Measurements of willingness to pay may be a promising method for assessing the value of treatments for common mental disorders.

Health care providers have an important role in acknowledging and supporting patients' self-management of chronic illnesses such as bipolar disorder. This report describes the development and evaluation of a brief measure for assessing patient perception of providers' support for self-management of bipolar disorder.A 10-item measure was developed combining generic items from an existing measure of providers' autonomy supportive versus controlling style with items specific to the self-management of bipolar disorder. The psychometric properties of the measure and its relation to clinical variables were evaluated in a sample of patients enrolled in an ongoing randomized intervention trial.Data were obtained from 420 patients with a chart diagnosis of bipolar disorder (mean age=44, 68% female, 88% Caucasian). The proportion of missing responses for items ranged from 0 to 3%. Reliability coefficient alpha for the full scale was 0.94. Corrected item-total correlations for individual items ranged from 0.70 to 0.83. Factor analysis identified a single factor accounting for 67% of total variance. Factor loadings for individual items were all at least 0.75. The measure showed moderate positive correlations with measures of self-efficacy for managing bipolar disorder (r=0.34; p0.001), treatment satisfaction (r=0.63; p0.001), small negative correlations with measures of mania symptoms (r=-0.11; p0.03) and depressive symptoms (r=-0.09; p0.10).This measure shows good psychometric properties and good evidence for convergent and discriminant validity. It is promising for assessing an important aspect of care for bipolar disorder.

Background Despite high rates of relapse and recurrence, few primary care patients with recurrent or chronic depression are receiving continuation and maintenance-phase treatment. We hypothesized that a relapse prevention intervention would improve adherence to antidepressant medication and improve depression outcomes in high-risk patients compared with usual primary care. Methods Three hundred eighty-six patients with recurrent major depression or dysthymia who had largely recovered after 8 weeks of antidepressant treatment by their primary care physicians were randomized to a relapse prevention program (n = 194) or usual primary care (n = 192). Patients in the intervention group received 2 primary care visits with a depression specialist and 3 telephone visits over a 1-year period aimed at enhancing adherence to antidepressant medication, recognition of prodromal symptoms, monitoring of symptoms, and development of a written relapse prevention plan. Follow-up assessments were completed at 3, 6, 9, and 12 months by a telephone survey team blinded to randomization status. Results Those in the intervention group had significantly greater adherence to adequate dosage of antidepressant medication for 90 days or more within the first and second 6-month periods and were significantly more likely to refill medication prescriptions during the 12-month follow-up compared with usual care controls. Intervention patients had significantly fewer depressive symptoms, but not fewer episodes of relapse/recurrence over the 12-month follow-up period. Conclusions A relapse prevention program targeted to primary care patients with a high risk of relapse/recurrence who had largely recovered after antidepressant treatment significantly improved antidepressant adherence and depressive symptom outcomes.

Objective: This article describes the conceptual underpinnings, implementation, and participation rates of a twelve-month low-intensity primary care-based intervention to prevent depression relapse. The intervention was designed to address the inherent problems in delivery of effective maintenance treatment in a population based sample of primary care patients. Methods: Patients at high risk of relapse based on psychiatric history who recovered from depression six to eight weeks after initiation of pharmacotherapy by their primary care physician were eligible; 194 were randomized to receive the intervention. The intervention combined education about depression, motivation-enhancing shared decision-making regarding the use of maintenance pharmacotherapy, and cognitive-behavioral strategies. The program included two visits with a Depression Prevention Specialist working in tandem with the primary care physician at the primary care clinic, with supervision and back up from a consulting psychiatrist, proactive follow-up telephone calls and mailed personalized feedback. Results: Ninety-three percent of patients attended both in-person visits; 97 percent attended one visit. Eighty percent of patients completed all three follow-up telephone calls, and 85 percent returned at least one mailed feedback form; 48 percent returned all four forms. Offered a menu of options for self-management, most patients chose medication as well as a variety of behavioral strategies. At six months, 72 percent of patients and at twelve months 62 percent of patients remained on antidepressant medication. Conclusions: We conclude that it is feasible to integrate a low intensity, twelve-month relapse prevention intervention for depression into a primary care clinic.

OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N=149) and mild to moderate depression (N=79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z=−3.06, P

The prevalence and impact of common psychological disorders in primary care were first described by Michael Shepherd (Shepherd, 1973) and David Goldberg (Goldberg & Blackwell, 1970) approximately 30 years ago. In 1985, Schurman et al. (1985) referred to primary health care in the US as a “hidden mental health network”. Given the sheer volume of recent research on depression in primary care (approximately 900 publications referenced in MEDLINE since 1993), we can no longer describe mental health problems in primary care as hidden. In this review, we attempt to summarize this recent research. Our focus is on effective clinical programs for the management of depression among primary care patients.

Background : Addressing non-alcoholic, at-risk patterns of alcohol consumption that are associated with increased morbidity and mortality is an important health care priority. Objective : The objective was to describe the prevalence and characteristics of at-risk drinkers in a population-based sample of adults with routine primary care visits. Methods : Three thousand four hundred thirty-nine patients with advance appointments in 23 primary care practices completed a health survey prior to their visit. At-risk drinking was defined as consuming an average of two or more drinks per day (chronic drinking), or two or more occasions of consuming five or more drinks in the past month (binge drinking), or, in the past month, one or more occasion of driving after consuming three or more drinks (drinking and driving). Results : Prevalence was: 11% at-risk drinking; 63% light to moderate drinking; 26% abstinence. Abstainers differed from alcohol users on demographics (older, fewer Caucasian, lower income, more unemployed), other health behaviors (less exercise, lower rates of smoking, and marijuana and cocaine use), and family history of alcohol problems (lower). Abstainers also reported poorer physical and psychological health. Compared to light to moderate drinkers, at-risk drinkers were more likely to be male, unmarried, and to use other substances (tobacco, marijuana, and cocaine). Among at-risk drinkers, those with two or more risk factors were more likely male, consumed more alcohol per week, had higher AUDIT scores and were more motivated to change their drinking. Among those with only one risk factor, binge drinkers reported high rates of tobacco and marijuana use, relatively poor perceived health, and the highest proportion of negative consequences from drinking. Conclusions : At least 1 in 10 patients making routine primary care visits have drinking practices that place them at risk for negative consequences from drinking. Three drinking patterns that can be used to define at-risk drinking are relatively distinct.

Background Prospective randomized trials have demonstrated that motivational telephone calls increase adherence to screening mammography. To better understand the effects of motivational calls and to maximize adherence, we conducted a randomized trial among women aged 50-79 years. Methods We created a stratified random sample of 5062 women due for mammograms within the Group Health Cooperative of Puget Sound, including 4099 women with prior mammography and 963 without it. We recruited and surveyed 3743 (74%) of the women before mailing a recommendation. After 2 months, 1765 (47%) of the 3743 women had not scheduled a mammogram and were randomly assigned to one of three intervention groups: a reminder post-card group (n = 590), a reminder telephone call group (n = 585), and a motivational telephone call addressing barriers group (n = 590). The telephone callers could schedule mammography. We used Cox proportional hazards models to estimate the hazard ratio (HR) and 95% confidence interval (CI) for documented mammography use by 1 year. Results Women who received reminder calls were more likely to get mammograms (HR = 1.9; 95% CI = 1.6-2.4) than women who were mailed postcards. The motivational and reminder calls (average length, 8.5 and 3.1 minutes, respectively) had equivalent effects (HR = 0.97; 95% CI = 0.8-1.2). After we controlled for the intervention effect, women with prior mammography (n = 1277) were much more likely to get a mammogram (HR = 3.4; 95% CI = 2.7-4.3) than women without prior use (n = 488). Higher income, but not race or more education, was associated with higher adherence. Conclusions Reminding women to schedule an appointment was as efficacious as addressing barriers. Simple intervention groups should be included as comparison groups in randomized trials so that we better understand more complex intervention effects.

To increase mammography participation, the authors implemented an outreach intervention translating concepts from expectancy value theory into a motivational interviewing telephone intervention that included the opportunity to schedule a screening appointment. Process data are presented from 491 women who had not scheduled a mammogram within 2 months of receiving a mailed invitation from a managed care organization’s centralized breast cancer screening program. A total of 83% of targeted women accepted the counseling calls. Counselors rated 84% of completed calls as either receptive or neutral in tone. Women with prior mammography experience were more likely to be receptive and to schedule a screening appointment during the calls than were women with no prior experience. Topics discussed during the calls also differed between women with and without prior mammography experience. Implications for dissemination of counseling interventions in health care organizations are discussed.

Objective . This study was undertaken to evaluate a smoking cessation intervention provided to women smokers as follow-up to cervical cancer screening. Methods . Women who had had a Pap test in the prior month ( N = 4,053) were called to complete a survey that assessed smoking status; 580 identified smokers were randomized to receive Usual care ( n = 292) or a Self-help intervention ( n = 288) that included a self-help booklet, a smoking and reproductive health infor mation card, and three telephone counseling calls. Women were followed up at 6 and 15 months postbase line. Results . Cessation rates in the Usual care (UC) and Self-help (SH) groups did not differ at the 6-month (UC 10.5% vs SH 10.9%, P = 0.56) or 15-month follow-up (UC 15.5% vs SH 10.6%, P = 0.17). Among women with an abnormal Pap test result there were no differences by study group in cessation rates at 6-month (UC 9.8% vs SH 11.0%, P = 0.71) or 15-month follow-up (UC 14.6% vs SH 13.4%, P = 0.96). Conclusion . Integrating interventions into the clini cal setting and involving providers at the point of care may have greater potential for capitalizing on this “teachable moment.”

The authors examined automated pharmacy and visit data for 502 members of a large-staff model health maintenance organization (HMO) who had been diagnosed with depression and started on antidepressants by their primary-care providers. Older patients (age ≥60; n=110) were less likely than younger adults (age 18–59, n=110) to receive adequate doses of antidepressant medications for 30 or 90 days. Older adults were also less likely than younger adults to receive more than two primary-care visits for depression in the 12 weeks after receiving a new antidepressant prescription and were less likely to receive specialty mental health care in the 6 months after receiving a new antidepressant prescription.

The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted.They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy.At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy.Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.

OBJECTIVE To determine the clinical predictors and rate of relapse for major depression in primary care. DESIGN A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted. SETTING A large primary care clinic of a staff-model health maintenance organization. PATIENTS Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months. MAIN OUTCOME MEASURES Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist. RESULTS Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither. CONCLUSIONS The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

SummaryCross-sectional analysis of 441 individuals with bipolar disorder treated at a US health maintenance organisation investigated the distribution of manic and depressive symptoms in that illness. Clinically significant depressive symptoms occurred in 94.1% of those with (hypo)mania, while70.1% inadepressive episode had clinically significant manic symptoms. DSM-unrecognised depression-plus-hypomania was over twice as prevalent as DSM-recognised mixed episodes. Depressive symptoms were unimodally distributed in (hypo)mania. Depressive and manic symptoms were positively, not inversely correlated, and their co-occurrence was associated with worse quality of life. Implications for the DSM and ICD nosological systems are discussed.

Background: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. Methods: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. Results: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. Conclusion: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Background/Aims Programs to translate the Diabetes Prevention Program (DPP) into effective real-life interventions are needed. In the Call-2-Health pilot study we designed and tested a telephone-based intervention modeled on the DPP. Here we present the impact of Call-2-Health on participants’ report of support from friends and family for diet changes. Social support may be critical to long-term maintenance of behavioral changes.

Context Patients with depression and poorly controlled diabetes mellitus, coronary heart disease (CHD), or both have higher medical complication rates and higher health care costs, suggesting that more effective care management of psychiatric and medical disease control might also reduce medical service use and enhance quality of life. Objective To evaluate the cost-effectiveness of a multicondition collaborative treatment program (TEAMcare) compared with usual primary care (UC) in outpatients with depression and poorly controlled diabetes or CHD. Design Randomized controlled trial of a systematic care management program aimed at improving depression scores and hemoglobin A 1c (HbA 1c ), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels. Setting Fourteen primary care clinics of an integrated health care system. Patients Population-based screening identified 214 adults with depressive disorder and poorly controlled diabetes or CHD. Intervention Physician-supervised nurses collaborated with primary care physicians to provide treatment of multiple disease risk factors. Main Outcome Measures Blinded assessments evaluated depressive symptoms, SBP, and HbA 1c at baseline and at 6, 12, 18, and 24 months. Fasting LDL-C concentration was assessed at baseline and at 12 and 24 months. Health plan accounting records were used to assess medical service costs. Quality-adjusted life-years (QALYs) were assessed using a previously developed regression model based on intervention vs UC differences in HbA 1c , LDL-C, and SBP levels over 24 months. Results Over 24 months, compared with UC controls, intervention patients had a mean of 114 (95% CI, 79 to 149) additional depression-free days and an estimated 0.335 (95% CI, −0.18 to 0.85) additional QALYs. Intervention patients also had lower mean outpatient health costs of $594 per patient (95% CI, −$3241 to $2053) relative to UC patients. Conclusions For adults with depression and poorly controlled diabetes, CHD, or both, a systematic intervention program aimed at improving depression scores and HbA 1c , SBP, and LDL-C levels seemed to be a high-value program that for no or modest additional cost markedly improved QALYs. Trial Registration clinicaltrials.gov Identifier: NCT00468676

OBJECTIVE: To test whether depression is associated with an increased risk of incident diabetic foot ulcers. METHODS: The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes. RESULTS: Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44). CONCLUSION: Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Background Physician practical support (e.g. setting goals, pro-active follow-up) and communicative support (e.g., empathic listening, eliciting preferences) have been hypothesized to influence diabetes outcomes. Methods In a prospective observational study, patients rated physician communicative and practical support using a modified Health Care Climate Questionnaire. We assessed whether physicians' characteristic level of practical and communicative support (mean across patients) and each patients' deviation from their physician's mean level of support was associated with glycemic control outcomes. Glycosylated haemoglobin (HbA1c) levels were measured at baseline and at follow-up, about 2 years after baseline. Results We analysed 3897 patients with diabetes treated in nine primary care clinics by 106 physicians in an integrated health plan in Western Washington, USA. Physicians' average level of practical support (based on patient ratings of their provider) was associated with significantly lower HbA1c at follow-up, controlling for baseline HbA1c (p = .0401). The percentage of patients with "optimal" and "poor" glycemic control differed significantly across different levels of practical support at follow (p = .022 and p = .028). Communicative support was not associated with differences in HbA1c at follow-up. Conclusion This observational study suggests that, in community practice settings, physician differences in practical support may influence glycemic control outcomes among patients with diabetes.

Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective.To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers.A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded.A telephonic outreach and care management program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.Depression severity (Quick Inventory of Depressive Symptomatology, QIDS) and work performance (World Health Organization Health and Productivity Questionnaire [HPQ], a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents).Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (beta=2.0; P=.02; equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed.A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers.clinicaltrials.gov Identifier: NCT00057590.

Context Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. Objective To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. Design Randomized controlled trial comparing systematic depression treatment program with care as usual. Setting Primary care clinics of group-model prepaid health plan. Patients A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. Intervention Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. Main Outcome Measures Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. Results Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). Conclusions For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

Context Despite the availability of efficacious treatments, the long-term course of bipolar disorder is often unfavorable. Objective To test the effectiveness of a multicomponent intervention program to improve the quality of care and long-term outcomes for persons with bipolar disorder. Design Randomized controlled trial with allocation concealment and blinded outcome assessment. Setting Mental health clinics of a group-model prepaid health plan. Patients Of 785 patients in treatment for bipolar disorder who were invited to participate, 509 attended an evaluation appointment, 450 were found eligible to participate, and 441 enrolled in the trial. Interventions Participants were randomly assigned to a multicomponent intervention program or to continued care as usual. Three nurse care managers provided a 2-year systematic intervention program, including the following: a structured group psychoeducational program, monthly telephone monitoring of mood symptoms and medication adherence, feedback to treating mental health providers, facilitation of appropriate follow-up care, and as-needed outreach and crisis intervention. Main Outcome Measures In-person blinded research interviews every 3 months assessed mood symptoms using the Longitudinal Interval Follow-up Examination. Health plan administrative records were used to assess the use and cost of mental health services. Results Intent-to-treat analyses demonstrated that the intervention significantly reduced the mean level of mania symptoms ( z = 2.09, P = .04) and the time with significant mania symptoms (19.2 vs 24.7 weeks; F 1 = 6.0, P = .01). There was no significant intervention effect on mean level of depressive symptoms ( z = 0.19, P = .85) or time with significant depressive symptoms (47.6 vs 50.7 weeks; F 1 = 0.56, P = .45). Benefits of the intervention were found only in a subgroup of 343 persons with clinically significant mood symptoms at the baseline assessment. The incremental cost (adjusted) of the intervention was $1251 (95% confidence interval, $55-$2446), including approximately $800 for the intervention program services and an approximate $500 increase in the costs of other mental health services. Conclusions Population-based systematic care programs can significantly reduce the frequency and severity of mania in bipolar disorder, and cost increases are modest considering the clinical gains. The incorporation of more specific cognitive and behavioral content or more effective medication regimens may be necessary to significantly reduce the symptoms of depression.

ContextBoth antidepressant medication and structured psychotherapy have been proven efficacious, but less than one third of people with depressive disorders receive effective levels of either treatment.ObjectiveTo compare usual primary care for depression with 2 intervention programs: telephone care management and telephone care management plus telephone psychotherapy.DesignThree-group randomized controlled trial with allocation concealment and blinded outcome assessment conducted between November 2000 and May 2002.Setting and ParticipantsA total of 600 patients beginning antidepressant treatment for depression were systematically sampled from 7 group-model primary care clinics; patients already receiving psychotherapy were excluded.InterventionsUsual primary care; usual care plus a telephone care management program including at least 3 outreach calls, feedback to the treating physician, and care coordination; usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone.Main Outcome MeasuresBlinded telephone interviews at 6 weeks, 3 months, and 6 months assessed depression severity (Hopkins Symptom Checklist Depression Scale and the Patient Health Questionnaire), patient-rated improvement, and satisfaction with treatment. Computerized administrative data examined use of antidepressant medication and outpatient visits.ResultsTreatment participation rates were 97% for telephone care management and 93% for telephone care management plus psychotherapy. Compared with usual care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom Checklist Depression Scale depression scores (P = .02), a higher proportion of patients reporting that depression was "much improved" (80% vs 55%, P

Background Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms. Methods A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status. Results Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months. Conclusions A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.

Sternheim and Boynton’s (1966) continuous judgmental color-naming technique was used to assess the elemental nature of achromatic colors. Results from three subjects indicate that the names “black” and “white” are necessary and sufficient to describe achromatic test lights associated with the name “gray.” On the basis of the criteria that establishes a color as elemental, black and white were confirmed as elemental, whereas gray was not. These findings support the assumption of various opponent processing models that there are only two elemental achromatic sensations. In addition, the results support Hering’s (1920) view that black and white differ from the paired-chromatic opponent colors in that they are not mutually exclusive.

This study described the prevalence and characteristics of at-risk drinkers among adults receiving care at an urban occupational medicine clinic. Comparisons were also made between occupational medicine and primary care patients. Among occupational medicine patients, prevalences were: 11% at-risk drinking; 51% light-moderate drinking; 38% abstinence. Abstainers differed from alcohol users with regard to race (fewer Caucasian) and marijuana use (lower rates). Compared to light-moderate drinkers, at-risk drinkers were more likely to be smokers. Compared to a primary care sample, non-at-risk drinkers in occupational medicine reported poorer health, more activity limitations, higher rates of smoking and more stress and depressive symptoms. In contrast, at-risk drinkers in occupational medicine were quite similar to those in primary care. Occupational medicine clinics are viable settings in which to screen for at-risk drinking patterns and to implement primary and secondary prevention strategies.

Background In the context of routine population-based alcohol screening to identify primary care (PC) patients who might benefit from brief intervention, many patients identified will have alcohol use disorders (AUD) [1] and will likely require more intensive treatments. FDA approved medications are recommended to treat AUD [2] and could be offered in PC. Currently, use of AUD medications is extremely rare. [3] This qualitative study sought to understand barriers and facilitators to prescribing AUD medications in PC.