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Objectives: Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact.Methods: Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival.Results: The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received.Conclusions: Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions. [ABSTRACT FROM AUTHOR]

Objective: Hospitalization for cardiac disease is associated with an increased risk for depression, which itself confers a poorer prognosis. Few prospective studies have examined the determinants of depression after hospitalization in cardiac patients, and even fewer have examined depression within the weeks after hospital discharge. The present study assessed the prospective relations among perceptions of social support and trait hostility in predicting symptoms of depressive symptoms at 1 month after hospitalization for a diagnostic angiography in 506 coronary artery disease (CAD) patients.Method: A series of structural equation models 1) estimated the predictive relations of social support, hostility, and depressive symptoms while in the hospital to symptoms of depression 1 month after hospitalization, and 2) compared these relations across gender, predicted risk classification, and age.Results: Social support assessed during hospitalization was independently negatively associated with depressive symptoms 1 month after hospitalization, after controlling for baseline symptoms of depression, gender, disease severity, and age. Hostility was an indirect predictor of postdischarge depressive symptomology by way of its negative relation with social support. This pattern of relations did not differ across gender, predicted risk classification, and age.Conclusions: Our findings suggest that a patient's perceived social support during hospitalization is a determinant of depressive symptoms 1 month later. The relation of social support and hostility to subsequent depressive symptoms was similar across a variety of populations. [ABSTRACT FROM AUTHOR]

Objective: To compare return-to-work rates after coronary angioplasty, coronary bypass surgery, and medical therapy in patients with coronary disease.Design: Prospective cohort study.Setting: Tertiary care referral center.Patients: Between March 1986 and June 1990, we enrolled 1252 patients who were younger than 65 years, who had not had previous coronary revascularization, and who were employed. All patients were followed for 1 year.Main Outcome Measure: One-year employment status.Results: After 1 year, 84% of patients who had coronary angioplasty were still working compared with 79% of patients who had bypass surgery and with 76% of patients who received medicine. After adjusting for the more favorable baseline characteristics of patients who had angioplasty (less severe coronary artery disease, better left ventricular function, and less functional impairment), however, no significant differences were noted in 1-year employment rates among the three groups. These adjusted 1-year return-to-work rates were 84% for angioplasty, 80% for surgery, and 79% for medicine (P > 0.05). In a random subset of 72 patients, 23 patients who had angioplasty returned to work after a median of 18 days (mean, 27 days) compared with 54 days (mean, 67 days) for 24 patients having bypass surgery and with 14 days (mean, 45 days) for 25 patients receiving medicine (P = 0.002).Conclusions: Patients who had coronary angioplasty were able to return to work earlier than those who had bypass surgery, but by 1 year no significant difference was noted in employment rates. Neither revascularization strategy improved employment rates when compared with initial treatment using medical therapy. [ABSTRACT FROM AUTHOR]

Social support and depression have been shown to affect the prognosis of coronary patients, and social support has been found to influence depression in community and patient samples. We investigated the characteristics of coronary patients whose depressive symptomatology was most likely to improve with social support. We predicted that social support would be most beneficial for the most severely depressed, the old, the poor, the most severely ill, and those with poor functional status. Patients (n = 590) with documented coronary artery disease were assessed for depressive symptoms, social support, and functional status while in hospital. They were reassessed for depression 1 month later during a home visit. Depression scores were lower at follow-up (p = 0.001), and improvement was more marked among those reporting more support (p <0.001). The social support effect was strongest among those with high levels of depression at baseline (p <0.001) and those with lower income (p = 0.01). Unexpectedly, social support was more strongly associated with improvement in younger patients (p = 0.01). Social support did not interact with gender, disease severity, or functional status. These findings are partially consistent with the notion that social support is most effective for those who are most vulnerable and/or have few coping resources. These findings also have implications for the design and interpretation of psychosocial interventions. [ABSTRACT FROM AUTHOR]

An investigation of the surrogate assessment of coronary artery disease (CAD) patients' functional capacity was conducted using 193 patient and surrogate rater dyads. Mean age of patients and surrogate raters were 60.4 and 54.4 years, respectively. Patients and surrogates independently completed a brief questionnaire that assessed health and psychosocial factors. The Duke Activity Status Index (DASI) was contained in the patients' questionnaire, while a similar form modified to assess patients' functional capacity was imbedded in the surrogates' questionnaire. Results indicated similar psychometric characteristics and clinical validity for patients' self-report and surrogates' ratings, suggesting that the Surrogate Rating Form of the Duke Activity Status Index (DASI-SRF) is a reliable and valid proxy method of assessing patient's functional capacity when this information may not be obtained directly from the patient. Further, while there were no effects of surrogates' health and psychological characteristics on their ratings of patients' functional capacity, in comparison with other surrogates, spouses were more likely to rate patients higher in functional capacity. Exploration of the patient/care provider relationship via concurrent use of the DASI and DASI-SRF is discussed. [ABSTRACT FROM AUTHOR]

Background: Few studies have assessed treatment effects on health-related quality of life (HRQoL) in patients with acute coronary syndrome (ACS) treated without revascularization. The TRILOGY ACS trial randomized patients with ACS to either prasugrel or clopidogrel therapy plus aspirin. Outcomes showed a complex pattern suggestive of late benefits with respect to repeat clinical events and benefits confined to patients who underwent angiography. Here, we examine the HRQoL correlates of these patterns., Methods: HRQoL was measured at baseline and 3, 12, and 24 months or end of study (EOS) in 7243 patients aged <75 years using the EuroQol 3-level, group 5-dimension index (EQ-5D). Linear mixed effects models for repeated measures were used to examine treatment differences in HRQoL overall, stratified by angiography status, and among patients who did and did not have non-fatal events., Results: No baseline differences in HRQoL were seen between patients randomized to prasugrel (n=3620) or clopidogrel (n=3623). At 24 months, remaining patients assigned to prasugrel (n=1450) vs. clopidogrel (n=1443) had higher EQ-5D index scores (86.4 vs. 84.9, P=.01). Mixed effects models found no difference in EQ-5D scores among prasugrel and clopidogrel patients overall across subgroups stratified by angiography status. However, among patients with non-fatal clinical events, patients on clopidogrel reported a larger decrement in HRQoL than patients on prasugrel (79.5±18.1 vs. 80.6±18.0; P=.02)., Conclusions: Overall, there was no difference in HRQoL outcomes among patients receiving prasugrel vs. clopidogrel. However, the differential effects of the treatments among patients with non-fatal events require further investigation., (Copyright © 2016. Published by Elsevier Inc.)

Importance: Randomized clinical trials have shown that implantable cardioverter-defibrillator (ICD) therapy saves lives. Whether the survival of patients who received an ICD in primary prevention clinical trials differs from that of trial-eligible patients receiving a primary prevention ICD in clinical practice is unknown., Objective: To determine whether trial-eligible patients who received a primary prevention ICD as documented in a large national registry have a survival rate that differs from the survival rate of similar patients who received an ICD in the 2 largest primary prevention clinical trials, MADIT-II (n = 742) and SCD-HeFT (n = 829)., Design, Setting, and Patients: Retrospective analysis of data for patients enrolled in the National Cardiovascular Data Registry ICD Registry between January 1, 2006, and December 31, 2007, meeting the MADIT-II criteria (2464 propensity score-matched patients) or the SCD-HeFT criteria (3352 propensity score-matched patients). Mortality data for the registry patients were collected through December 31, 2009., Main Outcome Measures: Cox proportional hazards models were used to compare mortality from any cause., Results: The median follow-up time in MADIT-II, SCD-HeFT, and the ICD Registry was 19.5, 46.1, and 35.2 months, respectively. Compared with patients enrolled in the clinical trials, patients in the ICD Registry were significantly older and had a higher burden of comorbidities. In the matched cohorts, there was no significant difference in survival between MADIT-II-like patients in the registry and MADIT-II patients randomized to receive an ICD (2-year mortality rates: 13.9% and 15.6%, respectively; adjusted ICD Registry vs trial hazard ratio, 1.06; 95% CI, 0.85-1.31; P = .62). Likewise, the survival among SCD-HeFT-like patients in the registry was not significantly different from survival among patients randomized to receive ICD therapy in SCD-HeFT (3-year mortality rates: 17.3% and 17.4%, respectively; adjusted registry vs trial hazard ratio, 1.16; 95% CI, 0.97-1.38; P = .11)., Conclusions and Relevance: There was no significant difference in survival between clinical trial patients randomized to receive an ICD and a similar group of clinical registry patients who received a primary prevention ICD. Our findings support the continued use of primary prevention ICDs in similar patients seen in clinical practice., Trial Registration: clinicaltrials.gov Identifier: NCT00000609.

Introduction: Remote monitoring is increasingly becoming the new standard of care for implantable cardioverter defibrillator (ICD) follow-up. We sought to determine whether remote monitoring of ICDs improves patient outcomes compared with quarterly device interrogations in clinic., Methods and Results: In this single-center pilot clinical trial, adult patients with an ICD were randomly assigned to remote monitoring versus quarterly device interrogations in clinic. The primary endpoint was a composite of cardiovascular hospitalization, emergency room visit for a cardiac cause, and unscheduled visit to the electrophysiology clinic for a device-related issue at 1 year. We also examined health-related quality of life, costs, and patient satisfaction with their ICD care. Of 151 patients enrolled in this trial, 76 were randomized to remote monitoring and 75 to quarterly device interrogations in clinic. There was no significant difference in the primary endpoint (32% in the remote monitoring arm vs 34% in the control arm; P = 0.8), mortality, or cost between the 2 arms. Quality of life and patient satisfaction were significantly better in the control arm than in the remote monitoring arm at 6 months (83 [25th, 75th percentiles 70, 90] vs 75 [50, 85]; P = 0.002 and 88 [75, 100] vs 75 [75, 88]; P = 0.03, respectively), but not at 12 months., Conclusion: We showed no significant reduction in cardiac-related resource utilization with remote monitoring of ICDs. However, given the small number of patients in our study, the real clinical and health economics impact of remote monitoring needs to be verified by a large, multicenter, randomized clinical trial.

Background: Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events. Although efficacious secondary prevention measures are available, levels of adherence to these strategies in patients who have had stroke are largely unknown. Understanding medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke., Methods: The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry is a prospective study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack. The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months. Potential patient-, provider-, and system-level barriers to persistence of medication use are also collected. Secondary outcomes include the rates of recurrent stroke or transient ischemic attack, vascular events, and rehospitalization and functional status as measured by the modified Rankin score., Results: The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008. The 12-month follow-up will be completed in August 2009., Conclusions: The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients. These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events.

Background: Ninety-nine percent of pacemakers implanted in the United States include an option for rate modulation., Objective: The purpose of this study was to determine whether dual-chamber rate-modulated pacing, when compared with dual-chamber pacing alone, improved quality of life., Methods: This was a single-blind randomized controlled trial comparing dual-chamber with rate-modulated dual-chamber pacing. Patients were enrolled between January 12, 2000, and January 10, 2002, with 1-year follow-up ending December 19, 2002. The study was a U.S. multicenter trial, with 95 sites participating. All patients received a rate modulation-capable dual-chamber pacemaker for standard indications. Patients were screened with an exercise test (Chronotropic Assessment Exercise Protocol) 1 month later. One thousand two hundred seventy-three patients were enrolled; 401 proved ineligible, and 872 (68%) made up the randomized patient cohort. Randomized patients had a mean age of 71 years, 64% were men, and 64% had sinus node dysfunction. Randomization was in a factorial design to (1) dual-chamber rate-modulated pacing versus dual-chamber pacing and (2) automatic mode switching versus no automatic mode switching. The present report is limited to the comparison of rate modulation with no rate modulation (DDDR vs. DDD). The primary endpoint was the score on the Specific Activity Scale, an activity-based cardiovascular disease-specific instrument at 1 year. Secondary endpoints included 6-month treadmill time and additional cardiovascular disease-specific, and generic health-related quality-of-life instruments at 1 year., Results: At 6 months, patients with rate modulation had a higher peak exercise heart rate (rate modulation 113.3 +/- 19.6, no rate modulation 101.1 +/- 21.1; P <.0001). Total exercise time was not different between groups. At 1 year, there were no significant differences between groups with respect to Specific Activity Scale or the secondary quality-of-life endpoints., Conclusions: We conclude that rate modulation is ineffective in improving the functional status or quality of life of patients with a bradycardia indication for dual-chamber pacing.

Background: The segment of patients with advanced coronary artery disease, or disease that is not amenable to conventional revascularization therapies, continues to grow. Because the natural history of these patients is less defined, the appropriate end points for trials of novel revascularization therapies involving patients with advanced coronary artery disease are not certain., Methods and Results: The Mediators of Social Support Study (MOSS) prospectively followed up outcomes of long-term survival, quality of life, resource use, and costs for 1189 patients and compared outcomes of patients with advanced coronary artery disease with those of a reference group who underwent bypass surgery or angioplasty., Conclusions: Despite greater disease burden, cost, and mortality for patients with advanced coronary artery disease, a number of self-reported measures of general health status improved in a similar fashion to that of patients eligible for angioplasty or bypass surgery. These findings should inform the design of trials involving novel therapies, suggesting that angina status and mortality be included as primary end points in the consideration of efficacy. This work also suggests that additional studies of novel therapies involving larger sample sizes may be required to confidently characterize efficacy.

Objectives: This study examined the descriptive relationship of self-rated health (SRH) with various psychosocial measures, sociodemographic variables, coronary artery disease (CAD) diagnostic/clinical measures, and medically abstracted comorbidities., Methods: The sample was 2,855 individuals from the Mediators of Social Support (MOSS) study who had at least 75% narrowing in more than one vessel, as indicated by a cardiac catheterization., Results: After adjusting for sociodemographic factors, individuals who rated their health as poor/fair had significantly worse performance on all psychosocial measures and were more likely to be female, non-White, and of a lower socioeconomic status than those who rated their health as being good or better. There were few differences on SRH across various diagnostic/clinical measures of health., Discussion: A single item measure of SRH may be useful; the generalizability of the item must be considered. In this sample of CAD patients, SRH was related more to psychosocial factors than to clinical and disease indicators.

Background: Stroke occurs concurrently with myocardial infarction (MI) in approximately 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States., Methods and Results: Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non-bypass surgery-related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non-hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with approximately $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002)., Conclusions: In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.

Background: It has been hypothesized that jobs that have both high psychological demands and low decision latitude ("job strain") can lead to coronary disease. The objective of this study was to test whether job strain was correlated with the presence of coronary disease at angiography or with long-term outcome in patients with angiographic coronary disease., Methods and Results: Employed patients under the age of 65 years undergoing diagnostic coronary angiography completed a self-administered questionnaire about their job duties and work environment. Job strain was measured by the method of Karasek. Patients were separated into three groups, based on extent of coronary disease: significant disease (> or = 75% stenosis), insignificant disease (> 0% but < 75% stenosis), and normal coronary arteries. Statistical analyses were performed using logistic regression and the Cox proportional hazards model. The 1489 patients enrolled had a median age of 52 years; 76% were male and 88% were white. By design, all patients were employed, 60% in white-collar jobs and only 16% in jobs requiring heavy labor. Traditional cardiac risk factors were most prevalent in the 922 patients with significant coronary artery disease, at intermediate levels in the 204 patients with insignificant disease, and least prevalent in the 363 patients with normal coronary arteries (all P < .01). Job strain was actually more common in patients with normal coronary arteries (35%) than in patients with insignificant (26%) or significant disease (25%, P < .002). In a multivariate analysis, job strain was not significantly correlated with the presence of coronary disease. Job strain was not correlated with angina frequency at the time of angiography. Job strain was not a predictor of cardiac events (cardiac death or nonfatal myocardial infarction) during follow-up., Conclusions: Job strain was not correlated with the prevalence or severity of coronary artery disease in a cohort of patients undergoing coronary angiography. The outcome of patients with angiographically defined coronary disease was not affected by the level of job strain as measured by the method of Karasek.

Background: Much attention has been directed to the use of medical resources and to patients' outcomes in Canada as compared with the United States. We compared U.S. and Canadian patients with respect to their use of medical resources and their quality of life during the year after acute myocardial infarction., Methods: A total of 2600 U.S. and 400 Canadian patients were randomly selected from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial. Base-line data from their initial hospitalizations were analyzed, and the patients were then interviewed by telephone 30 days, 6 months, and 1 year after myocardial infarction to determine their use of medical care and quality of life., Results: The Canadian patients typically stayed in the hospital one day longer (P = 0.009) than the U.S. patients but had a much lower rate of cardiac catheterization (25 percent vs. 72 percent, P < 0.001), coronary angioplasty (11 percent vs. 29 percent, P < 0.001), and coronary bypass surgery (3 percent vs. 14 percent, P < 0.001). At one year 24 percent of the Canadian and 53 percent of the U.S. patients had undergone angioplasty or bypass surgery at least once (P < 0.001). The Canadian had more visits to physicians during the follow-up year (P < 0.001), but fewer visits to specialists (P < 0.001). At 30 days, functional status was equivalent in the patients from the two countries. However, after one year the U.S. patients had substantially more improvement than the Canadian patients (P < 0.001). The prevalence of chest pain and dyspnea at one year was higher among the Canadian patients (34 percent vs. 21 percent and 45 percent vs. 29 percent, respectively; P < 0.001)., Conclusions: The Canadian patients had more cardiac symptoms and worse functional status one year after acute myocardial infarction than the U.S. patients. The Canadian patients also underwent fewer invasive cardiac procedures and had fewer visits to specialist physicians. These results suggest, but do not prove, that the more aggressive pattern of care in the United States may have been responsible for the better quality of life.

The self-reported family support and stress of 249 ambulatory adult patients, aged 18-49 years, were studied relative to their self-reported functional health. Support from family members was found to be related positively with emotional function. Stress from family members was associated negatively with symptom status, physical function, and emotional function. Patients' severity of illness was related negatively to their symptom status, physical function, and social function, but not to their emotional function. During the study a new self-report instrument, the Duke Social Support and Stress Scale (DUSOCS), was developed to measure family and non-family support and stress. Also, a new chart audit methodology, the Duke Severity of Illness Scale (DUSOI), was designed to assess severity in the ambulatory setting. Reliability and validity of the DUSOCS and the DUSOI were supported. The importance of the patient's perception of health and its family determinants is emphasized.

Multidisciplinary geriatric evaluation units are being established in hospitals and, to a lesser extent, as outpatient clinics. This paper presents results of a chart audit of 332 patients seen from 1978 to 1982 at a university based geriatric outpatient evaluation unit. The relationships of clinic staffing to types of referrals and other aspects of clinic operation are investigated. During the time under study, the proportion of patients whose problems were medical rather than psychiatric or social increased. Presenting problems varied by referral source. Family and self referrals were most likely to identify a medical presenting problem, while physician and community agency referrals were most likely to identify a psychiatric problem. Patients frequently received diagnoses in areas of function other than those identified as the presenting problems. For example, medical clinicians made at least one psychiatric diagnoses for 86 per cent of patients they evaluated. Important questions about the potential contribution of such geriatrics clinics to health care of the elderly remain to be answered.

Two hundred three women from a primary care medical practice with symptoms of lower urinary tract infection and positive urine cultures were treated with trimethoprim-sulfamethoxazole. One hundred eleven women received a single dose and 92 were treated for ten days. Cure rates were 87 percent and 89 percent, respectively, one week after therapy. A narrow 95 percent confidence interval for the difference between the two cure rates (.02 +/- .09) suggests the treatments are equally effective. Patients were followed by chart audit and a self-reporting questionnaire. No difference in recurrence rates was found between the two groups six months after therapy. Single-dose trimethoprim-sulfamethoxazole is as effective as ten-day treatment in women with symptoms suggestive of lower urinary tract infection and has no greater relapse rate.

In a private pediatric practice, 94 infants who were breast-feeding were followed for the first 2 months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would predict mothers and infants at risk for early cessation. At 8 weeks, 30% of the mothers had stopped nursing. Factors associated with cessation were: maternal lack of confidence in breast-feeding (P less than .001); anticipated duration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant's excessive crying (P = .007), infant's demanding personality (P = .007), trouble with feeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the mothers who terminated breast-feeding. Supplementing with formula before the 2-week office visit also led to termination of breast-feeding by 8 weeks (P = .006). This decision was frequently made without medical advice. Nearly 64% (14/22) of the mothers who added formula within the first 2 weeks did so without contacting the pediatric practice.

Persons 65 years and older are the most rapidly growing age group in the United States. As age increases, functional ability deteriorates and the need for help from another person escalates. Caring for elderly persons experiencing functional deterioration is stressful, creating hidden patients among caregivers. This study surveyed randomly selected active family practice patients 40 years and older to determine the prevalence and extent of the caregiving role and functional disability among elderly relatives. One in five patients (126/602) surveyed had caregiving responsibilities for noninstitutionalized relatives (total, 153 patients). One third of caregivers lived with the relative; most of the remaining two thirds visited their relative at least twice weekly. Caregivers reported some functional impairment in 60% of their relatives, and substantial impairment in 40%. The caregiving experience is common, and the potential for stress from managing an elderly relative's disability is substantial. Further research is needed to elaborate on the burden of the caregiver.

The specific aims of this pilot study were to describe the treatment received by depressed patients in a family practice residency setting and to compare treatment modalities and intensity of treatment between patients with and without medical illnesses. A 12-month chart audit of a cohort of 340 patients randomly sampled from a family practice waiting room for a previous study revealed a 1-year period prevalence for diagnosed depression of 10.3% (35 patients). No patient met DSM-III-R criteria for major depressive disorder and yet 57% received tricyclic antidepressant therapy and 60% were eventually referred for specialist mental health care. Tricyclic therapy and follow-up visits for depression were less likely to take place for patients with more severe medical illnesses or high levels of somatic symptoms. These findings suggest that patients in primary care settings may have depressive symptoms severe enough to provoke tricyclic therapy or referral but do not meet current diagnostic criteria. Furthermore, medical illness and somatic symptoms may deleteriously affect treatment in primary care patients. Additional prospective research is needed to determine appropriate criteria for treatment of depressive symptoms in primary care patients and to evaluate the effects of medical illness and somatic symptoms on treatment by primary care physicians.